Amorim, AM

Gapo, C

Paiva, A

Silva, C

Name not available

Complications of ear mold impressions: two case reports

Repositório Institucional dos Hospitais da Universidade de Coimbra

CASE REPORTComplications of ear mold impressions: two case reportsClara Silva • Ana Margarida Amorim •Carla Gapo • Anto´nio PaivaReceived: 4 March 2014 / Accepted: 29 July 2014 / Published online: 29 August 2014 Springer-Verlag Berlin Heidelberg 2014IntroductionThe performance of an ear mold is considered to be a safeand routine procedure. Complications are rare but canoccur, namely the entrance of impression material in themiddle ear in case of iatrogenic perforation or in a pre-existent perforation [1–4].We report two cases in which the impression material ofear mold entered into the middle ear through a pre-existentperforation.Case report 1An 8-year-old male, with a past history of right chronicotitis media, with tympanic membrane perforation wasadvised to use an external auditory canal protector forpreventing the entrance of water in the ear. This was ameasure to prevent the occurrence of infections beforefurther surgery. During the process of impression taking,the patient experienced extreme pain and worsening ofhearing loss and the ear mold was impossible to remove.He was referred to the ENT emergency department wherein otoscopy, it was possible to see a foreign material underthe tympanic membrane (Fig. 1). Audiometry evidenced aconductive hearing loss with an air bone GAP of 45 dB(Fig. 2a). The computerized tomography (CT) demon-strated the filling of the middle ear and antrum, with a softtissue density material, without bone erosion (Fig. 2b). Aright atticotomy with type I tympanoplasty, with removalof the foreign material was performed. The postoperativeperiod held uneventful.Case report 2A 62-year-old female with left chronic otitis media and aright canal wall down cavity, was using bilateral hearingaids for her deafness. While taking a hearing aid impres-sion, she had intense pain and worsening of hearing loss inthe left ear. She was immediately sent to the emergencyroom and in otoscopy it was possible to see a strangematerial through the tympanic membrane perforation site(Fig. 3). Audiometry demonstrated a mixed bilateralhearing loss with a pure tone average of 80 dB in right and70 dB in the left and with an air bone GAP of 35 dB in theright ear and a 10 dB in the left ear (Fig. 4a). A CT wasperformed and evidenced a soft tissue density within theleft middle ear cavity (Fig. 4b). An anterior tympanotomywith remotion of a ‘‘white material’’ was done (Fig. 5). Inthe follow-up period the perforation was closed, with noother events.DiscussionThe cases presented lead us to some important consider-ations, especially that in the ear mold fitting complicationsmay occur. Even though there are some case reports andshort series descriptions such complications are rarelyreported but are likely to be more frequent [1–3, 5].These complications range from a simple foreign body inthe ear canal or the mastoid cavity (through perforation) totraumatic tympanic membrane (TM) perforation, ossicularC. Silva (&)  A. M. Amorim  C. Gapo  A. PaivaOtorhinolaryngology Department, Centro Hospitalare Universita´rio de Coimbra, Praceta Mota Pinto,3000-075 Coimbra, Portugale-mail: claranetosilva@gmail.com123Eur Arch Otorhinolaryngol (2015) 272:253–255DOI 10.1007/s00405-014-3217-xchain discontinuity and even involvement of the facial nerve[6]. There is a case of perilymph leakage secondary tosubluxation of stapes reported by Leong et al. [7].Patients at particular risk should be informed [1, 4]. Wemention those with altered anatomy of the ear, such as TMperforations, retracted TM pockets, tympanostomy tubesand canal wall down mastoid cavities. The procedure is notcontraindicated in these conditions but the technician or thedoctor, should inform the patients prior to it [4, 8].The symptoms related depend on the length of time thatthe foreign body is in the ear. In the acute stage, patientspresent acute pain, tinnitus, hearing loss, and dizzinessduring the process of mold-making [1]. In the cases ofasymptomatic patients, if the hearing aid dispenser isunaware that the hearing aid impression mold material isretained, the onset of symptoms may take several years. Atthat time, the symptoms are often similar to the ones ofchronic otitis media, such as intractable otorrhea and for-mation of granulation tissue