BackTable / ENT / Podcast / Transcript #61

Podcast Transcript: The Ins and Outs of Ear Tubes

with Dr. Ashley Murray 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. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Addressing Clogged Ear Tubes

(2) Treating Blood Clots from Ear Tube Surgery

(3) Returning to the Operating Room

(4) New Ear Tube Guidelines

(5) Managing Tube Otorrhea

(6) Decision Making for Retained Tubes

(7) Tube Replacement and the Use of Biofilm

(8) The Role of T Tubes

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The Ins and Outs of Ear Tubes with Dr. Ashley Murray and Dr. Gopi Shah on the BackTable ENT Podcast)
Ep 61 The Ins and Outs of Ear Tubes with Dr. Ashley Murray and Dr. Gopi Shah
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[Gopi Shah MD]
Hello everyone. And welcome to the BackTable ENT podcast, where we discuss all things ENT, and we bring you the best and brightest in the field with a hope that you can take something from our show to your practice.

My name is Gopi Shaw, and I'm a pediatric ENT. And I'm here today with my Mamacita, partner in crime, Ashley Agan.

[Ashley Agan MD]
What's up. I'm a general ENT and I'm always happy to be across the mic, whether it be in person or virtually from my dear Gopi, dearest frient, and cohost.

[Gopi Shah MD]
Well, I've called you Mamacita even before the baby, because to me you're my little my little hot mama, before, and you still are even now with the baby.

[Ashley Agan MD]
I’m just a tired mama now, but it's amazing. It's amazing. Baby's doing great. And, growing like a weed, so it's pretty cool to watch her change and develop. She's four months now, four months yesterday. So it's pretty cool.

[Gopi Shah MD]
Cute, with the best laugh. The best little laugh.

[Ashley Agan MD]
Oh, those chuckles and giggles. It's the best. Absolutely the best. So pretty cool. What are we talking about today?

[Gopi Shah MD]
We are talking about something very exciting, the management of ear tubes. Now it is something that's very, very practical and no matter if you're a super specialized ENT to a general ENT, city, private, group, academic, you're going to deal with ear tubes.

[Ashley Agan MD]
Yeah, that definitely comes up a lot for everybody.

(1) Addressing Clogged Ear Tubes

[Gopi Shah MD]
Yeah. So whether they're clogged, whether they're draining, whether the tube hasn’t fallen out, there's lots of little things in clinic. So I guess I wanted to ask you, for your clogged ear tubes, let's say it's the two year old that comes in had tubes, whether it was six weeks ago or maybe it was like six months ago, it's a tube. And one of the tubes is clogged. You got your hearing tests, let's say it's normal audio. And it's either, maybe that Type A tymp, or a small volume B tymp, tube looks good, but it's clogged.

[Ashley Agan MD]
But it looks clogged, but the hearing's normal.

[Gopi Shah MD]
But the hearing's good.

[Ashley Agan MD]
So in a kid I would probably not do much. Well, okay. It depends. So if the parent says we've been doing great, no issues, no ear infections, speech, development's fine. School is fine. Audiogram shows normal hearing and the tube just looks clogged. I’d probably leave it alone. I'd probably just say like, let's just watch it. It's not technically really giving you any issues. Right.

In an adult, well in an adult that will let me really examine and mess with their ear. I'll probably go in there and try to pick it out. Just because I feel like if it's going to be there, I'd like for it to be working, we put it in there for a reason. But, kids are a lot different. I wouldn't want to traumatize– sometimes less is more. But if there's issues, obviously you might feel differently. So if they're having recurrent ear infections and you really want that tube to be open and working, then I would want to do something. I'd probably start with just starting drops to see if it would dissolve away that clog. I would probably use just like Floxin drops, have them do it twice a day, pump the tragus to make sure the drops are really getting all the way down there. And then kind of see them back in a short amount of time to kind of see if it's working at all. I don't know. What do you do?

[Gopi Shah MD]
I agree. I think if they're asymptomatic and hearing is good, speech is good, they're not having issues with ear infections, sometimes I'll just watch them and I’ll also give the family an option. If we want to try some floxin, Ciprodex. And you’re right, we do have to be a little more aggressive when there are issues.

