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JohannaNokso-Koivisto
PaulaTähtinen

Tympanostomy Tubes

Essentials

  • The most common indications for insertion of tympanostomy tubes (ventilation tubes, grommets) are persistent middle ear fluid (over 3 months) Otitis Media with Effusion (Glue Ear), and recurrent acute otitis media (AOM) .
  • Insertion of tympanostomy tube cures the hearing loss caused by middle ear fluid.
  • The insertion of tympanostomy tubes will probably not reduce the frequency of recurrent AOM but may relieve symptoms of inflammation and make it easier to diagnose infections.
    • Tympanostomy tubes are most beneficial for children in whom middle ear fluid does not clear between recurrent AOM episodes.
  • Problems associated with tympanostomy tubes may include inflammation and otorrhoea due to the tube, a blocked tube or persistent tympanic membrane perforation.
  • During an AOM episode, an ear with a tympanostomy tube will leak fluid (otorrhoea). In such a case, the primary treatment is ear drops.
  • If an open tube does not leak fluid, there is no middle ear infection, even if the tympanic membrane appears abnormal.

General remarks

  • A tympanostomy tube is usually made of silicone or titanium. The tube is typically inserted in the anterior inferior quadrant of the tympanic membrane, at the site of the light reflex.
  • The mean time tympanostomy tubes remain in place is from 6 to 18 months and they are expelled spontaneously.
  • Of children with tympanostomy tubes in situ, as many as more than half will have one or more episodes of AOM (tympanostomy tube otorrhoea) at some stage.

Indications

  • The insertion of tympanostomy tubes can be considered if
    • AOM has reliably been diagnosed 4 or more times in 6 months or 5 or more times in a year (see article Recurrent acute otitis media and its prevention Recurrent Acute Otitis Media and its Prevention)
    • middle ear effusion has persisted for over 3 months (see article Otitis media with effusion (glue era) Otitis Media with Effusion (Glue Ear))
    • there is persistent, highly negative pressure in the middle ear, causing stretching of the tympanic membrane.
  • The decision to proceed with surgery should always be made individually, considering any benefits and harms.
  • The need for insertion of the tubes is influenced by risk factors for otitis media (such as predictedexposure to infections in the near future, age) as well as by uni- vs. bilaterality of the effusion (unilateral effusion can be monitored for longer).
    • In the spring, for instance, the exposure to infections will be low during the next few months and recurrent infections may therefore end and middle ear effusion resolve during the summer.

Benefits and risks Grommets (Ventilation Tubes) for Recurrent Acute Otitis Media in Children

  • Benefits
  • Risks
    • The tube may cause an infection or granulation tissue or polyp formation on the tympanic membrane (see below tympanostomy tube otorrhoea).
    • There may be permanent tympanic membrane perforation after the tube is expelled.
    • Water and bacteria may enter the middle ear via the tube. However, protecting ears against water whilst swimming does not reduce the incidence of infections Swimming with Tympanostomy Tubes. Routine protection from water is not necessary unless the patient does deep diving.
    • Atrophy or scarring may develop on the tympanic membrane (so-called myringosclerosis, a white plaque present on the tympanic membrane); rarely causes functional impairment.

Follow-up

  • The doctor carrying out the procedure is responsible for the follow-up instructions.
    • The typical interval between follow-up appointments is 4-6 months, until the tubes no longer remain in place.
    • Tympanometry is a good tool for examining an ear with a tympanostomy tube in place Tympanometry.
  • Removal of a tube should be considered in specialized care if it is still in place 2 years after insertion (increased risk of persistent tympanic membrane perforation).

Tympanostomy tube otorrhoea

  • In association with an upper respiratory tract infection, ears may discharge mucus or AOM may develop, causing purulent ear discharge.
  • The risk factors for an acute middle ear infection associated with tympanostomy tubes Otitis Media in Children: Risk Factors and Pathogenesis are the same as those for any other AOM; the causative bacteria are likewise the same (Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis as well as Streptococcus pyogenes).
  • Particularly in older children, the proportion of infections caused by Pseudomonas aeruginosa and Staphylococcus aureusis higher. These pathogens usually enter the middle ear through the ear canal, typically in association with water exposure.

Treatment of tympanostomy tube otorrhoea Interventions for the Prevention of Postoperative Ear Discharge after Insertion of Ventilation Tubes (Grommets) in Children

  • Bacterial culture should readily be taken before treatment is started.
  • Any secretions should be removed by either rinsing or suction or with a cotton swab.
  • Topical antimicrobial drops for 5-7 days is the first-choice option, since topical treatment is more effective than oral antimicrobial therapy and it has fewer adverse effects than oral antimicrobials Antibiotic Eardrops Compared to Oral Antibiotics for Tympanostomy Tube Otorrhoea in Children 3.
  • Instructions for parents/guardians: with the child lying on its side, gently pull back the earlobe in order to straighten the ear canal. Pushing on the tragus (i.e. applying tragal pressure) after the drops have been administered will aid deeper penetration. A sufficient amount of drops should be administered so that some reach all the way to the middle ear.
  • Oral antimicrobials should be considered Interventions for Ear Discharge Associated with Grommets (Ventilation Tubes) if otorrhoea continues despite ear drops for over a week or if the child has severe symptoms. Take into account other possible foci of infection, too.
  • When is treatment by a specialist indicated?
    • If otorrhoea persists for more than one week despite a course of an antimicrobial drug based on susceptibility testing.
    • If there is prolonged otorrhoea (over 3 weeks).
    • If granulation tissue on the tympanic membrane or around / on top of the tube does not resolve after a one-week course of ciprofloxacin + fluocinolone acetonide drops (checkup 2-4 weeks after beginning treatment).
    • If there is a suspicion of a complication (e.g. mastoiditis, facial paralysis)
    • If there are frequent episodes of AOM (recurrent tympanostomy tube otorrhoea)
    • Whenever considered appropriate in children with pre-existing hearing impairment, an underlying disease affecting the immune response, or immunosuppressive medication, for example

Tympanostomy tube obstruction

  • A tympanostomy tube may become obstructed by mucous or purulent discharge from the middle ear or by blood oozing after tube insertion.
  • Ear drops may be used (e.g. one single-dose dropper with chloramphenicol drops twice daily for one week) to try to dissolve the obstruction. An ear specialist can try to remove the obstruction mechanically.
  • If no effusion develops within the middle ear and episodes of AOM do not recur, the obstruction needs no further intervention. If more than 6 months have passed since tube insertion, the obstruction may be due to the expulsion process (tympanic membrane tissue penetrating the tube), and the tube cannot be opened by courses of ear drops. If so, normal expulsion of the tube can be awaited, and the next checkup can be performed in 6 months.

    References

    • Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg 2022;166(1_suppl):S1-S55 [PubMed]
    • Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. N Engl J Med 2021;384(19):1789-1799 [PubMed]
    • van Dongen TM, van der Heijden GJ, Venekamp RP, et al. A trial of treatment for acute otorrhea in children with tympanostomy tubes. N Engl J Med 2014;370(8):723-33 [PubMed]
    • Ruohola A, Meurman O, Nikkari S, et al. Microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses. Clin Infect Dis 2006;43(11):1417-22 [PubMed]
    • Carbonell R, Ruíz-García V. Ventilation tubes after surgery for otitis media with effusion or acute otitis media and swimming. Systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2002;66(3):281-9 [PubMed]