Podcast Transcript: The Ins and Outs of Ear Tubes

[Gopi Shah MD]
All right. What do you do about tube otorrhea?

[Ashley Agan MD]
Ciprodex is probably the first, most common, that's so common that even when patients call most of the time, the nurses will just check and be like, I'm sending in some Ciprodex and I'll be like, yep, that sounds great. Let's try that first. So I would say, I don't know, what percentage would you say? A significant part of the time that's going to clear it up and help. And I always tell patients to do pumping the tragus. So putting a finger on the tracheal cartilage and kind of pushing in and letting go, pushing in and letting go, to try to drive those drops down, to the drum and through the tube. I know the otologist have always told me that's important. And so that's kind of my first go-to, if they're in the clinic, I like to try to section as much as I can. Because if there is a bunch of really thick stuff down there maybe the drops can't even get through the tube and where you want them to go. So getting it cleaned out as much as you can to allow for the drops to get there, I think it can be helpful too.

[Gopi Shah MD]
So if I can see that ear tube, and there's just a little bit of drainage on the drum I'll just have him start Ciprodex. This is if I've seen them in clinic. Obviously, if I can't see the tube at all, because there's so much otorrhea we're going to section and it's going to require papoose. And I always tell families, at the time of surgery before we do the tubes and that one of the things, especially in kids under two, otorrhea and having to be papoosed and getting suctioned, that might be on more than one occasion sometimes, is a very real part of the process.

[Ashley Agan MD]
So you prepare them that prepare them for that.

[Gopi Shah MD]
Yeah. Because as a parent, even if it's five minutes, we’re burrito-ing their kid and it's loud, the child is screaming most of the time. Yeah. And you may have to do it more than once. It may not resolve the first time around. But usually, that's kind of when I decide to section. Most of my kids that are primary ciliary dyskinesia, I just section them every time, their ears, depending on the age and their tolerability. So I have a handful of younger PCD kids that I just can't do it every time because they're not gonna let me look in their ears. And those are the ones, as long as I can see the tube and their audios, are good, even if there's a little fluid, just kind of by the tube, that's actually a good outcome.

[Ashley Agan MD]
Because the fluid is coming out.

[Gopi Shah MD]
And then the kid, the patients that are a little bit older, who I've known now for a couple of years, they come in, they understand what their pathophysiology, why, and what's happening. There are a lot more amenable to it and they're used to it now.

[Ashley Agan MD]
What size suction do you use?

[Gopi Shah MD]
In my kids that are under five, under three to three to five, I use the five section usually, for the lateral canal. Unless it's just so thick, then I have to start with a seven in the lateral canal. But what I like with the five is then I don't have to necessarily switch over to a three. I can at least get it so I can section, see my tube, see the lumen and get anything thick. I mean, they're not gonna let me get in with a three, we're just trying to make sure the drops go in. For my older kids, again, if it's thick, I might have to start out with a seven for that lateral canal and then go to the five usually, so that's kind of how I do it.

[Ashley Agan MD]
Do you ever put anything in there, in clinic, to thin things out before you section?

[Gopi Shah MD]
No, not necessarily, unless I'm worried the lumen is clogged.

[Ashley Agan MD]
Yeah. I mean, they're papoosed and you're on the clock and it's like, all right,

[Gopi Shah MD]
Yeah. Not my older kids though. I can’t papoose, once they're like seven, eight years old… It's like under five, you might be able to.

[Ashley Agan MD]
Yeah, yeah.

[Gopi Shah MD]
Okay. So let's say they come in and you've sectioned their ears. You tried Ciprodex for about a week, but they're still having otorrhea.

[Ashley Agan MD]
So we'll take a look. Sometimes with Ciprodex, you can get some clumping, the medication will crystallize and you'll get this like white clumping down on the tube or on the drum that sometimes will continue to clog your tube. So you have to be mindful of that. So you may have to clear that under the microscope in the office.