Sometimes I will do a little attempt. It depends on the family and kind of what the parent is up for. Every once in a while, I'll have them try little diluted peroxide at home. So I'll have them, do you half distilled or bottled water and half peroxide. Put it in like a little cup, like a tablespoon each and then get a dropper and do like a couple of drops, three, four drops with the tragus, and then chase it with Ciprodex. And I tell the family, if the babies, if the child starts to cry, hopefully that means that the tube is open because the peroxide's going to irritate the middle ear, usually. And I might have him do that for about three to five days, unless the child starts to cry before and then just switch over to regular, Cirpodex or Floxin for another three days and then see them back and see how they look. But again, it depends, and I'll tell the family, like with the peroxide expect that they could be in a little bit of pain at home. And then see what the reaction is. And if they look at me like, I'm crazy, then we're going to just start with some Ciprodex or Floxin and see how they do. Every once in a while I'll have a family that is like, no, I want to try what you think is going to be best. And so sometimes I'll do that.

[Ashley Agan MD]
Before you move on, for the peroxide. So do you feel, do you have a thought about whether it's clogged with like what looks to be like mucus from the middle ear or some sort of like cresting versus like a blood clot, like have you ever looked in there and you see like a blood clot and it's probably from surgery and do you feel differently about how you would treat it?

(2) Treating Blood Clots from Ear Tube Surgery

[Gopi Shah MD]
That's a great question. 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.

[Ashley Agan MD]
Yeah, I feel like in adults, I feel like that's kind of what I'm picking out a lot is like this little cast, some old drainage or mucus or something that has kind of just, occupied the lumen long enough that it just stuck there. And usually I can take like a little rosen or something and just kind of slowly pick it out.

[Gopi Shah MD]
Do you peroxide and let it sit and soften it and then section and pick or does it tend to kind of work its way out?

[Ashley Agan MD]
It tends to work its way out. I don't usually put anything in there. I mean, it's all patient dependent too. Some patients just really don't tolerate you kind of flicking, because you're going to touch the tube a little bit, but those tubes, I think that that silicone material doesn't adhere to it very well. So it tends to kind of come out pretty, like if you can kind of get an edge on it and gently just tease it out, it'll slide out. But sometimes if it's like wax or something, that's been pushed down there with a Q-tip or something like that, sometimes I'll do like some baby oil. But again, I like don't want that going into the middle ear. So, it's only if the tube is like really clogged and the wax is hard enough that I'm not really able to get it out with other instruments and I just really need to soften it up. Baby oil's really good for that.

[Gopi Shah MD]
So they're in the clinic, in your chair, you do a couple of drops of baby oil. Let them sit for a little bit.

[Ashley Agan MD]
Yeah. And then just kinda try to section it out or tease it out. And then, but I've pulled out a tube before once or twice too, that happens.

[Gopi Shah MD]
I guess in your clinic, in adult, you can just put a new one in.

[Ashley Agan MD]
Exactly that. Yeah. That's what I've done if it comes out, it's like, oh, whoops. Yeah. Can we get another tube?

[Gopi Shah MD]
Yeah. And kids like, because most of the time, I mean there are people that do tubes in kids in the office with the, what is it called? The hummingbird. I always want to call it the butterfly, the hummingbird. But for my practice, I usually end up going to the OR. So the question is who, when, and why are we going? Because if we just put the tube in, I always, it always kind of makes me so sad that we're back three or four months later because it's clogged and they're still having ear infections and it's OME and it requires orals or affecting hearing or speech. And so that doesn't happen often, but when it does, I'm always like, ughh.

(3) Returning to the Operating Room

[Ashley Agan MD]
Yeah. So how long do you wait? And what's your follow-up? Let's say you see a kid and they've got a clogged tube that you just put in, I don't know, six weeks ago, three months ago, whatever it is. Are you going to try some things and bring them back every two to three weeks? And then if you're not making progress, at some point, go back to the OR? I know it's not like a clear cut answer for everyone, but kind of what's your thought process on that?

