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Overview of tympanostomy tube placement, postoperative care, and complications in children
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Overview of tympanostomy tube placement, postoperative care, and complications in children
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2017. | This topic last updated: Jul 21, 2015.

INTRODUCTION — Tympanostomy tube insertion is among the most common operative procedures in childhood [1,2]. As such, tympanostomy tube surgery has considerable impact on the health of young children and upon medical economics.

An overview of tympanostomy tubes, the postoperative care of the child with tympanostomy tubes, and the diagnosis and management of complications of tympanostomy tubes in children are reviewed here. The indications for, and efficacy of, tympanostomy tubes in children with otitis media with effusion (OME) and recurrent acute otitis media (AOM) are discussed separately. The prevention and management of tympanostomy tube otorrhea is also reviewed in detail separately. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Acute otitis media in children: Prevention of recurrence" and "Tympanostomy tube otorrhea in children: Causes, prevention, and management" and "Otitis media with effusion (serous otitis media) in children: Management".)

EPIDEMIOLOGY — In the United States in 2006, 667,000 children less than 15 years of age underwent surgery for insertion of tympanostomy tubes [1]. Tympanostomy tube insertion rates are high in other developed countries as well. In Denmark, approximately 30 percent of children undergo at least one ventilation tube insertion by their fifth birthday [3].

The rate of tympanostomy tube placement is higher in children who attend daycare. Children with autism spectrum disorder and/or developmental delay also undergo tube insertion at a higher rate, possibly because of a lower threshold to perform the surgery in children at greater risk for speech delay or protracted ear difficulties [4]. In addition, children with craniofacial anomalies, such as cleft palate or trisomy 21, are more likely to have dysfunction of the eustachian tube leading to the development of otitis media, with a subsequent increased risk for tympanostomy tube placement [5]. (See "Autism spectrum disorder: Clinical features", section on 'Language impairment' and "Eustachian tube dysfunction".)

The frequency of tympanostomy tube insertion in young children in the United States has declined since the introduction of the pneumococcal conjugate vaccine into the routine childhood immunization schedule in 2000. (See "Acute otitis media in children: Prevention of recurrence", section on 'Pneumococcal conjugate vaccine'.)

BACKGROUND — The middle ear is a closed space that requires periodic replenishment of mucosally-absorbed air via the eustachian tube. The ventilating function of the eustachian tube is less well developed in young children than in adults. Underventilation of the middle ear results in negative pressure that may lead to aspiration of nasopharyngeal secretions and transudation of intracellular fluid, important steps in the development of acute otitis media (AOM) and otitis media with effusion (OME, also called serous otitis media) [6]. (See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications" and "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Eustachian tube dysfunction".)

This information, combined with the observation that middle ear disease stabilized in some patients with perforations of the tympanic membrane (TM), led to attempts to provide middle ear ventilation via surgical perforation of the TM (myringotomy). Unfortunately, simple perforations of the TM close rapidly [7]. In the early 1900s, various materials (eg, catgut, fish bones, lead wires, and gold rings) were used in efforts to keep the perforations open [8].

Successful ventilation of the middle ear by myringotomy and insertion of a straight, narrow polyethylene tube that remained in place for a few weeks was described in a series of patients in 1954 [9]. The initial tube design has been modified since then to achieve greater duration of function and lower rates of permanent perforation after extrusion.

The small, approximately 1 mm opening in the tympanostomy tube prevents the development of negative pressure in the middle ear. The tube does not "cure" otitis media, but bypasses the child's immature and poorly functioning eustachian tube to equalize middle ear and atmospheric pressures. Tympanostomy tubes also allow administration of antibiotics to the middle ear topically. Tympanostomy tubes are sometimes called "pressure-equalizing (PE) tubes" or "ventilation tubes." Relapse of AOM or OME when a tube extrudes or is obstructed reflects persistent inadequate function of the child's eustachian tube and should not be interpreted as a surgical "failure" [10].

GENERAL CONSIDERATIONS FOR PATIENT SELECTION — Tympanostomy tubes are indicated when long-term ventilation of the middle ear space is desired [2,11]. Tympanostomy tubes are used to control conductive hearing loss associated with middle ear effusion (MEE), control recurrent acute otitis media (AOM), and prevent acquired cholesteatoma due to a retraction pocket of the tympanic membrane (TM). Specific indications for tympanostomy tubes and comparison of tympanostomy tubes with prophylactic antibiotic therapy in children with otitis media with effusion (OME) and recurrent AOM are discussed separately. (See "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes' and "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes' and "Cholesteatoma in children", section on 'Acquired'.)