If they're continuing to have just nasty drainage, despite being on Ciprodex sometimes I will have them come back more frequently to where I can suction them more often because the thought being like, okay, maybe the medication is not able to get through the tube and into the ear to treat that mucosa because there's just so much drainage and they just need to have more suctioning more often. But I've never tried the blue bulb trick that you're talking about with your kids. So maybe I’ll start trying that in adults and see if that helps just to give them some, a way to kind of clear some of that so that the drops can get down to the drum and through the tube.

[Gopi Shah MD]
I think that's only really helpful for that thick lateral stuff. Yeah. But at least it’s something.

[Ashley Agan MD]
It's something. Yeah, for sure. Especially if patients have drainage, that's coming out of their ear onto the pillow like, if you're dealing with like a large volume. Let me think. Sometimes I'll switch up the drops. In a patient who has really bad allergies or maybe as like a chronic sinusitis patient, sometimes I will switch to just a steroid drop, like dexamethasone or a Pred Forte, with the idea that the middle ear is like an accessory sinus. And so in the same way that we use Flonase or nasonex or some sort of nasal steroid in the sinuses, you're trying to apply some steroid into that middle ear space. But again, the tube needs to be open and working so that that medication can get in there and treat those surfaces. Sometimes I'll use some mastoid powder. You have to be careful with that because it can clog the tube too. But I have had a little bit of success doing a little bit of puff of that in there, if the ears just really wet and really draining a lot and you need something to kind of help absorb some of that, I don’t know, what are your thoughts?

[Gopi Shah MD]
Yeah. I’ll probably see them back a little bit closer and follow up compared to the clogged tube. Say two to three weeks. And a lot of times, if it's still significant, otorrhea that patient's going to be back within about a week or so. Or sooner rather than later, cause they can see it, right? And I'll section again. And I might try some mastoid powder at that point, but you're right, it's different than just like a perf that keeps draining or a otitis externa that just won't dry up. And so, you're right, that can get clumpy and it can clog the tube as well. And so sometimes I'll do the mastoid powder and then maybe let that sit at home for a couple of days and maybe even restart something like Ciprodex or Floxin a couple of days later, like maybe two, three days later to kind of clear some of that.

And, I don't do this a lot, but it had a handful of kids where, we've been doing this now for four to six weeks and it's just still, and every once in a while I might add like augmentin or something. I know we're always like tell the pediatricians, not just do oral antibiotics when you have tubes. But every once in a while you've already maybe brought them into clinic, papoosed and suctioned two or three times, and we're still doing this. And it's catching the one virus after, you know what I mean? Maybe they caught something else three weeks later and here we are again. And so every once in a while, do we have to do that. It's not common, but something that I'm like, well, I guess what else can we try? I like the steroid drop. I haven't done that as much in my kids, but maybe my older ones where it's more allergy related. Makes sense.

[Ashley Agan MD]
What are your thoughts as far as thinking of the otorrhea as a good thing in that having the tube there means that all of this fluid isn't stuck in the middle ear and it's able to come out and yes, that's annoying and you're seeing it, but like what about that reframing? Do you ever have that conversation with your families?

[Gopi Shah MD]
Absolutely. So I actually had that conversation recently in clinic a couple of days ago and it was probably, the baby, about 15 months, had ear tubes about, maybe six months ago. And mom was a little nervous, like, Hey we've been on eardrops three or four times in the last six months for drainage. And when I look in the ears, the ears look great. Fortunately they weren't wet or draining on the date of visit. And like, that's a good thing, they're working. These are because of the tubes. Have you had to be on any oral antibiotic since? And they're like, no. At the time of consent I say that the tubes aren't going to make the ear infections go away, but hopefully they are less frequent. Although sometimes they still get those six to eight colds a year and they may still have drainage with all of them, but hopefully they're less and less frequent and less severe. So they're not fussy and crying at night and not eating, not sleeping, hopefully not fevering, things like that. And so I think that the expectation of what the tube is there for is it should be said upfront so that it's not all of a sudden that the ear infections are going to go away. It's just we manage them hopefully differently in a more tolerable, easier for the child and the family. But yeah, the reframing is very important.

[Ashley Agan MD]
Yes. Setting those expectations and you know what to expect and yeah, for sure.