[Gopi Shah MD]
Yeah. So I used to be like, look, I'll see you back. It depends on how, obviously, like we said, if it's otherwise hearing, good sound field or good audio, Type A tymp, it's functioning normally. I might just see them back in three to six months for regular tube check. I don't get too crazy and I tell the families, Hey, if we’re back in the same cycle, recurrent ear infections, if there's hearing or speech concerns or chronic fluid, come back and see me sooner. If it's the kid where, Hey, we had tube six weeks ago, the other side is draining good. The side that's clogged has OME I might do more of a four to six week followup, because that gives me a little time to see, are we still in the same habit of infections again? Am I giving your eustachian tube an opportunity to clear? Sometimes I'll do like six to eight, even because I have to remember like every visit is time off from either work or having to figure out childcare. It's a lot of visits otherwise.

[Ashley Agan MD]
Yeah.

[Gopi Shah MD]
And it's different than chronic otorrhea. Or not chronic otorrhea, otorrhea that just doesn't get better.

[Ashley Agan MD]
Are you having them use drops that whole time?

[Gopi Shah MD]
No, I might just do it for like 10 days or something like that and see how they do. And then kind of give them an opportunity to see, does it clear on its own, does the fluid in the middle ear clear on its own? Does the eustachian tube get any better? Are we back in ear infections again? Just cause otherwise I'm going straight back to the OR and I know it's only a five, ten minute but every time it's still like, okay, I want to make sure that it's worthwhile.

[Ashley Agan MD]
And a lot of times it comes down to how we're, how worried are we? Right. What's the risk benefit ratio and what are we really treating? Because, it's easy to want to treat the tube. You want to have that pretty patent tube that's functioning and ventilating the middle ear really nicely. But I, sometimes I have to remind myself, wait, the kid's doing fine. Like don't worry just because the ear doesn't have that pretty textbook picture. if the kid's doing fine, then, there's time.

(4) New Ear Tube Guidelines

[Gopi Shah MD]
Yeah. So, which makes me kind of ask, what are your thoughts? So the new ear tube guidelines came out and one of the changes is not routinely using antibiotic eardrops at the time of ear tube placement. I think there is some flexibility in the language right. Obviously if it's pus or something, you'd probably do Cirpodex after, but after placing the tube, is it worth still doing the Ciprodex and the recommendations are no. What do you think? I mean, they just came out. I haven't changed my practice yet. I tend to do Ciprodex still.

[Ashley Agan MD]
I've been doing this in adults for a while now. Because, there was a point when Ciprodex got really expensive, and it just didn't make sense to me. Like if at the time of tube placement, if the middle ear looked healthy and not inflamed. Let's say I went to suction and it was dry. This might be for these patients who have occasional eustachian tube dysfunction related to flying, or maybe they just have some issues equalizing the pressure in their ears, meaning the tube is for kind of some intermittent eustachian tube dysfunction. And so at the time of tube placement, they don't really have pathology in the middle ear and it doesn't make sense to me to instill drops if it looks normal.

[Gopi Shah MD]
Yeah.

[Ashley Agan MD]
So I've kind of been in that habit on the adult side for a while and everything's been okay. I still send them with a prescription for Ciprodex and say if you have otorrhea, go pick this up. If you have pain or something that seems like you have an ear infection, then start the drops. So yeah, I think that that makes sense.

[Gopi Shah MD]
Yeah, I think it makes sense. I have to start figuring out how and when I would use it in my practice. So I think for let's say the kids that are recurrent. Oh, I think with the guidelines that came out, I can't remember maybe 2011 where it's like, yes, you have the number of ear infections three and six months for a year, but fluid on the day of the ENT visit. So that when you take those kids that are, I think it's still probably 50-50, whether they're going to have fluid at the time of that ear tube or not. And then, so I guess then it boils down to, is there fluid at the time of the tube? Is the fluid a lot or a little bit? Is it purulent? Do you have a lot of bleeding? Whether it's just the myringotomy and the drum is inflammed to, Hey, my canal got a little dinged and there's some bleeding. And I think I have bleeding when I put my tubes in, there's always something right. There's a little bit.

