Ear Tubes

If your child has frequent ear infections and tends to retain fluid in the middle ear between infections, has chronic fluid build-up in the middle ear, or has hearing or speech problems related to fluid and infections in the ears, your child’s doctor may recommend ear tubes.

Ear tubes are tiny cylinders, usually made of plastic and sometimes metal, that are surgically inserted into your child’s eardrum. These tubes allow air to flow in and out of the middle ear, which prevents the development of negative pressure as well as fluid build-up. Ear tubes may also be called tympanostomy tubes, myringotomy tubes or ventilation tubes.

Ear tube surgery, also known as tympanostomy tube insertion surgery, is the most common childhood surgery performed in the United States. Surgeons in the Division of Otolaryngology at CHOP surgically implant ear tubes in more than 4,000 children each year.

The ear tube insertion surgery is performed under general anesthesia and takes on average eight to 15 minutes. After a brief recovery in a post-operative unit, most children will be sent home the day of surgery.

The average age for ear tube insertion is 1 to 3 years, but babies can get ear tubes as young as 6 months.

Ear tubes are generally extruded (forced out naturally as the child’s ear grows) from the ear drum anywhere from six to 18 months after insertion. If the tubes fall out and your child still has frequent ear infections, continues to accumulate fluid, or his eardrum collapses again, he may need to have the tubes reinserted.

Middle ear infections and fluid are thought to result from problems with a child’s eustachian tube — the tube that connects the open space behind the nose (the nasopharynx) to the middle ear space. The eustachian tube permits air to ventilate the middle ear and allows the drainage of normal ear fluid into the nasopharynx.

A child’s eustachian tube is narrower, shorter and more horizontally positioned than an adult’s. These normal anatomy issues mean children have inherently poorer eustachian tube function, which causes inadequate ventilation and drainage from the eustachian tube. With decreased ventilation and drainage, children can become prone to developing negative pressure and fluid build-up, which leads to frequent ear infections.

Ear tubes are often recommended for children with:

• Frequent middle ear infections (chronic otitis media) that are difficult to treat with antibiotics, especially if children retain fluid in between the infections.
• Hearing loss caused by the build-up of fluid in the middle ear (otitis media with effusion)
• A collapsing ear drum, a condition known as atelectasis. In children who have had chronic negative pressure, the ear drum can, over time, stretch, thin out and collapse onto the ossicles (the three small bones that transmit sound) of the middle ear, the floor of the middle ear, or both. The pressure exerted on the ossicles can lead to permanent bony erosion and a conductive hearing loss.

Ear tube surgery is not recommended for every child with an ear infection or fluid build-up in the ear. In many cases, antibiotics or other treatments will be best suited for children with occasional ear infections.

However, if your child has multiple ear infections, talk to your child’s doctor about whether ear tubes may help her. Surgeons at CHOP will recommend tubes only if they feel the benefits clearly outweigh the risks of placing the tubes.

The general guidelines our surgeons use are:

• Three or more infections within six months, especially if the child tends to retain fluid in between episodes
• Fluid that is always present over a period of three months with diminished hearing
• A collapsed drum that is draped onto the middle ear bones, causing decreased hearing, the potential for eroding those bones, or both

Frequent ear infections can lead to decreased hearing, speech and balance problems and changes to the child’s ear drum. The benefits and risks of ear tube insertion, however, are different for each child. It is important to discuss all of the benefits and risks with your child's healthcare provider and jointly decide what is best for your child.

Benefits

Ear tubes can:

• Reduce the risk of future ear infections and the need for repeated courses of oral antibiotics. Even if your child develops an ear infection with tubes in place, many of these infections can be treated by putting antibiotic drops in the affected ear rather than having to resort to oral antibiotics.
• Improve hearing or correct hearing problems caused by the presence of either fluid or negative pressure.
• Improve speech development.
• Correct balance issues.
• Improve behavior, sleep and communication problems caused by chronic ear infections.
• Decrease the pain of an ear infection by eliminating the pressure (either positive or negative) that occurs during a middle ear infection or fluid build-up.

Risks

Ear tube placement is one of the most common childhood surgeries, with a low risk of serious complications. As with any surgery, there are still risks that need to be fully considered before deciding if ear tubes are the best option for your child.

Generally speaking, tubes remain in the eardrum (the tympanic membrane) and provide improved ventilation of the middle ear and do not require any further intervention other than routine follow-up in clinic. The first post-operative check usually occurs at six to eight weeks. Your child is then usually evaluated every six months until the tubes have extruded (been forced out) and the ear drums have healed.