Decisions regarding the placement of tympanostomy tubes should be made on a case by case basis [2,11]. Factors to be considered in the decision include:

Efficacy of tube placement in controlling middle ear disease. In a systematic review of studies comparing tympanostomy tubes with myringotomy (without tube placement) or nonsurgical treatment for OME, children with tubes spent 32 percent less time with MEE during the first year of follow-up than children in other groups [12]. (See "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes'.)

The relative risks of tube placement, including the risks of general anesthesia, weakening of the TM related to surgery, and permanent perforation of the TM, compared with those of no treatment or prophylactic antibiotics (eg, development of antibiotic-resistant pathogens). (See 'Complications and sequelae' below.)

The physical discomfort and medical complications of repeated AOM. The tympanostomy tube permits drainage of infected middle ear fluid and episodes of AOM are less painful than in children without tubes. (See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications", section on 'Complications and sequelae'.)

The possible long-term adverse effects of hearing loss related to MEE during the period of rapid speech acquisition in children without tubes. For children with tubes, the middle ear cleft remains fluid free as long as the tubes are patent [13,14].

Whether the child is at risk for speech, language, or learning problems for other reasons (eg, cleft palate, Down syndrome, autism) [11,15]. Some of these patients may benefit from earlier placement of tympanostomy tubes [16].

The cost to the healthcare system of tube placement compared with medical management.

TYMPANOSTOMY TUBES — Short-term tubes are indicated for most children. The tube materials available (metal, plastic, or ceramic) all seem to have similar efficacy. Caregivers should be educated with regard to the expected duration of tube function [2,15].

Short versus long term — The duration of tympanostomy tube function is largely dependent on tube design and placement. There are two general types of tympanostomy tubes:

Short-term tubes (grommet tubes), intended to remain in the tympanic membrane (TM) for 4 to 18 months, have flanges on the inner and outer surfaces, which span the eardrum on either side and hold the tube in place (picture 1). Grommet tubes with right angles or beveled flanges (Armstrong-type tubes) (picture 1) normally last about 13 months, with 95 percent extruding between 6 and 18 months [17] (see 'Tube extrusion' below). Shepard-type grommets with an hourglass shape extrude sooner, after a mean duration of about eight months [18].

Long-term tubes (T-tubes), intended to remain in the TM for more than 15 months, have shafts that are too long to fit in the middle ear (picture 2). These tubes frequently require active removal [19] (see 'Tube removal' below). Implantation of tympanostomy tubes beneath the tympanic annulus provides very long-term ventilation (median 35 months) [20].

In theory, the prolonged ventilation provided by a long-term tube is desirable. However, only 30 to 40 percent of children initially treated with short-term tubes require additional tubes or surgery for otitis media. In addition, long-term tubes are associated with higher rates of otorrhea and persistent perforation of the TM [17,21,22]. Thus, short-term tubes are recommended for most children.

Indications for long-term tubes include:

Weakened or atelectatic TMs

Previous early extrusion of grommet tubes

Expected need for many years of ventilation (eg, adolescents with a long history of Eustachian tube dysfunction).

T-tubes are relatively painless to remove in the office, especially if the inner flanges are trimmed. They may be a good choice for short-term ventilation in an older child who needs winter ventilation but desires to be free of tubes during the summer swimming season. (See 'Tube otorrhea' below and 'Persistent perforation' below.)

Earlier extrusion of all types may occur when tubes are inserted into TMs that have been previously intubated, or have been weakened focally by atrophy or atelectasis [23].

Tube materials — Tympanostomy tube materials are selected for maximum biocompatibility and resistance to clogging and extrusion. The materials, in general order of frequency of use, include plastics (polytetrafluoroethylene [fluoroplastic or Teflon], silicone elastomer [Silastic]), metals (stainless steel, titanium, gold), and calcium phosphate-based ceramic (hydroxylapatite) [24]. Research on ion-bombarded surfaces, antibiotic-eluting coatings, and resorbable tubes is ongoing [25-32]. No single material has proven superior to the others, although metal tubes, particularly steel, have a greater tendency to clog than tubes made from other materials. Fluoroplastic tubes have been used in most studies of tube safety and efficacy.