[Ashley Agan MD]
Yeah. If there's bleeding, I think I would use drugs.

[Gopi Shah MD]
Yeah, and so then the question is, so I have a colleague that does some Afrin and maybe if it's just a little bleeding or maybe a little bit of mucoid fluid, but doesn't look purulent and you felt happy with overall, it looks clinically healthy the drum in the middle ear, are those alternatives okay? Or do you really not need to do anything? And so I feel like I am out in my practice long enough to where like, oh, what, we're changing up my routine, whereas like 10 years ago, right. We stopped doing antibiotics for tonsillectomy. We stopped doing narcotics. And of course, that's just what it was. That's what I did. And now I'm like, wait what?

I appreciate the fact that the guidelines are there because the cost of drops, can be exorbitant. And if you're depending on where you're putting the tubes and whether it's a hospital setting, an outpatient surgery setting, those charges can be exorbitant. And so, in terms of practical purposes and what's actually indicated, I think it's helpful.

[Ashley Agan MD]
Yeah, I would say if I'm sectioning any fluid, if there's effusion and I'm suctioning anything, whether it's like serous mucoid purulent, I'll probably use drops. I don't know. That's my gut reflexive answer. And if there's bleeding, I'd worry more about the tube getting clogged with like a blood clot, but trying your trick with the with the half strength, hydrogen peroxide maybe you do a little Afrin at the time of surgery. And then if they come back with it clogged, then you could do the peroxide. But I don't know, you just feel so bad when that first post-op visit, you look and it is a clogged tube it's just kinda like, oh.

[Gopi Shah MD]
Can I blame the tube on that one?

[Ashley Agan MD]
Whatever you can do to prevent that from happening. I guess it's just always about weighing the risk-benefit, cost, all that kind of stuff.

(5) Managing Tube Otorrhea

[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.

(6) Decision Making for Retained Tubes

[Gopi Shah MD]
All right. What do you do with the tube that just hasn't fallen out? How long do you wait to consider it a retained tube in the middle ear? Obviously we're not talking about the external ear, but middle ear.

[Ashley Agan MD]
Like it's still in the drum?

[Gopi Shah MD]
Sorry, not medialized. I ment in the drum.

[Ashley Agan MD]
So in adults, I try to just hold their hand for as long as I can and just say, it's gonna come out, because I feel like we put tubes in in the clinic all the time and it's relatively easy and adults, it's a little harder. It's a lot harder to take them out to kind of reverse that. Cause there's not a great way to anesthetize the drum. It's kind of like a 1, 2, 3 pull kind of thing, which is uncomfortable. I suppose you could always go to the operating room to take it out which I've done on a very rare occasion. So that's not super common. So, yeah, I mean, for me, it's a lot of just like, well, let's just give it some more time. Let's give it some more time. And in most, in most adults, it's not it's not causing issues. Like if it's still there and it's still open, unless, well, so like for example, you maybe have that patient, that's wanting to learn to scuba dive this summer. And they can't have that hole in their eardrum. That might be one example of a patient that you may need to speed it up. And I don't have any tricks other than I would say, probably have to just take them to the operating room and pull it out and maybe put a little paper patch or something. I don't know. What are your thoughts?

[Gopi Shah MD]
I take it out in clinic now because I papoose them. So, first of all, if it's been about two and a half to three years, that's when I start to prep the family so that it's not like, cause I just don't want them to end up the child end up with a perforation. To me that's a bigger headache. I'd rather have to go back and put a tube in cause we took it out and they're still having issues, but usually the other ear will have declared itself. Whether the eustachian tubes are working or not. and so we've gone six to nine months without having any issues in the ear or the tube has fallen out in terms of fluid infections, things like that. And the other ear that does have the tube in the drum, and now we're getting to three years, I talk to the family. Most families don't want to do the general anesthesia for this, and if we can papoose the child, it's a band-aid, a rip right, it is quick, like you said. And the kids cry, but I find that most families are okay with doing that. Now, if I can barely get the otoscope in the kid’s ear and if the mom or dad are like, I sit down and explain it to them. Like, listen, they're going to feel this, but it's a quick band-aid. And we do have to burrito them and the child is going to cry a little bit. And if the family say, no, we'd rather go to the OR then that's where we're headed. And obviously I'm not doing like a patch or something at the time of, we're just getting the tube out, if I can get another quick look to see about the hole. And if there's bleeding that I've called that a great success.