Risks during and shortly after the operation include:

• Typical risks of general anesthesia (i.e. allergic reaction, breathing or heart irregularities, or nausea and vomiting after surgery)
• Bleeding, which can plug the tube’s opening
• Infection
• Fluid drainage

Tubes are not perfect and may cause a number of the following problems after they are placed:

• They may fall out earlier than expected. This typically occurs when a child has an ear infection shortly after the tubes are placed.
• They may become plugged with dried ear fluid, blood or debris, and they may need to be cleared or replaced.
• They may fail to extrude from the ear drum and need to be surgically removed after two to three years.
• They may fall out and leave a hole in the ear drum. This is typically the result of the ear drum being in poor condition and not having sufficient healing capacity to close the small incision site in the ear drum (the myringotomy site) after the tube has fallen out. Extremely thin drums or drums with a lot of scar tissue (known as myringosclerosis) have a harder time healing. If this occurs, your child’s doctor will wait to see if the perforation will spontaneously close. If it fails to close, another operation to repair the hole (paper patch, myringoplasty or tympanoplasty) is typically recommended.
• Very rarely, a tube may fail to extrude and, instead, fall into the middle ear, despite having been properly seated in the ear drum for months. This is typically addressed surgically by making a small incision in the ear drum (myringotomy) and removing the tube from the middle ear.
• After extrusion, the ear drum may be thinner at the tube site. Usually this does not cause any problems. 
• A common misconception is that tubes can cause scarring of the eardrum. The scarring of the drum (tympanosclerosis, myringosclerosis) is caused by the repeated exposure to inflammation (infections), not by the tubes themselves.

A surgeon who specializes in ear, nose and throat conditions will perform your child’s ear tube placement procedure. In most cases, this is an outpatient surgery, which means your child will have surgery and go home the same day.

Before your child’s surgery, you will meet members of the healthcare team who will be involved in the procedure, including:

• Otolaryngologist — an attending surgeon from the Division of Otolaryngology who will place the tubes.
• Anesthesiologist — a physician who will give your child anesthesia and monitor your child during the procedure.
• Nurses who care for your child before, during and after surgery. Operating room nurses assist the surgeon during the procedure; recovery room nurses care for your child as she recovers from general anesthesia.

Your child’s tympanostomy will be performed under general anesthesia. The procedure usually takes eight to 15 minutes, though your child will need more time to recover from general anesthesia.

You will typically meet a preoperative nurse as well as your child’s surgeon and anesthesiologist prior to the operation. They will evaluate your child to make sure she is fit for her operation. If you have any last-minute questions, this is a good time to ask them.

An operating room nurse will come to meet your child and escort her to the operating room. The anesthesiologist will place some stickers on your child’s skin to monitor her heart rate and oxygen levels. The anesthesiologist will also place a blood pressure cuff to monitor your child’s blood pressure during the procedure.

Your child will receive anesthetic medication that is either inhaled through a breathing mask (most common) or administered through a vein. Your child will be asleep within a minute of receiving the medication and will not be aware of the operation.

During the procedure, the surgeon will use an operating microscope to:

• Remove wax and debris from the ear canal and examine the ear drum.
• Make a small incision in your child’s eardrum (called a myringotomy); there are no skin incisions during this operation.
• Suction the fluid from the middle ear.
• Insert the tube into the myringotomy, allowing air to flow in and out of the middle ear and preventing the development of negative pressure.

After the procedure, your child is woken up in the operating room. She will then be moved to a recovery room where nurses and doctors will monitor her recovery.

While your child is recovering, she may be irritable or sleepy. You will be able to stay with your child in the recovery room to soothe and reassure her as she recovers. Some children may also be nauseated after sedation.

Most children can go home one to two hours after surgery, though they may continue to be sleepy, irritable or nauseated for the rest of the day. Your child should be able to resume her normal activities within 24 hours of the ear tube insertion.

If you and your child’s doctor agree that ear tube insertion is the best treatment for your child’s condition, you will receive instructions about how to prepare your child for surgery and how to care for your child after the procedure.

Detailed instructions will include:

• When you should arrive at the Hospital or one of CHOP’s ambulatory surgical centers (ASCs)
• Where you should check in
• What you should bring with you (including a baby blanket, pacifier or favorite toy that may help soothe your child)
• When your child should stop taking medications before surgery
• How long your child should fast before the procedure and anesthesia
• How long the procedure will take
• Expected recovery time

If you have any questions about your child’s procedure, please talk to your child’s healthcare team.

Follow-up care 

Before your child is discharged, you will receive instructions about how to care for your child at home, what to expect and when to call the doctor. We’ll schedule a follow-up appointment for six to eight weeks after your child’s surgery. You’ll also be asked to schedule follow-up visits typically every six months thereafter until the tubes fall out.

• Antibiotic ear drops are recommended for five to 10 days, starting the day of surgery and after significant water exposure.
• Bathing is allowed.
• Since approximately 2 feet of water pressure is required to drive fluid through the small tubes, swimming is usually not a problem, unless your child likes to dive under water.
• Lakes, rivers and hot tubs tend to have higher bacterial loads — ear plugs may be recommended in those instances.
• Postoperative hearing tests are often considered if hearing loss was a concern before the procedure. Generally speaking the tubes are first checked to make sure they are in good position before ordering the hearing test.

Please call your child’s surgeon if your child experiences any of the following:

• Persistent or increased drainage from the ear more than a week after surgery
• Bloody, yellow or brown discharge from the ear that lasts more than three days
• Ear pain
• Hearing or balance problems
• Fever
• An ear tube moves or falls out

For most young children, ear tubes are highly effective at treating chronic ear infections and middle ear fluid. It’s important to note, though, that about 1 in 4 children who receive ear tubes before age 2 may need the tubes reinserted until their eustachian tube function matures sufficiently to provide adequate middle ear ventilation and drainage.