An overview of ear tubes
- 1 An overview of ear tubes
- 1.1 Types of ear tubes
- 1.2 Who needs ear tubes and why?
- 1.3 How to place an ear tube in eardrum?
- 1.4 What are tympanostomy tubes?
- 1.5 Technology of tympanostomy
- 1.6 What is the procedure of tympanostomy tubes?
- 1.7 Anesthesia during procedure
- 1.8 What are the indications of tympanostomy tube treatment?
- 1.9 What are the anticipated outcomes of tympanostomy?
- 1.10 What are the consequences and adverse events associated with tympanostomy?
- 1.10.1 Tympanostomy tube otorrhoea associated with tympanostomy tubes
- 1.10.2 Cholesteatoma associated with tympanostomy tubes
- 1.10.3 Blockage of tube lumen associated with tympanostomy tubes
- 1.10.4 Granulation tissues associated with tympanostomy tubes
- 1.10.5 Premature extrusion associated with tympanostomy tubes
- 1.10.6 Tympanosclerosis associated with tympanostomy tubes
- 1.10.7 Persistent Perforation of the Tympanic Membrane associated with tympanostomy tubes
- 1.10.8 Atelectasis and Retraction Pockets associated with tympanostomy tubes
- 1.10.9 Harms of Anesthesia associated with tympanostomy tubes
- 1.11 What are the costs of the tympanostomy procedure?
- 1.12 What are the comparator treatments of tympanostomy tube insertion?
- 1.13 Watchful waiting or delayed tube insertion versus tympanostomy tubes
- 1.14 What to do the day of surgery?
- 1.15 Myringotomy versus tympanostomy tubes
- 1.16 Adenoidectomy versus tympanostomy tubes
- 1.17 Antibiotics versus tympanostomy tubes
- 1.18 Other medications versus tympanostomy tubes
- 1.19 Auto inflation of the Eustachian tube versus tympanostomy tubes
- 1.20 Complementary and alternative medicine treatment versus tympanostomy tubes
- 1.21 What are the clinical outcomes of tympanostomy tube insertion?
- 1.22 Other functional and quality of life outcomes
- 1.23 Number of office visits associated with tympanostomy tube treatment
- 1.24 Possible complications during tympanostomy
- 1.25 Can you swim with ear tubes?
- 1.26 How many ear infections before tube should be put in?
Ear tubes come in different length, diameter and different angle to accommodate various patients. There may be some different indications such as co-morbidity, age, operator ease, and how long the tubes will remain in place. There are two types of tubes are invented, short term and long term. Short term ear tubes are intended to last less than 15 months whereas the long term ear tubes are intended to last greater than 15 months. Devices or ear tubes with small grommet or bobbin can fall out more quickly as compared to the large flanges, for example, T tube. T shaped tube has one large flange which is usually not affected y the epithelial mass build up on the outer side of the tympanic membrane. Some tubes are designed to be easier to grip and maneuver for the operator during insertion, including the Shah Ventilation tube. Sometimes tubes fall out due to the keratin accumulation in between the tube flange and tympanic membrane surface. This makes the tube to force out naturally.
Types of ear tubes
Ear tubes are made up of the material of plastic, metal or biocompatible ceramic. Ear tubes come in different length, diameter and different angle to accommodate various patients.
There may be some different indications such as co morbidities, age, operator ease, and how long the tubes will remain in place. In order to treat the disease like otitis media, there are 100 FDA approved tympanostomy tube devices are available. Some manufacturers of FDA approved devices are Exmoor Plastics Ltd., Xomed-Treace Inc., and Treace Medical. Commonly used ear tubes types include:
Shepard tube also known as “Sheppard”. These tubes are made up of fluoroplastic and manufactured by Xomed Inc. This ear tube is a grommet style tube which has a shape of an hour glass. It needs to eject out between 6 to 10 months.
Shah Tubes are a grommet-style tube with a single circular beveled flange, with a mean extrusion time of greater than 12 months. These tubes are made of fluoroplastic and polyethylene and are manufactured by Exmoor plastics, Ltd.
Armstrong tubes are a grommet-style tube with one 90 degrees flange and one angled flange. They have a mean extrusion time of 16.5 months. Made from fluoroplastics and polyethylene, these tubes are manufactured by Treace Medical, Inc.