[Ashley Agan MD]
Right.

[Gopi Shah MD]
Because every once in a while, you can't even look afterwards, you just got to get them out and then I'll see them in about three months, and see where we are and things like that. So that's I’ve been doing.

[Ashley Agan MD]
And most of the time, it just heals up fine.

[Gopi Shah MD]
Yeah. Most of the times it does. And then if we have to go back and do something, cause it's now been several months or hey the perf is now causing issues with hearing or otorrhea that changes the game a little bit.

[Ashley Agan MD]
Yeah. Maybe I need to talk to my adults about the 1, 2, 3 pull.

[Gopi Shah MD]
I used to be a lot more hesitant, but, I got to talk to Dr. Mitchell, every episode. Dr. Mitchell, hello. He just does it in clinic and I'm like, well, man, if Mitchell can do it in clinic, then come on. Let's do it. So if the boss is doing it…

[Ashley Agan MD]
Yeah. I bring it up to patients as far as like we can, we can take it out, it hurts a little bit, or maybe a lot. I don't know. I haven't experienced it myself, but, I think in a lot of them, if it's not an issue, it's just like, okay, that's fine. We'll just wait. Adults, it's a lot different than kids. I feel like. and so we just give it a little bit more time and most of the time it will fall out eventually.

[Gopi Shah MD]
What about granulation that starts to form around the tube?

[Ashley Agan MD]
Oh man. That's such a pain. Why we gotta talk about that? So when I see that sometimes I'll just try to start some sort of steroid drop. Sometimes depending on where it is, if it's blocking the lumen of the tube I will try to like grab it with some cups and try to like, kind of de-bulk it. It will bleed. Yeah. It bleeds. I spend another 15 to 30 minutes messing with it and suctioning and, it can be a real headache. Yeah. I dunno. I would love for you to share some pearls.

[Gopi Shah MD]
Oh, God, I wish I had some pearls.

[Ashley Agan MD]
Tell me all your secrets.

[Gopi Shah MD]
Yeah right. So I think that when it’s sort of around or coming through. If there's drainage, I'll try to section, if it's huge, I might try to remove it. Ciprodex. For those, I might even do oral antibiotics to cool it down. The one thing with any sort of granulation or anything like that I just want to make sure I'm not missing something like cholesteatoma. Sometimes that can be a red herring. It's not always, it might just be a bad infection, but those always can make me a little nervous, like am I missing? So I really would try to cool it down so that I can see if there's any skin, things like that. If the tube has been there a long time, over two, three years, and we're dealing with us every once in a while, I might just take the tube out maybe. I might try to cool it down for see how they look when they come back and get it out. Cause it could be now acting a little bit more like a foreign body type reaction. Also, kind of give you a better exam if I am worried about something like cholesteatoma. Those are tough and they're hard to cool down, hard to get an exam, they bleed. And then in the back of my mind, that's when my, like am I missing anything else? kind of starts so in those patients, I’ll see back in two to three weeks and kind of make sure they know what I'm thinking about too, because I don't want them to be like, all right? Bye. And then like, here we are with something else that’s an issue later on, but they'll usually come back. Because they're going to have symptoms from it or something.

