CLINICAL CASES
CLINICAL CASES
Using the Wispr Digital Otoscope
31-year-old with Decreased Hearing 2
A 31-year-old woman had ear tubes installed a month ago for decreased hearing and chronic middle ear effusion. After a robust coughing spell, this image of her ear was obtained by a family member with the Wispr digital otoscope.
What is unusual about her tube?
A. There is scarring superior to the tube that is unusual for a tube this new.
B. The tube is occluded.
C. The tube should be in the superior-posterior quadrant.
D. There is evidence that the tube is starting to extrude.
D. There is evidence that the tube is starting to extrude.
Ear tubes (ventilation, tympanostomy tubes) are inserted to equalize the pressure between the middle ear space and the “outside world.” They are often used in cases of repeated acute otitis media (AOM) or chronic effusions. The tubes are installed by making a small incision in the eardrum. The tubes can have different geometries, but there is always a mechanism of retaining the tube in the ear. The mechanism can be tabs, flanges, or t-tubes. In this case, the tube has tabs that should be behind the eardrum when installed. Here, the tab has become dislodged from its position in the middle ear space. This normally occurs 6 months after tube installation and heralds the start of the extrusion process. What’s unusual here is that the coughing spell seems to have caused the early extrusion of the tube, no doubt due to increased middle ear pressure communicated via the Eustachian tube.
Compare the partially extruded tube with the appearance of the tube when first installed. The tabs in the newly installed tube are correctly positioned behind the eardrum.
What appears to be scarring is coalesced middle ear space fluid that was drained from the tube. This is normal. There is no evidence that the tube is occluded – the portion of the lumen that is visible appears to be patent. Ventilation tubes are never placed in the superior-posterior quadrant, as that is the location of the fragile middle ear ossicles.
Because the tube is starting to extrude, a reasonable expectation would be that it will completely fall out in weeks. If the patient has pain or decreased hearing, she should be seen by otolaryngology (ENT).