Donaldson tubes are a grommet-style tube with two equally-sized flanges and have a mean extrusion time of 11 months. These tubes are made from silicone or fluoroplastic and are manufactured by Xomed, Concept, Inc.; Treace Medical, Inc.; and Exmoor Plastics, Ltd.
Bevel Bobbins are a grommet-style tube with one flared flange and are similar to a collar button tube. These tubes are made from fluoroplastics and silicone and are manufactured by Baxter, Reuter, and Circon/Gyrus ACMI.
Who needs ear tubes and why?
Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by persistent middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, poor school performance, or changes in the structure of the ear drum. Other less common conditions that may warrant the placement of ear tubes are malformation of the ear drum or eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure, usually seen with altitude changes as in flying and scuba diving).
Each year, more than half a million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age for ear tube insertion is one to three years old. Inserting ear tubes may:
- Reduce the risk of future ear infection;
- Restore hearing loss caused by middle ear fluid;
- Improve speech problems and balance problems; and
- Improve behavior and sleep problems caused by chronic ear infections; and
- Help children do their best in school.
How to place an ear tube in eardrum?
A variant of ear tube replaced with a traditional plastic ventilation tube due to successful ear of antibiotics. Ear tube insertion is very frequent in children in the United States.
- A plastic grommet is inserted and is made to remain within the tympanic membrane.
- It prevents the earlier closure of incision that made with myringotomy.
- These grommets are tiny and easily tolerated by the tympanic membrane.
- The main function of this plastic grommet is to maintain a ventilator port for middle ear space for almost 1 to 2 years.
- Your surgeon may describe the shape and size of ear tube that needs to be inserted as per the anatomy of the ear of a patient.
- Alternatives to ear tube insertion are myringotomy and tympanocentesis.
What are tympanostomy tubes?
Tympanostomy tubes, ventilation tubes, pressure equalization tubes are known as ear tubes, which are tiny, hollow cylinders made up of plastic material or metal. These tubes are designed to be inserted in the eardrum. The main function of these ear tubes is to create an airway that ventilates the middle ear and also it prevents the accumulation of fluids behind the eardrum. The another main purpose of the ear tubes is to drain out the fluid that is caused due to the severe disease like chronic Otitis media effusion or recurrent acute otitis media.
The children who have persistent fluid buildup behind the eardrum that causes hearing loss and affects speech development needs to undergo the ear tube procedure. If your child gets frequent ear infections, his/her pediatrician will recommend you for ear tubes. The insertion of the ear tube is carried out by making a hole in the eardrum; most ear tubes fall out within six to nine months. The holes that created to insert the ear tube will heal on their own. In many cases, these ear tubes need to be removed and some holes need to be closed by surgical methods.
Technology of tympanostomy
Tympanostomy tube insertion method is mainly used for the treatment of otitis media. Approximately 667,000 children undergo this treatment every year. These ear tubes are usually 1 mm in diameter. Ear tubes are beneficial in alleviating the symptoms of otitis media by effectively equalizes the middle ear pressure with atmospheric pressure and allow fluid drainage.
What is the procedure of tympanostomy tubes?
The main purpose of the ear tubes is to drain out the fluid that is caused due to the severe disease like chronic Otitis media effusion or recurrent acute otitis media. The procedure of tube insertion is of 10 to 15 minutes in which tubes are inserted unilaterally or bilaterally. Normally general anesthesia is used for tube insertion in the pediatric population.
- After the administration of anesthesia, an incision is made on the tympanic membrane by the surgeon; this procedure is called as myringotomy.
- The tympanic membrane has multiple locations which are used by a surgeon for tube insertion. Tubes inserted anteriorly or superiorly do not cause any significant difference in tube retention time.
- The most common insertion site is pars tensa, whereas a site named posterosuperior quadrant is rarely used.
- Before tube insertion, surgeons usually withdraw the fluid persisting in the middle ear.
- The tube is inserted after myringotomy, through the tympanic membrane and it is held in place by the flanges, these flanges are located on inner and outer surfaces of the tympanic membrane respectively.
- The tube once inserted in the tympanic membrane, it holds the incision open and ventilates the middle ear.
- At the time of tube insertion, there may be a chance of complications such as discharge from ear called as otorrhoea.
- In order to prevent the condition like otorrhoea, prophylactic antibiotic drops or corticosteroids can be used.