as reported by Lee et al. andDhawan et al. [1, 2].A CT scan of the temporal bone may be required toadequately assess the extension of middle ear and/ormastoid penetration by the impression material [1, 4].The treatment of retained impression material, in someinstances, like the reported cases, is surgical removal.Well-established surgical techniques, including meato-plasty, middle ear exploration, atticotomy or tympanoma-stoidectomy with a facial recess approach, enable propervisualization and safe removal of impacted impressionmaterial [1, 6]. The elastic nature of silicone impressionmaterial makes it difficult to remove under local anesthesia[8]. In some cases it is possible to remove it in the officeunder microscope control, by an experienced doctor [5, 6].Mold impressions taken by untrained hands can causeserious trauma leading to further hearing impairment anddisability [2, 3, 5]. Other than a careful history taking, it isimportant to perform an adequate assessment of a cleanexternal ear canal in order to have a complete visualizationof the tympanic membrane [4, 6]. Care should be taken toput an adequate protective device (a cotton plug) in theFig. 1 Otoscopy: foreign material under the tympanic membraneFig. 2 a Conductive hearing loss at right ear. b CT showing the filling of antrum and middle ear with soft tissue density materialFig. 3 Otoscopy: strange material in the tympanic membrane perfo-ration site254 Eur Arch Otorhinolaryngol (2015) 272:253–255123external canal prior to the mold impression making [5, 7,9]. The selected material for the mold should be appro-priate, like the silicone that is more viscous, and careshould be taken not to push it in the ear canal with toomuch pressure to prevent the rupture of an intact tympanicmembrane [3, 4, 7, 9]. The ear canal should not be sealedoff by the piston so that if the pressure rises in the earcanal, the material has space through which to flow insteadof causing trauma to the tympanic membrane [3, 4, 9].In summary, the majority of the situations are avoidable.It is important to follow strictly proper protocols during theprocess of making ear mold impression and be aware of thepossible hazard complications. The mold should be madeby an experienced person trained in this area and preven-tion should be the mainstay of the treatment. It isrecommended that a patient with an impacted moldimpression should be referenced to an otorhinolaryngolo-gist. So, a close cooperation between hearing dispensersand otorhinolaryngologist must be present.Conflict of interest No conflict of interest.References1. Lee DH, Cho HH (2012) Otologic complications caused byhearing aid mold impression material. Auris Nasus Larynx39:411–4142. Dhawan N, Gupta N, Goyal A, Singh V (2008) Otoplast in the middleear cleft—a rare complication of hearing aid fitting and its surgicalmanagement. Indian J Otolaryngol Head Neck Surg 60:234–2373. Awan MS, Iqbal M, Sardar ZI (2007) Iatrogenic insertion ofimpression mould into the middle ear and mastoid and its retrievalafter 9 years: a case report. J Med Case Rep 1:34. Jacob A, Morris TJ, Welling DB (2006) Leaving a lastingimpression: ear mold impressions as middle ear foreign bodies.Ann Otol Rhinol Laryngol 115:912–9165. Syms CA, Nelson RA (1998) Impression-material foreign bodiesof the middle ear and external auditory canal. Otol Head NeckSurg 119:406–4076. Kohan D, Sorin A, Marra S, Gottlieb M et al (2004) Surgicalmanagement of complications after hearing aid fitting. Laryngo-scope 114:317–3227. Leong SC, Banhegyi G, Panarese A (2012) Serious complicationsduring aural impression-taking for hearing aids: a case report andreview of the literature. Ann Otol Rhinol Laryngol 121:516–5208. Shashinder S, Tang IP, Velayutham P, Rahamat O et al (2008)Foreign body in the middle ear, a hearing aid complication. Med JMalays 63:267–2689. Hof JR, Kremer B, Manni JJ (2000) Mould constituents in themiddle ear, a hearing-aid complication. J Laryngol Otol 114:50–52Fig. 4 a Audiometry: mixed hearing loss bilaterally with an air bone GAP of 10 dB in the left ear and 35 dB in the right ear. b CT showing softtissue density in the left middle ear cavity. HA hearing aid, RE right ear, LE left earFig. 5 Impression material being removed from the middle ear cavityEur Arch Otorhinolaryngol (2015) 272:253–255 255123

Complications of ear mold impressions: two case reports

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