Ear Tubes

Ear Tubes Procedure

Ear infections (otitis media) are the most common infections requiring treatment in young children. They have a tendency to become more frequent and less responsive to antibiotic therapy. Some infections may resolve spontaneously after a short period, while others may require medication to aid in resolution. Almost all children experience one or two infections in the first two years of life, but the environment and head and neck anatomy make some children more prone to multiple infections. A complication of otitis media may cause long-term damage that may result in hearing loss or neurologic problems and may contribute to speech or developmental delay.

When a child experiences multiple ear infections, ear tubes (also called tympanostomy tubes, ventilation tubes, or PE [pressure equalization] tubes) may be recommended by an otolaryngologist. These tiny tubes are inserted through the eardrum and perform a number of functions:

• The tube prevents many ear infections by allowing air in the middle ear to exchange freely with the outside air, preventing the formation of a vacuum in the middle ear. This tends to keep the infection from coming to the ear from the back of the nose and causing the ear infection.
• The equalization of the middle ear pressure prevents most of the complications to the eardrum that result from the formation of negative pressure in the middle ear.
• Should an ear with a tube in place become infected, the tube then functions as a drain, without pain, by allowing pus to drain out.
• The tube then allows the parent to insert medication directly to the site of the infection using antibiotic/steroid ear drops.
• The tubes can alleviate hearing loss caused by the accumulation of fluid in the middle ear.

Ear tubes are made from various materials and consist of small, cylindrical tubes that are positioned through the eardrum. Some tubes are designed to fall out on their own, and others may require removal by a doctor.

Each year, hundreds of thousands of children undergo procedures to have ear tubes placed in their ears.

After an ear doctor determines that the child will benefit from the insertion of ear tubes, the parents (or primary caretakers) should be given the following information to assist in their decision to proceed with the operation.

• The full extent of the child's problem and why the doctor feels tubes are the best solution for that particular child
• The details of the proposed procedure and any common complications that might arise
• The type and extent of anesthesia to be used for the case including possible preoperative medication and discharge instructions
• Any possible long-term benefits or complications
• Any nonsurgical alternatives and the risks of not performing the procedure
• Instructions for care of the child after the tubes are inserted

Generally, the entire procedure from the departure of the child from the preoperative area to the recovery room takes approximately 10 to 15 minutes. Once the child is under anesthesia, the procedure to insert the ear tubes (called a myringotomy and tube insertion) usually takes 2 to 3 minutes to complete.

Using magnification under an operating microscope, the doctor begins by making a small hole in the eardrum in an area where the membrane has the least vibration. The fluid in the middle ear is then aspirated by suction, and the tympanostomy tube is placed in the opening. This tube allows air to enter the ear and allows fluid to drain. Often antibiotic/steroid ear drops are inserted to prevent blood or secretions from clotting in the tube. The drops are then given to the caregiver with instructions on further use.

The child's recovery from the procedure is brief (10-15 minutes) unless preoperative sedation was used. Pain is usually minimal to absent. The hearing is generally improved immediately.

Sometimes when ear tubes are placed, the surgeon may recommend removal of the adenoid, an area of lymphoid tissue that is located behind the palate near the opening of the Eustachian tube. This is most often recommended if the patient has had previous ear tube placements or chronic nasal congestion, infection, or obstruction to breathing at night (apnea).

Generally, as the child awakens from the anesthesia, the parents return and the final recovery takes place with them present. In most cases, children are discharged as soon as they are fully awake and drinking fluids. Children with special needs or other problems may be kept longer, particularly infants who have other problems.

Prior to discharge, the caregiver receives instructions on care, feeding, and activity for the child. The doctor may prescribe antibiotic ear drops (or give those used in the operating room) to treat any residual infection or swelling of the middle ear, most often for two or three days.

The doctor, according to preference, will give instructions on whether the ears need to be protected from water. Most otolaryngologists agree that it is not necessary to avoid water exposure after the procedure, although some doctors may feel that it is necessary to keep the ears dry. Your doctor may recommend a follow-up examination 7-14 days after the procedure. Further appointments are typically scheduled every 3-6 months, depending upon the specific needs of the child. You may be given a prescription for ear drops and instructions for what to do about ear drainage that may occur from the ear.

Depending on the design and the needs of the child, ear tubes may eventually fall out on their own or require surgical removal. Generally, tubes that extrude on their own will last 9-15 months, but children will require new tubes if they have more infections after the first ones come out or the doctor notes more problems requiring ventilation. Long-term tubes can remain for many years are sometimes recommended as a second or subsequent ventilation tube.

No surgical procedure is free of risks. Tympanostomy tube placement should be considered just like any other surgical procedure. While generally safe and quick, complications can occur with the procedure as with any procedure requiring anesthesia. It is equally important to select to have the procedure performed in a facility where experienced pediatric providers are found as it is to pick the surgeon.

Placement of tympanostomy tubes carries few long-term risks and usually many advantages when an appropriate patient selection has taken place. Complications may include:

• Persistent perforation at the tube site: This is often a function of the failure of the ear to heal because of failure of the ear to resolve its underlying problem.
• Scarring: Some increase in scarring may be noted, but this is generally more cosmetic than functional.
• Persistent ear drainage (otorrhea): This may be seen in some children where the underlying disorder is that the Eustachian tube is "too open" or patulous. Children with Down's syndrome, cleft palates, or cerebral palsy are more prone to this complication but other children may show the same problem.
• Cholesteatoma or polyp formation: This is the invasion of skin into the middle ear from the rim of the hole for the tube. Most often this is seen in children who are not returned to the otolaryngologist for appropriate follow-up on a regular basis.

The objectives of placing tympanostomy tubes are one or more of the following:

• Decrease the frequency of infections: Generally, the incidence of ear infections is dramatically decreased when tympanostomy tubes are placed.
• Lessening of severity: When an infection occurs, the child most often has ear drainage without pain or fever associated with the ear itself. Pain may occur if the skin of the ear canal becomes infected.
• Ease of treatment: If ear drainage develops, the caregiver can treat the infection with ear drops alone, decreasing the need and complications of using antibiotics for the whole body.
• Decrease complications: In children prone to the complications associated with negative pressure in the ear, the process is halted and damage to the ear and eardrum is minimized.
• Hearing preservation: The type of hearing loss associated with ear infections is called conductive hearing loss or a mechanical blockage of transmitting sound through the ear to the inner ear. This type of loss is generally reversed by placing tubes in the ears and hearing is restored and maintained.

Medical attention may be necessary in the following circumstances:

• If the child has experienced several ear infections (ear drainage, particularly bloody drainage) within a relatively short period of time.
• The child has persistent ear drainage after using the drops as ordered.
• The child has increasing ear pain without ear drainage.
• The ear becomes swollen with ear drainage and the drops will not go in.
• If the caregiver is told there is an ear problem and there is no ear drainage.
• If any significant change of hearing is noted.