Exact time to remove the tube from ear tube depends upon the model of tube used. Children are needed to revisit the clinic every 4 to 6 months for checking the proper functioning of the tubes. Time to time checkups helps the doctor to check the middle ear status, detect any anatomical changes to the middle ear, and to recheck the efficacy of the ear tubes in order to treat otitis media.
Tympanostomy tubes, ventilation tubes, pressure equalization tubes are known as ear tubes, which are tiny, hollow cylinders made up of plastic material or metal. These tubes are designed to be inserted in eardrum. The main function of these ear tubes is to create an airway that ventilates the middle ear and also it prevents the accumulation of fluids behind the eardrum. These ear tubes are mainly used for the treatment of the disease such as acute otitis media, otitis media with effusion, and recurrent otitis media with effusion etc.
After the conditions like respiratory tract infections, otitis media (OM) also known as Middle ear inflammation another common childhood ailments that diagnosed most frequently. Approximately 63% of the children by the age one, had at least one episode of OM. otitis media is the condition that resolves spontaneously, but sometimes children may have more than three episodes of otitis media with effusion (OME) by the age 3. Due to the high prevalence of otitis media in the population, the short term and long term effects are quite significant.
Anesthesia during procedure
The surgeon usually performs the procedure during general anesthesia, so your child isn’t aware of anything during the procedure. The anesthetic medication may be inhaled through a mask, injected into a vein or both, and is administered by a doctor who practices anesthesia (anesthesiologist).
The surgical team places several monitors on your child’s body to help make sure that his or her heart rate, blood pressure and blood oxygen remain at safe levels throughout the procedure. These monitors include a blood pressure cuff on the child’s arm and heart-monitor leads attached to your child’s chest.
What are the indications of tympanostomy tube treatment?
Otitis media (OM) and acute otitis media (AOM) as an indication of tympanostomy tubes
Otitis media is considered a matter of concern if it occurs as long term and persistent otitis media because it reduces the quality of life of a patient, affects great economic costs, and impairs child development in long run. Whereas Acute otitis media (AOM) can cause symptoms like fever, earache which results in poor quality of life in children and parents as well.
It may also lead to increased physician’s visits, missed school days, and missed working days as well. otitis media is also associated with a hearing loss, It is studied that otitis media with effusion is related to the conductive hearing level of 25-30 dB which is quite high as compared to normal hearing which is 0-20 dB. The children with otitis media and acute otitis media can suffer from developmental delays due to associated hearing loss. A patient who is suffering from otitis media and if it continued for a longer time, it may result in poorer reading and verbal abilities, and overall lowers IQ. Along with it, there are structural changes have been noted in the middle ear. The economic burden of this is enormous: in 1992, it was estimated that otitis media-related Medicaid costs were $555 million for children under the age of 14.
Otitis media with effusion (OME) as an indication of tympanostomy tubes
When there is an accumulation of fluid occurs in the middle ear without any symptoms of an ear infection for example fever and pain, this is called as Otitis media effusion (OME). It is estimated that 90% of children will have at least one episode of Otitis media with effusion by age 10. Approximately 30 % to 40% of Otitis media with effusion cases turn into chronic Otitis media with effusion, whereas many cases of Otitis media with effusion resolve by its own without any medical intervention. Chronic Otitis media with effusion is a disease characterized by Otitis media with effusion that lasts for more than 3 months. When fluid accumulates in the middle ear due to factors like Eustachian tube dysfunction, respiratory tract infections, allergies or other irritants, this condition is called as otitis media with effusion. Young children are on target of this disease because the immune system of not properly developed in children. Due to which they became highly prone to get respiratory infections that lead to middle ear inflammation thereby otitis media. The immature Eustachian tube and its anatomy in children prevent the clearance of middle ear into the nasopharynx. Ear examination and pneumatic otoscopy are two tests which are helpful in the diagnosis of otitis media. These tests diagnose the movement of the ear drum, In the procedure of otoscopy, when the air is blown into the ear drum, the ear and eardrum shows limited or lack of movements in the ear with middle ear effusion; because ear with Otitis media with effusion become stiff and shows no movement.