A variety of modifications have been proposed that are of uncertain value. Silver-oxide impregnated silastic tubes slightly reduce postoperative otorrhea [33], but long-term benefits are poorly studied. Bacterial biofilms can develop on silver-oxide impregnated and polyvinylpyrrolidone-coated tubes, but ion-bombarded silicone tubes and phosphorylcholine-coated fluoroplastic tubes appear to resist Staphylococcus aureus and Pseudomonas aeruginosa biofilm formation [26,34,35]. Organoselenium coating on silicone tubes also decreased S. aureus, Haemophilus influenzae, and Moraxella catarrhalis biofilm formation in vitro [36]. However, rates of postoperative otorrhea, tube blockage, and tube extrusion were no different with phosphorylcholine-coated versus uncoated standard fluoroplastic tubes in a trial of 240 children randomized to receive the coated tube in one ear and the uncoated tube in the other [25].

Tube placement — Most tubes are placed in the pars tensa of the TM, in any location except the posterosuperior quadrant, which overlies the incus and stapes (figure 1 and picture 3).

Although the anterior half of the drum is generally chosen, location does not correlate with duration of intubation [37]. Routine placement in the anterosuperior quadrant, for example, does not prolong intubation compared with placement in the anteroinferior quadrant [38-40]. Rarely, tubes are placed between the tympanic annulus and bony ear canal as permanent devices [41].

POSTOPERATIVE CARE — Follow-up care with the operating otolaryngologist, in conjunction with primary care clinicians, is required once tubes have been placed to assure that the tubes are functional, hearing loss has been corrected, and potential complications are properly diagnosed and managed [42,43]. The planned schedule for follow-up visits should be communicated with caregivers [2,15]. Caregivers should also be educated regarding manifestations of complications that may require additional evaluation and management.

Follow-up schedule — Regular and timely follow-up of all children with tympanostomy tubes is essential for optimum outcomes [42-44]. The initial postoperative follow-up visit should be performed by the otolaryngologist within four weeks of tube placement to verify the patency and functional status of the tube [43]. Subsequent tube "check-ups" are scheduled with the otolaryngologist or pediatrician at four- to six-month intervals, regardless of how well the child is doing. Otolaryngology follow-up should continue until healing of the tympanic membrane (TM), normal eustachian tube function, and normal hearing have been established [43-45].

Referral indications — Referral to the otolaryngologist earlier than regularly scheduled follow-up is indicated for [42-44]:

Chronic, recurrent, or bloody otorrhea unresponsive to antibiotic ear drops (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Tympanostomy tube otorrhea')

Persistent ear pain, deterioration in hearing, or problems with balance

Structural disease or suspected structural disease of the TM (eg, perforation, cholesteatoma, retraction at tube site) (picture 4)

Symptomatic children with tympanostomy tube obstruction, particularly if they have preexisting sensorineural hearing loss, or language or developmental delay (see 'Blocked tubes' below)

Symptomatic children in whom the tympanostomy tube cannot be visualized

Children with an extruded tympanostomy tube that cannot be removed from the ear canal

Children in whom the tympanostomy tube has migrated into the middle ear space

Children in whom the tympanostomy tube remains within the TM for more than two to three years (see 'Tube removal' below)

Audiologic evaluation — An audiologic evaluation should be performed postoperatively, especially if normal hearing was not established before surgery [43,46,47]. The purpose of the audiologic assessment is to identify children with persistent conductive or sensorineural hearing loss, independent of otitis media with effusion (OME), who require additional diagnostic evaluation. (See "Hearing impairment in children: Evaluation".)

Rarely, the tube itself may cause a mild conductive hearing loss (about 10 to 20 dB, typically in the lower frequencies), which resolves if the tube is occluded temporarily with a paper patch [48]. Extended follow-up of children with tubes, however, shows no evidence of persistent hearing loss directly attributable to intubation [49].

Assuring tube function — Proper function of a tympanostomy tube is assured if it is seen to span the eardrum, its lumen is unobstructed, and no middle ear effusion (MEE) is present (picture 5). When these three features are observed, ventilation of the middle ear through the tube lumen will maintain good hearing and reduce the frequency, duration, and severity of subsequent otitis media episodes [50].

Visualization of a tympanostomy tube may be difficult if the child is struggling, cerumen obstructs the external canal, a long-shafted tube has been used, the tube is oddly angulated, or the tube is placed in the anterosuperior quadrant of the TM (figure 1). Adequate cerumen removal and appropriate restraint are needed for any good ear examination. Irrigation and cerumenolytics should be avoided in the presence of a functional tube or perforated eardrum. (See "Acute otitis media in children: Diagnosis", section on 'Otoscopy' and "Cerumen", section on 'Cerumen removal'.)

