BackTable / ENT / Podcast / Episode #61
The Ins and Outs of Ear Tubes
with Dr. Ashley Agan and Dr. Gopi Shah
Hosts Dr. Ashley Agan and Dr. Gopi Shah discuss the complications of ear tubes and differences in adult and pediatric ear tube management, including the management of clogged ear tubes with normal hearing, which may require different treatments for different patients.
BackTable, LLC (Producer). (2022, June 7). Ep. 61 – The Ins and Outs of Ear Tubes [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
In this episode of BackTable ENT, Dr. Ashley Agan and Dr. Gopi Shah discuss the complications of ear tubes and differences in adult and pediatric ear tube management.
First, the doctors discuss management of clogged ear tubes with normal hearing, which require different treatments for different patients. In kids with no ear infections and normal speech and hearing, Dr. Shah recommends leaving the tube alone to minimize discomfort and traumatization associated with clot removal. In adults with clogged tubes, Dr. Agan usually picks out the clot herself in the office. If the clogged tube is interfering with speech and hearing, ear drops–such as Floxin, 50% diluted peroxide, and Ciprodex can be used to dissolve the clot. It is important to note that blood clots are common to see in the first post-operative follow up appointment after ear tube placement. Additionally, patients with primary ciliary dyskinesia (PCD) may present with thick mucoid clots and may need in-office suctioning to remove the clot. At-home suctioning may be performed with blue bulb syringes. After clearing a clogged tube, the doctors recommend following up in 3-6 months with patients, unless they have other middle ear pathologies, such as recurrent otitis media. In the latter case, a 4-6 week followup is recommended.
Next, the doctors discuss the new ear tube guidelines, which do not recommend routinely using antibiotics during ear tube placement if no purulence is observed during the time of surgery. Both doctors agree with the guidelines if the ear tube is being placed as a solution for Eustachian tube dysfunction. Dr. Shah notes that in some cases of recurrent otitis media, kids may not have fluid at the time of ear tube placement but present with purulence post-operatively. Because of these cases, she still sends her patients home with a prescription for Ciprodex in case they develop otorrhea or pain. For bleeding or mucoid fluid without purulence, the doctors recommend Afrin or hydrogen peroxide drops upon follow up.
Then, Dr. Shah and Dr. Agan discuss management of persistent tube otorrhea. They recommend Ciprodex drops and consequent pumping of the tragus to drive the drops down to the drum. If suctioning is required, especially in PCD patients, papoosing infants may be necessary. For patients with a conjunction of otorrhea and bad allergies, steroid drops like dexamethasone may be helpful. Also, Dr. Shah mentions the importance of reframing otorrhea in the case of frustrated families; she explains that otorrhea means that the ear tube is working because the drainage would’ve been stuck in the middle ear otherwise. The ear tubes will not make ear infections go away forever, but will make management of infections more tolerable for the children and their families.
The last three complications the doctors talk about are a retained tube, granulation of the ear tube, and the development of biofilms on ear tubes. For retained ear tubes, Dr. Agan leaves the tubes alone in adults with the expectation that they will fall out naturally. She rarely removes ear tubes in her adult patients, as they require a trip to the OR. If a tube has been retained for two and a half or three years in a child, Dr. Shah starts to prepare the family for tube removal. Most of the time, after tube removal, the hole in the tympanic membrane heals on its own. If granulation tissue develops around the tube, steroid drops, debulking, and temporary removal of the tube may be helpful. When biofilms have developed on the tube, the tube can be left in and treated conservatively if the tube is still functioning. Removal of the old tube and replacement with a new one can cause a tympanic perforation that requires tympanoplasty. Dr. Agan emphasizes the importance of a shared decision-making process with families and patients in this scenario.
[Gopi Shah MD]
So in terms of the blood clot from surgery, that's definitely, I think where the peroxide probably is gonna give you the most bang for your buck. And that's going to be the kid that is gonna be your first post-op follow-up, although every once in a while you might see it a little bit later on down the line. In terms of really thick mucus, it makes me think of my primary ciliary dyskinesia kids or the kids that are under two and they're still in daycare or there's just 15 months and we're in the middle of January. They're going to keep getting those six to eight colds a year and it's like, well, dang, we just had ottorhea three weeks ago, two weeks ago, like it's just constant. And, I don't see it and I'm not necessarily worried about cholesteatoma at that time. I'm worried about more of these colds that keep happening. For my PCD kids, I will tell them to routinely do a little diluted peroxide and get one of those blue bulb syringes, the baby ones that flare out. I'll have them then kind of suction their own ear. Because the diluted peroxide kind of thins it, cause it's thick and then they can get one of those blue bulb syringes. It's going to flare out, so it's not like they can shove it too deep to their ears, but I'll have them mark from the tip about seven millimeters or so, and then gently squeeze the bulb, put it by the ear and suck it out. Cause otherwise those kids are constantly in my clinic, getting papoosed, especially the three to five-year age. And at a certain point, they're not gonna let you even look in their ears. So this is something that maybe would avoid that. Because overall the thick stuff's gone and then they can get the drops in. And so sometimes I'll have them do that a couple of nights a week, or even once a week, depending on how much they get, because it's just oral toilet for that population. And so those are the two that I tend to be a little bit more. And then if it's mucoid thick stuff that's blocked, I'll talk to the family. Every once in a while, if it looks like it's worth papoosing and suctioning, I might do that. Versus trying and some drops. If I can see the tube and think the drops will go in and have them come back. And if that still didn't do it, maybe try to see if it's worth, if it's loose enough to section out the second time around. In terms of a pick and trying to do wax in the lumen. That sounds lovely. It just depends on the kid and what I think is actually feasible, but that's not a part of my routine practice. I'd say sometimes. They cast too, right. Like you've taken the tube out and it's a whole cast that's like two millimeters or something, which sounds kind of small, but it isn't, and it's hard.
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