The main symptom associated with the Otitis media with effusion is the “fullness” in the middle ear and it occurs due to fluid accumulation in the middle ear which can result in a conductive hearing loss; Usually, Otitis media with effusion is asymptomatic. Hearing loss in children can affect the development of the child in term of language, behavior, and academic achievement. The adverse effect of Otitis media with effusion has increased the risk of cholesteatoma, retraction pockets and atelectasis (weakened portions of the ear drum that have collapsed), Acute otitis media, cysts in the middle ear, and tympanic scarring.
Acute otitis media (AOM) as an indication of tympanostomy tubes
An ear infection is commonly known an Acute otitis media. An ear infection can be viral or bacterial in nature and readily cause an onset of inflammation of the middle ear. Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhal are the common pathogens for the Acute otitis media in the United States and the United Kingdom. Symptoms associated with the acute otitis media are ear pain, irritability, loss of balance, fever, and impaired hearing. The main symptom associated with the Otitis media with effusion is the “fullness” in the middle ear and it occurs due to fluid accumulation in the middle ear which can result in a conductive hearing loss; Usually, Otitis media with effusion is asymptomatic. Hearing loss in children can affect the development of the child in term of language, behavior, and academic achievement. The adverse effect of Otitis media with effusion has increased the risk of cholesteatoma, retraction pockets and atelectasis (weakened portions of the ear drum that have collapsed), Acute otitis media, cysts in the middle ear, and tympanic scarring.
Chances of redeveloping the recurrent acute otitis media are in 15% to 20% of preschoolers. The recurrent acute otitis media is defined as three or more episodes of Acute otitis media within 6 months period or four episodes within 12 months period. Acute otitis media usually affects about half of children by age 1; by age 3, almost 70% of children will have been diagnosed with an episode of Acute otitis media.
After the age of seven, the incidence of acute otitis media is greatly reduced and it starts occurring rarely after such age. Eustachian tube dysfunction exacerbates the condition of Acute otitis media. Children with Acute otitis media may also have reduced hearing which can lead to development delays and along with that it also presents lower quality of life of patients.
The conditions like Otitis media with effusion, children with craniofacial disorders, Down syndrome, or cleft palate increases the risk for acute otitis media. The reason behind this is that the Eustachian tube dysfunction is prevalent in these conditions. Upper respiratory infection is a risk factor for developing the condition like acute otitis media due to its bacterial or viral.
Other risk factors include exposure to irritants, such as cigarette smoke. Although Acute otitis media is distinct from Otitis media with effusion, the two conditions exist on a continuum; all children who have Acute otitis media are thought to experience some period of Otitis media with effusion after the infection clears, and as mentioned previously, chronic Otitis media with effusion puts children at risk for Acute otitis media.
What are the anticipated outcomes of tympanostomy?
Exact time to remove the tube from ear tube depends upon the model of tube used. Children are needed to revisit the clinic every 4 to 6 months for checking the proper functioning of the tubes. Time to time checkups helps the doctor to check the middle ear status, detect any anatomical changes to the middle ear, and to recheck the efficacy of the ear tubes in order to treat otitis media.
Tubes have been shown to be effective at managing chronic Otitis media with effusion, with systematic reviews indicating a reduction in middle ear effusion by 32% in the first year and an average improvement in hearing levels of 5 to 12 dB. The effectiveness of tubes at managing recurrent Acute otitis media is less supported, with many systematic reviews indicating little evidence or small short-term benefits. Overall, tube insertions have been suggested to improve quality of life for children and parents. Tubes have been shown to improving hearing, but these improvements dissipate in the long-term; a systematic review for children receiving grommets with chronic Otitis media with effusion showed that hearing benefit is greatest at 3 months, but is reduced at 6 to 9 months. It should be noted that these are all systematic reviews that have been conducted in otherwise healthy children.
What are the consequences and adverse events associated with tympanostomy?
The most common adverse events associated with the intervention and comparators of interest are described below.
Tympanostomy tube otorrhoea associated with tympanostomy tubes
- The most common adverse effect of ear insertion is tympanostomy tube otorrhoea. In patients with Acute otitis media, otorrhoea is a greater risk.
- After tympanostomy tube insertion, approximately 10-20% of children suffer from otorrhoea and it can affect some children even when the tube is in its place.
- Chronic otorrhoea can also develop in almost 4% of children.