When tube function cannot be confirmed by visual inspection, pneumatic otoscopy and tympanometry are helpful. If the TM is immobile and translucent on pneumatic otoscopy, with no other signs of MEE, the tube is probably functioning. A flat (type B) tympanogram (figure 2) with a large volume measurement (static compliance) confirms that a functioning tube (or a perforation) connects the ear canal and middle ear. A peaked (type A or C) tympanogram (figure 2) suggests a clogged or extruded tube without MEE. A flat tympanogram with small volume measurement indicates a nonfunctioning tube with MEE [51].

Blocked tubes — The lumen of a tympanostomy tube can become plugged with mucus, blood, or suppurative secretions (picture 5). Elution profiles of hydrolyzed plugs are most often consistent with mucoid MEE as the obstructing substance [52]. Tube blockage may occur in the immediate postoperative period or after an initial period of patency.

Blocked tubes can sometimes be cleared by applying ototopical drops, although none are approved by the US Food and Drug Administration (FDA) for this purpose. The ability of ear drops to clear blocked tympanostomy tubes was demonstrated in a trial in which 110 obstructed tympanostomy tubes in children ≥27 months of age were randomly assigned to active treatment or observation for 14 days [53]. Patients in the treatment groups filled the ear canal with ear drops (5 percent sodium bicarbonate or 3 percent hydrogen peroxide) twice daily and remained supine with the ear upright for five minutes before draining the solution. Clearance of the obstruction occurred in 56 and 71 percent of tubes treated with hydrogen peroxide and sodium bicarbonate, respectively, and in 0 percent of tubes in the observation group. Mild pain developed in 17 percent of patients, but did not prevent them from completing 14 days of therapy.

A skilled otolaryngologist can occasionally unclog a plastic grommet by sliding a 3-French metal suction catheter or 18-gauge spinal needle through the tube lumen using the binocular microscope for visualization. This procedure should not be attempted without magnification and is usually unsuccessful with metal or long-shafted tubes.

Prophylactic ear drops — The use of prophylactic ear drops (including antibiotic drops) to prevent tympanostomy tube otorrhea is discussed in detail separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Prevention of tympanostomy tube otorrhea'.)

Otorrhea and episodes of AOM — Tympanostomy tubes reduce the frequency of AOM, but do not prevent all episodes. The average child has at least one episode of acute otitis media (AOM) in the year after tube insertion, and some children have numerous episodes [54]. Significant episodes of AOM routinely cause purulent drainage from the tube. This often presents as visible otorrhea emanating from the ear canal, but it may be subtle, apparent only on otoscopy. Some of these episodes are painful. Many have minimal discomfort. Most occur on the third or fourth day of a cold [55]. In older children, otorrhea may follow repeated water contamination without an antecedent upper respiratory infection [56]. Treatment of acute tympanostomy tube otorrhea is discussed in detail separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Treatment'.)

If a new AOM is noted at the time of surgery, the author cultures the middle ear contents at the time of tube placement and follows a treatment plan similar to that suggested for acute tympanostomy tube otorrhea. Bacterial pathogens are identified in about 30 percent of MEEs that are cultured at the time of tube insertion [57]. Polymerase-chain reaction (PCR) testing, which is a more sensitive technique, yielded pathogenic bacteria with or without concomitant viral pathogens in 54 percent of ears with effusion at tube insertion [58]. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Acute tympanostomy tube otorrhea'.)

Water precautions — The need for water precautions (eg, the use of ear plugs, swimming caps, or antibiotic-containing ear drops) in children with tympanostomy tubes is discussed separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Water precautions'.)

Tube extrusion — Extrusion of short-term tubes is initiated by the continual shedding of squamous debris from the epithelium of the TM [40]. The migrating keratin from the TM accumulates between the surface epithelium and the outer flange of the tube. As debris accumulates under the outer flange of a grommet tube, the pressure causes the flange to lift up from the surface of the TM (picture 6). The inner flange of the tube becomes visible as it presses against the eardrum, and begins to extrude as the tube tips posteriorly. When both flanges are clearly in view, extrusion is complete (picture 7).

Small amounts of keratin debris adjacent to a functioning tube are a normal and expected finding. The debris requires no attention unless it obstructs the tube lumen or causes a local inflammatory response (granulation tissue).

Long-shafted tubes (T-tubes) are designed without an outer flange, which prevents the above sequence of events from occurring. Migrating epithelium may accumulate along the length of the shaft during the months following insertion.