(7) Tube Replacement and the Use of Biofilm

[Ashley Agan MD]
One thing I'm into that, I was thinking of asking you earlier, the concept of a thought of like biofilms and so like a patient having a tube, let's say it's been there for a while, maybe a little over a year, longer than it should. And, the patient still has eustachian tube dysfunction still needs a tube. Do you ever change it out? Or this is a common example, patient has had bilateral tubes. One tube has extruded. The other tube is still there. It's been there for like maybe over a year. It's fine. You're going to the OR anyway, cause you're going to put a tube in the other ear. So do you need to replace that tube with a new tube because it's an old tube?
[Gopi Shah MD]
Those are great questions. And it's funny cause those are the conversations I have with the residents, right? Like, cause this is the stuff they have to think about. Like this is actual decision-making in clinic, which sounds so simple because we think of just, oh, it's just a tube, but like it's not right. So in terms of biofilms, so I think in pediatric, especially in kids that are young with tube otorrhea, if it's just doesn't go away before I go back and switch stuff out and that kind of stuff, I might send them to immunology. I might think of something else, like sweat test, PCD, other stuff. CF doesn't have it as much in terms of OME, but, PCD would and just like what are we missing or is it just like you're kid that gets six to eight colds a year. And so. I tend not to necessarily go switch tubes out for biofilms for those reasons. And I do think that oral toilet is our best friend for that. Cause if I put a new tube in, we might still be in the same situation afterwards. Cause we're still 15 months in a daycare or not daycare, and we're just getting these. In terms of biofilms for tubes that have been sitting there for four or five years in a PCD kid that I'm going to the OR with, if the tubes are working, I kind of want to leave those alone too. I've had issues where maybe we try to put a new tube in. It gets pushed out. You know what I mean? That's happened. And so I don't always do that. I know I keep talking about my PCD kids, but that’s their issue is tubes and otorrhea. And then in the child where the left ear tube is out, the right tube is open and working, but the left ear keeps getting OME or acute OMs and it's been a year. I talk to the family, and I say, I guess my concern is I've had issues. One where if I try to replace the tube, taking a good tube out can make the perf bigger and then I can't get a tube in, that's happened. And that's really frustrating. And then the second thing is if I'm putting a new tube in, I have to remember that that perf now has been there a year plus however long that tube may be. So I don't forget about it because I don't want that child to end up with a perf after. And so I always tell him, like, if it looks good, it doesn't look like it's halfway out. It's not blocked. It's in a decent spot, meaning it's inferior or at six o'clock, whatever, it looks good. I hedge on leaving it alone and tell the family, listen, you might be frustrated with me three to six months down the line. Cause we may or may not have to go back, but maybe by then, the kid is two and a half, three, closer to four and I don't know if they were my own kid, I'd rather go back for an ear tube than end up with a perf. Perfs to me in kids are just a much bigger issue, especially under five. It's not just otorrhea, but it's hearing, speech. Whether they end up having to get a typanoplasty, postdoc care, success rate like that should be our next podcast.

[Ashley Agan MD]
Yeah.

[Gopi Shah MD]
That's kind of how I phrase it. Now, I know I have partners that routinely switch them out, just cause it's like, well, we're going to the OR, but that's just my personal preference, I think. I don’t know.

[Ashley Agan MD]
Yeah. I've had that same feeling before where you pull out a perfectly good but “old” tube, and then when you put the replacement tube in, that hole, it's too big. Right? It's big. And so you're like maybe putting a piece of gel foam or something to just kinda give you some extra, something to hold it in place. Because it just looks like it's just sitting there kind of on the edge of a big perf.

[Gopi Shah MD]
When you take a tube out, there might be a little wax on the drum. and so when you take the tube out, some of the drum comes with you or it’s just the bottom, the medial end of it, kind of. And I like that the fact that when you pull a tube out, it refreshes the edges, right? Like the act of pulling it out kind of is that sort of freshening it up for epithelialization, but man, and then you end up with something bigger. Can't get anything in. And I've had kids that end up with perfs. I'm just like, ugh, gosh, why? So I don't know. That's just my personal, opinion on it.

[Ashley Agan MD]
Yeah, but you're right. It's a conversation to have with the family and a lot of medicine is that shared decision-making and depending on the kid maybe, the the risk of a second anesthesia event in three months is really a big deal.

[Gopi Shah MD]
And maybe, they're a malignant hyperthermia family history or a cardiac kid, or absolutely. Absolutely.

[Ashley Agan MD]
There's not a one size fits, right?

(8) The Role of T Tubes

[Gopi Shah MD]
Yeah. Okay. Really quickly. Just a yes, no. T tubes, no T tubes? You don't have to do a yes or no.