- The main predictors of otorrhoea are:
- Recent history of recurrent respiratory tract infection
- Recurrent Acute otitis media as an indication of ear tube placement
- Presence of older siblings with history of Otorrhoea
Cholesteatoma associated with tympanostomy tubes
Chronic otitis media can result into cholesteatomas. In this, abnormal skin growths occur inside the middle ear which can further grow in size and can cause hearing loss, dizziness, mastoiditis, or even intracranial infections. The only effective management for this is surgical treatment. If the cholesteatomas are of small size they can be treated by the means of middle ear excision or removal of the middle ear. For the larger cholesteatomas, tympanostoid surgery is needed.
Blockage of tube lumen associated with tympanostomy tubes
The blockage in the ear tube lumen can occur due to mucus, blood, or other secretions in 7% of patients approximately. For the proper functioning, the ear tube lumen should be clear properly. The risk of blockage of the tube is higher in case of T-Tubes. This blockage can lead to excessive pain and hearing loss, so topical drops can treat this blockage sometimes if delivered in the middle ear for a week. Sometimes, the blockage can get so complicated that the ear tube becomes non-functional and need to be replaced.
Granulation tissues associated with tympanostomy tubes
The children who receive the tubes are more prone to develop new connective tissues and capillaries around the tube called as granulation tissues or granulomas. This condition is not so severe and can be treated with the help of corticosteroid and antimicrobial drops. This condition can be resolved within one to two weeks of treatment.
Premature extrusion associated with tympanostomy tubes
If the tympanic membrane has been loosened or weakened by atrophy or atelectasis, or in case if the tympanic membrane is previously treated with ear tubes, the tubes may extrude early. It is considered that extrusion can occur when after insertion; a tube falls out within 6 months of the procedure.
This condition can be treated by reinsertion of the tubes, which can further lead to perforation sometimes it came along with side effects and harms of anesthesia. Reinsertion is the procedure in which surgeon re insert the tube in the tympanic membrane, this procedure can weaken the ear drum which is associated with adverse effects such as retraction and cholesteatoma.
Tympanosclerosis associated with tympanostomy tubes
Another adverse event associated with insertion of ear tube is the formation of generally asymptomatic plaques of calcium and phosphate crystals on the tympanic membrane, this condition is called as Tympanosclerosis. Tympanosclerosis can occur as a result of trauma, such as insertion of ear tubes.
Persistent Perforation of the Tympanic Membrane associated with tympanostomy tubes
A perforation in the ear tubes can persist after tubes have been falling out. Persistent perforation can occur in long term tubes as compared to the short term tubes. The persistent perforation can be resolved by clear sure. Normally an observation period of 6 to 12 months is recommended because most perforations resolve naturally. Tympanic membrane perforations are more common in children with short term grommet tubes and long term T-Tubes.
Atelectasis and Retraction Pockets associated with tympanostomy tubes
An atrophy or collapse of the tympanic membrane is called as Atelectasis., it can result from tube re-insertion. Whereas Retraction pockets can be defined as a condition when after tube extrusion from a weakened tympanic membrane, a part of this tympanic membrane collapses into the middle ear. Retraction pockets are responsible for the accumulation of debris in the middle ear and therefore it can lead to the formation of cholesteatoma.
Harms of Anesthesia associated with tympanostomy tubes
Generally, the administration of general anesthesia in children undergoing tube insertion is considered as safe. There is a matter of concern that early exposure to general anesthesia can affect the developing brain of the children, However, the studies still need to be found on the relation between anesthesia and development disorders.
What are the costs of the tympanostomy procedure?
The expenditure for pediatric population in the United States is about $2 billion. The costs associated with otitis media can be carried, direct costs include clinic visits, medications, and associated procedures, whereas Indirect costs include parental wages, loss of time, transportation costs, and cost of a caregiver (from the clinic).
Each episode of
- AOM costs ranges from $108 to $1,330
- OME cost ranges from $120 to $406 for medical management
- Surgical treatment costs $2,173 for tube insertions
- Tube insertion along with adenoidectomy is $3,334
What are the comparator treatments of tympanostomy tube insertion?
A tympanostomy tube is not only the treatment for Otitis media with effusion; there are other comparative treatments available for this disease. Such treatments include antibiotics, or other medications such as steroids or mucolytics, a myringotomy (eardrum incision), adenoidectomy, or auto-inflation of the Eustachian tube. Watchful waiting and delayed tube replacement are considered first because Otitis media with effusion often resolves naturally within 0-6 months. It is observed that in most cases it does not lead to long term hearing loss and developmental problems. Due to the bacterial etiology, antibiotics are used to treat individual cases of acute otitis media.
