Tympanostomy Tubes


A Teflon or plastic grommet...commonly used as the initial type of tube by many surgeons	Metal grommets were once popular...but probably have increased complications.	This long-shafted tube has a large T-shaped inner flange...that keeps it in place for a relatively long time.

Why are tubes recommended or inserted? Two reasons are common: 1) Fluid that has not cleared for a long period of time...usually at least 3-4 months. The fluid, especially if on both sides, always causes some degree of hearing loss. 2) Multiple ear infections that have not been adequately controlled with medical treatment or that are particularily severe. Other less common reasons include: severe retraction or distortion or the ear drum, pressure problems (barotrauma) - such as seen in patients undergoing hyperbaric oxygen treatment, or a "patulous eustachian tube".

What do tubes actually accomplish? Since fluid is usually removed at tube placement, hearing is immediately restored. Most experts feel that the aeration of the ear reduces the likelihood of acute otitis media (ear infections). Infections become more reliably detected, since they will drain out through the tube...and the infectious material can be cultured, if necessary.

How are they placed? Typically, a small incision is made in the ear drum (called a myringotomy), fluid is suctioned out, and a tube is placed. Antibiotic ear drops may be placed. In young children, this is usually done under a light general anesthesia, although there are some other options that are occasionally used. Older patients may tolerate the procedure under local anesthesia. The hole can be created with a laser, as well.

Why are there different types? There are over 50 different designs...varing in shape, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. (Longer duration is not always advantageous.) Metal tubes were fashionable some years ago, but probably have an increased complication rate (plugging, certain types of infections). Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

Why don't we just drain the fluid and not place tubes? The main reason is that the hole (myringotomy) closes within 48 hours...and the fluid almost always reaccumulates. Some recent investigations...using a laser to create the hole...suggests that those holes may stay long enough (2-4 weeks) to be sufficient for some children.

What problems can be seen with tubes? Most children have no particular problems. The following problems can be seen: a) Tubes come out too early...or remain in place longer than desired (probably each occurs about 5% of the time) b) Infection (see below). c) chronic perforation of the ear drum - probably occurs in 1-5% of ears. It is higher in children with recurrent otitis who have normal ears (thin ear drum) at the time of surgery. Long-lasting tubes, or large tubes, have a much higher rate of perforation (Up to 10%). These perforations may need to be surgically repaired (a procedure called a tympanoplasty or myringoplasty.) d) Any irritation of the ear drum can cause scarring (called myringosclerosis or tympanosclerosis) of the drum. For the vast majority of patients, this has no clinical or hearing significance.

Can tubes get infected? Yes, and there are two general types of infections. The first is the regular type of acute otitis media (ear infection) and is caused the same bacteria. This type is most common in the younger child (who has more respiratory infections) and is more common in the winter months. Since the infection may be in other parts of the respiratory tract (sinuses, bronchial tree), oral antibiotics are usually prescribed...along with ear drops. The second type of infection is caused by bacteria coming in through or around the tube...and is more common in the summer and in older children. The bacteria that commonly cause this (Pseudomonas aeruginosa) are NOT inhibited by oral antibiotics that are approved and safe for children. Therefore, the treatment is drops alone.

How long do the tubes stay in? The duration of tube retention is related several factors...especially tube design. For the average child, we usually recommend a tube that stays in, on average, about 8-12 months. In certain situations, such as children having multiple sets of tubes, cleft palate patients (who may need tubes for a longer time), or other patients with chronic eustachian tube dysfunction, we may place longer acting tubes...such as a Touma T-tube or a Goode T-tube.

Do the tubes have to be removed? Over 90% of the time, the tubes extrude spontaneously. If the tube is staying in for several years, or if the tube is causing infections, the tube may be removed. Depending on the patient, this require general anesthesia.

Do we have to keep the ears dry after tubes? This is controversial...and many ear doctors still recommend all sorts of water precautions or ear plug use. However, most experts agree that multiple well done studies have NOT supported avoidance of water or use of ear plugs...for young children or infants. Therefore, for children less than about 5-6 years old, we allow bathing, hair washing, surface swimming, or ocean exposure...without any precautions. Diving deeper under water, or swimming in (dirtier) lakes and rivers is more likely to cause infections. In those cases, the preventitive use of certain antibiotic ear drops (such as Floxin Otic) may help. Your ear doctor may be adamant about keeping your infant's ears dry...just realize that is his/her opinion...and is not necessarily supported by scientific evidence.

How often should we see the ENT doctor after tubes? Most ENT docs like to see their tube patients every 3-6 months, or until the ears are normal. Some primary care clinicians are skilled enough that they can follow most tube patients.

What if the tube becomes plugged or blocked? If the ear drum remains normal, and there is no reaccumulation of fluid, there may be no need for intervention. On the other hand, if the ear is symptomatic, and the tube plugged, one of several types of drops may be recommended. Rarely, the tube will need to be replaced.

What else can be done...other than tubes? Adenoidectomy, with just myringotomies (making an incision, no tubes) may be appropriate in certain children...as might a laser myringotomy.