The Ins and Outs of Ear Tubes

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.