Watchful waiting or delayed tube insertion versus tympanostomy tubes
Waiting and watching is another treatment approach in case of Otitis media with effusion, this is acceptable in case of Otitis media with effusion because Otitis media with effusion is observed to cure naturally within 6 months of its existence. In this process, children are actively checked in order to determine the change in health status or if the child needs more active treatment. Depending upon the symptomatology or undue persistence, the active treatment should be given to the child.
It is a WA – Health Technology Assessment October 16, 2015, Tympanostomy tubes in Children: Final Evidence Report Page 44 common tactic for treating chronic Otitis media with effusion and recurrent acute otitis media, as both often resolve without further treatment.
What to do the day of surgery?
It is important that you know precisely what time you are to check-in with the surgical facility, and that you allow sufficient preparation time. Bring the required papers and forms with you, including the preoperative orders and history sheets. Your child should wear comfortable loose fitting clothes (pajamas are permissible). Leave all jewelry and valuables at home. They may bring a favorite toy, stuffed animal, or blanket.
Myringotomy versus tympanostomy tubes
In order to relieve the severe otalgia and to drain the middle ear fluid in cases of persistent Otitis media with effusion, Myringotomy is advised.
- Myringotomy is a surgical procedure in which an incision is made on the tympanic membrane in order to release the pressure and to drain out the fluid from the middle ear.
- The incision can be made by cold knife or a laser, called as cold knife myringotomy, it allows ventilation for 72 hours
- Whereas the incision made by laser myringotomy called as contact diode laser myringotomy and it allows ventilation for 1 to 7 weeks
- As it is also a surgical procedure, it requires anesthesia, which can cause further complications.
- Contact diode laser myringotomy takes half time to perform as compare to tympanostomy tube insertion
- Ventilation time in case of laser myringotomy is half as that of tympanostomy tube insertion. Therefore Ear tube insertion is more powerful and effective procedure in severe cases of Otitis media with effusion.
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Adenoidectomy versus tympanostomy tubes
In patients with obstructive sleep apnea and frequent throat infections that cause enlargement of adenoids, the surgical treatment called Adenoidectomy is recommended. The throat infections cause the enlargement of adenoids that ultimately leads to blockage of the eustachian tube and thereby causes recurrent acute otitis media and chronic Otitis media with effusion.
- Adenoidectomy is found effective in treating Otitis media with effusion but not considered as first line treatment of Acute otitis media.
- Adenoidectomy is considered effective in children with Acute otitis media which had previous ear tube insertion also it is carried out in conjunction with tonsillectomy.
- However, without the existence of additional conditions such as nasal obstruction or chronic adenoiditis, this procedure (adenoidectomy) is not a first line procedure for OME
- It is also performed under general anesthesia, therefore it presents with the usual risks associated with an anesthetic procedure.
- Tympanostomy tubes are found more effective as compared to adenoidectomy in reducing the frequency of otitis media and associated time.
- Adenoidectomy when performed along with tube insertion or a myringotomy it is found quite effective in non-responsive cases of Otitis media medically.
Antibiotics versus tympanostomy tubes
Due to its bacterial etiology, antibiotics are used to treat individual cases of acute otitis media. Due to increased antibiotics resistance, the prophylactic antibiotics treatment for recurrent acute otitis media is not recommended as per current guidelines. Antibiotics treatment is most preferable in children with tube otorrhoea. The antibiotics should be administered with the help of a dropper.
FDA approved topical antimicrobial for treating otorrhoea in a perforated tympanic membrane is ofloxacin.
Other medications versus tympanostomy tubes
Other medications for the children with persistent Otitis media with effusion are mucolytics steroids and analgesics which are given in hope of reducing respiratory infections, Eustachian tube, and middle ear inflammation. However, these treatments are not recommended in the Otitis media with effusion guidelines because they lack evidence of relieving Otitis media with effusion in children. Some conditions like an earache can be reduced by taking oral and topical analgesics in children with acute otitis media.