[Ashley Agan MD]
Most of the time, no. I don't like them that much. But in the right patient, there are some patients where maybe it's worth a try. Like I put in a T tube the other day in a patient who, she had a skull based tumor that basically, caused her, eustachian tube to be obliterated on one side after her surgery and radiation, everything like that. So she basically does not have a eustchian tube on one side. Is always going to need a tube. And so, we talked about the benefits of having a T tube and it being there being able to stay in longer and blah, blah, blah, and the risk of it causing a perforation compared to like a smaller Paparella tube or something like that. She's one of those patients who has a lot of anxiety with even just looking in the ear and so getting her to put a tube in clinic was a big feat. There was a lot of like handholding and like talking her through, allowing me to do that. And so it was just like the best plan was like, okay, this is potentially a one time thing that we can do that will last us longer. Maybe it causes a perf if it does cause a perf maybe that wouldn't be such a bad thing because you don't have a eustachian tube. If it causes some hearing loss, you kind of need hearing aids anyway, because you've got some sensory neural loss as well. But it was a long conversation. Because as you're alluding to, T tubes are not my favorite thing. Because I always think about the times when I put in a T tube and I see patients back in clinic and it's just sitting in a perf. It's there, but it's just kind of got this spotlight on it. The perf, it's just sitting right there. Yeah, it's kind of cringy. What are your thoughts?

[Gopi Shah MD]
Initial gut. Yeah, I don't like them. No. But I think what you described as like patient selection is probably the most important thing. I used to kind of be like, well, if it's been more than three or four sets and they’re six to eight years old, that might be something to consider and I was a lot more open to them. But I agree. I find that they leave really big perforation sometimes. Usually those kids that are having that many sets of tubes have really thin eardrums. They're pretty atrophic. And so when you're trying to get the T tube in, everything kind of tears apart, I feel like and then I don't know how much of a service I'm doing.

And so I tend to lean away from them. That being said you do have a handful of kids that have had a history of radiation to the head and neck, and so that might be somebody to consider them in. But, it just depends. I agree. That's one where it's a good conversation with like, we need to sit down because parents will ask, Hey, I want those permanent ones. I want those the ones that are the permanent ones. And, I kind of tell them some of the issues that can come along with them. But yeah, I think there's a role. But, it's gotta be discussed and thought out, I think.

[Ashley Agan MD]
Yeah, for sure.

[Gopi Shah MD]
This was a very stimulating conversation on the management of tubes.

[Ashley Agan MD]
I'm impressed that, that we were able to talk about so much. I guess there's more to it than you think.

[Gopi Shah MD]
And I'm sure there's other things. If there's anybody out there that has more on the management of ear tubes or other common ENT things that sometimes is practice dependent, what you see, these conversations I think are great. Reach out to us.

[Ashley Agan MD]
Yeah, I'm sure hopefully we'll get feedback from people about all the different ways these topics can be managed. Because it's one of those things that's just so common and probably depending on where you practice and your resources and all those kinds of things, it, affects how you manage it. But good idea. I think this was great. Shall we put a pin in it? Shall we land this plane?

[Gopi Shah MD]
I think this plane is ready to land. I think it is. I've been trying to say that in all the prior ones, it just doesn't sound as good. I'll leave that to you.

[Ashley Agan MD]
Well, it's been a pleasure. Always a pleasure to spend my weekend mornings with you.

[Gopi Shah MD]
Likewise Ash. Likewise. You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter @ _BackTableEMT. We'd love feedback. Reach out to us for topics, ideas, speakers, if you ever want to come on the show. And I think it's a wrap Mamacita.

[Ashley Agan MD]
Yes. That's a wrap, like, subscribe, share. That's a wrap. We'll see you next time.

Podcast Contributors

Dr. Ashley Agan discusses The Ins and Outs of Ear Tubes on the BackTable 61 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses The Ins and Outs of Ear Tubes on the BackTable 61 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2022, June 7). Ep. 61 – The Ins and Outs of Ear Tubes [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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