Auto inflation of the Eustachian tube versus tympanostomy tubes
In this procedure, the air is forced into the Eustachian tube by increasing the pressure of air in the nose. This procedure of introducing the air into the middle air is carried out for balancing the pressure as well as it allows better drainage of middle ear fluid. It is somewhat complicated procedure and is difficult for children to undergo this procedure; it is very unlikely that effusion can be completely cleared via auto inflation. And so it is not recommended for alleviating Otitis media with effusion. It can be considered better than ear tube insertion because of low cost and it can be a feasible adjunct to watchful waiting for normal resolution of Otitis media with effusion.
Complementary and alternative medicine treatment versus tympanostomy tubes
Homeopathy, chiropractic administration, Xylitol, elimination diets for food allergies, herbal medicines (e.g., Echinacea), naturopathic ear drops, and acupuncture are other complementary and alternative medicine (CAM) treatments of Otitis media with effusion. No studies were identified that evaluated the use of CAM treatments on children with chronic Otitis media with effusion or recurrent acute otitis media.
What are the clinical outcomes of tympanostomy tube insertion?
Improvement in hearing levels:
As per the studies conducted on the patients suffering from Otitis media and associated hearing loss, following results have been noted. At six months, two trials are reported, in which mean improvement in hearing reporting in tympanic tubes ear as compared to myringotomy treated ears. No statistically significant differences were noted after 1 year; however, normal hearing levels are noted in all patients after 12 months. Similarly, no differences were seen after a period of 24 months. Another trial shows that TT (Tympanic tubes) patients who had hearing loss have 7-8% lesser audiometry evaluations as compared to myringotomy.
Improvement in otorrhoea:
Otorrhoea is reported on different subjects after treatment with TT and myringotomy. There were no statistically meaningful differences in otorrhoea occurrence between TT and myringotomy through three months. Patients treated with TT are reported to show no significant difference in one, two, three or more episodes of Otorrhoea. Patients in the TT group had more episodes of otorrhoea per year as compared to myringotomy, but the statistical reports were not reported.
Improvement in acute otitis media episodes:
Patients with TT group had lesser episodes of acute otitis media as compared to Myringotomy group for the first 12 months. One trial of the study showed the occurrence of acute otitis media in similar proportions in both Tympanostomy tubes and Myringotomy patients over a period of 24 months. There was no cumulative difference was reported in both the cases (Tympanostomy tubes versus Myringotomy) in the incidence of acute otitis media.
Improvement in acute otitis media and Otitis media with effusion recurrence:
Chances of redeveloping the recurrent acute otitis media are in 15% to 20% of preschoolers. The recurrent acute otitis media is defined as three or more episodes of acute otitis media within 6 months period or four episodes within 12 months period. Acute otitis media usually affects about half of children by age 1; by age 3, almost 70% of children will have been diagnosed with an episode of Acute otitis media.
As the results are shown with acute otitis media episodes, the re-occurrence of acute otitis media or Otitis media with effusion is noted in patients treated with Tympanostomy tubes and myringotomy. The results of the studies showed that the frequency of Otitis media with effusion or acute otitis media recurrence is lower in the first year of Tympanostomy tubes treatment as compared to Myringotomy treatment. Whereas there is no significant difference is noted in both the treatments over a period of 3 years. The studies showed that the in the first year of the treatment,
- The patients in the Tympanostomy tubes group spent 9.8% to 17% of the time with acute otitis media or Otitis media with effusion.
- The patients in the Myringotomy group spent 57% to 61% of the time with acute otitis media or Otitis media with effusion.
Over the entire first three years of follow-up, patients in the Tympanostomy tubes group had effusion 21% to 31% of the time, while those treated with myringotomy alone had acute otitis media or Otitis media with effusion 38% to 41% of the time. There was no statistical significance of these results were reported.
Improvement in balance and coordination:
None of the included studies reported this outcome.
Improvement in cholesteatomas:
As per studies conducted on different trials, no cholesteatomas were formed in two years Similar is the case with myringotomy, there was no formation of cholesteatoma was formed through 36 months. There no statistical difference was noted. One child was treated with tympano-mastoid surgery and the other underwent tympanostomy tubes insertion and reported no significant difference in the formation of cholesteatomas.
Improvement in functional and quality of life outcomes:
Functional and quality of life outcomes of the patients with tympanostomy tubes can be evaluated by two analyses:
Improvement in auditory processing:
Auditory processing was evaluated in patients of the age 0.6 to 12 years. It was studied that the noise threshold for speech recognition was 2.0 to 3.4 dB higher in the Tympanostomy tubes group at baseline. When compared with the watchful waiting the speech recognition threshold was 3 to 21.2 dB lower in Tympanostomy tubes group as compared with watchful waiting group at one, two, and four months follow up. There was no statistical difference were noted among the two.
Improvement in subanalysis: Presence of middle ear effusion classifies the level of hearing in patients. The trials were done on the speech recognition thresholds measured at any point during the course of the study for three years. The result shows the lower speech recognition threshold in tympanostomy tubes group and watchful waiting group in patients with either a functional tube or without middle ear effusion was present. The difference between the tympanostomy tubes and myringotomy groups was small.
Improvement in pain
A trial has been done on the patients with Otitis media with effusion and the earache occurred in a similar percentage of tympanostomy tubes and myringotomy ears after one, two, three, and six months after treatment.
Other functional and quality of life outcomes
None of the included studies reported any other functional or quality of life outcomes, including attention and behavioral outcomes, academic achievement, speech and language development, parent or patient satisfaction with treatment/outcomes, or patient and parent quality of life.
Surgical outcomes of tympanostomy tube treatment
Details on repeat surgery or tube insertion were provided by four trials. In two trials, in which tube reinsertion in the Tympanostomy tubes group or tube placement in the myringotomy group was reported. And the results show that during the first year follow up tympanostomy tubes patients were half likely to undergo reinsertion as compared to myringotomy patients. The difference found to be 3-14% versus 61-64%. After two years of the follow-up, there was no significant difference were noted in tube replacement in tympanostomy tubes (36%) Vs myringotomy group (47%).
Medication usage with tympanostomy tube treatment
Medication usage was reported by one trial. There was no difference between tympanostomy tubes and myringotomy patients in the need for medical retreatment for Otitis media with effusion; however, tympanostomy tubes patients required on average 0.75 fewer courses of medical treatment for Otitis media with effusion than myringotomy patients. There was no difference between groups in need for medical treatment of Acute otitis media.
Number of office visits associated with tympanostomy tube treatment
The need for unscheduled office visits for illness as well as the mean number of unscheduled office visits for illness per child was reported to be similar between groups Tympanostomy tubes and Myringotomy as well.
Possible complications during tympanostomy
When complications do occur, they may include:
- Perforation: This can rarely happen when a tube comes out or a long-term tube is removed and the hole in the tympanic membrane (ear drum) does not close. The hole can be patched through a surgical procedure called a tympanoplasty or myringoplasty.
- Scarring: Any irritation of the ear drum (recurrent ear infections), including repeated insertion of ear tubes, can cause scarring called tympanosclerosis or myringosclerosis. In most cases, this causes no problem with hearing and does not need any treatment.
- Infection: Ear infections can still occur with a tube in place and cause ear discharge or drainage. However, these infections are usually infrequent, do not cause hearing loss (because the infection drains out), and may go away on their own or be treated effectively with antibiotic ear drops. Oral antibiotics are rarely needed.
- Ear tubes come out too early or stay in too long: If an ear tube expels from the ear drum too soon (which is unpredictable), fluid may return and repeat surgery may be needed. Ear tubes that remain too long may result in perforation or may require removal by an otolaryngologist.
Can you swim with ear tubes?
The parents of the children are reported quite satisfied after placement of ear tubes in their children’s ear. Because after ear tube insertion, children suffer less likely from ear infections and ear pain. Swimming with ear tubes was one of the main concerns of the parents. As per a recent study, published in Archives of Otolaryngology and Head and Neck Surgery, investigators showed that swimming in children does not cause any harm; until and unless they swim on the surface. Under water pressure and below 6 feet from surface, swimming is still not recommended; because under water pressure, the soapy water can enter in the middle ear by the means of ear tubes. The reason behind taking the precautions against entering the soapy water in the ear is that the soapy water has lower surface tension which can make it easier for soapy water to enter into the ear. Another prevention that can be adopted by parents in order to allow their kids to enjoy under water is antibiotic ear drops. After entering into the water in swimming, head showers and bathing, a dose of antibiotic ear drops is necessary every night after they played with water.
How many ear infections before tube should be put in?
Ear tubes are mainly indicated in the children who had three ear infection in last six months, or four ear infections in the last 12 months.