Tube removal — A small percentage of short-term tubes and many long-term tubes do not extrude spontaneously and require surgical removal. The overall risk of failed extrusion is 5 to 10 percent [59]. A child who fails to extrude one of the bilateral tympanostomy tubes has an increased risk of nonextrusion of the other tube. The risk of nonextrusion also appears to be increased in the siblings of a child with failed extrusion, suggesting a possible genetic mechanism, perhaps related to wound healing [59].

Most otolaryngologists wait at least two to three years before considering the surgical removal of an uncomplicated short-term (grommet) tube and four years before considering the surgical removal of a long-term tube [44,60,61]. The rates of persistent perforation are increased when tubes are left in place for longer than three years than when tubes are removed electively before three years (15 versus 3 percent in one retrospective analysis) [62]. (See 'Complications and sequelae' below.)

Flexible silicone tubes may occasionally be removed in the office setting. However, general anesthesia is usually necessary for removal of tympanostomy tubes made of rigid materials. An additional advantage of anesthesia is that epithelial debris or ingrowth can be removed from the perforation edges under microscopic visualization (picture 8).

Indications — Indications for surgical removal of tympanostomy tubes are well described [60,61,63]. Children aged six years or older are the best candidates for tube removal because otitis media declines rapidly as the immune system and eustachian tube reach maturity. Younger children, however, also may benefit from removal based upon the frequency and severity of morbidity associated with tympanostomy tubes that have been in place for longer than two to three years [62]. (See 'Complications and sequelae' below.)

Specific indications for tube removal include [60,61,63]:

Failure of spontaneous tube extrusion after three years

Retained unilateral tympanostomy tube in a child aged six years or older, when the contralateral TM is intact and has been free of AOM or OME for at least one year [64-66]

Retained bilateral tympanostomy tubes in a child with normal eustachian tube function, resulting from growth, medical therapy, or surgery (adenoidectomy or cleft palate repair)

Frequent recurrent otorrhea despite medical management, particularly in older children with longstanding tubes (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management")

Chronic otorrhea, unresponsive to topical and systemic antimicrobials (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Tympanostomy tube otorrhea')

Tube-associated granulation tissue or granuloma that does not respond to topical therapy or debridement

Myringoplasty with a paper-patch [61], Steri-Strip tape [63,67], silastic sheeting [68], or gelfilm at the time of tympanostomy tube removal may increase the rate of perforation closure. Not all children require myringoplasty when tubes are removed. Reasonable indications for myringoplasty include long-term tubes, a history of multiple prior intubations, and short-term tubes with epithelial ingrowth or an intubation period of two years or longer.

COMPLICATIONS AND SEQUELAE — A child with middle ear disease severe enough to require tympanostomy tubes remains at risk for recurrent infection, persistent middle ear effusion (MEE), and for several late complications of tube placement. Complications and sequelae of tympanostomy tubes [69-72] and their frequency in a meta-analysis of tympanostomy tube sequelae [69] include:

Tympanostomy tube otorrhea (16 percent of patients within two weeks of placement, 26 percent of patients more than two weeks after placement) (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management")

Occlusion of tubes (7 percent of ears) (see 'Blocked tubes' above)

Premature extrusion (4 percent of ears)

Medial displacement of tubes (picture 9) (0.5 percent of ears)

Persistent perforation (2 percent of ears with short-term tubes, 16 percent of ears with long-term tubes)

Tympanosclerosis or myringosclerosis (32 percent of ears)

Focal atrophy of the tympanic membrane (TM) at the site of insertion, which increases the risk of retraction pockets and cholesteatoma (25 percent of ears)

Retraction pocket (picture 10) (3 percent of ears)

Cholesteatoma (0.8 percent of ears with short-term tubes, 1.4 percent with long-term tubes) (see "Cholesteatoma in children")

Although most of these complications are uncommon, early detection and management are necessary to reduce long-term morbidity.

Tube otorrhea — The prevention and management of tube otorrhea are discussed separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)

Persistent perforation — Persistent perforation (picture 11) after tube extrusion occurs in 2 percent of cases when short-term tubes are used and approximately 15 percent when long-term tubes are used [69,73]. Persistent perforation is also related to duration of intubation and baseline structural integrity of the TM [22,69,73,74].

In a review of 2604 ears in which tympanostomy tubes were placed for recurrent acute otitis media (AOM) or otitis media with effusion (OME), the overall rate of persistent perforations was 3 percent [73]. The rate of persistent perforation was dependent upon the following factors:

Age − The rate was higher in children <5 years compared with those ≥5 years (6 versus 4 percent).

Indication for tube placement − The rate was higher in children with recurrent AOM compared with those with OME (16 versus 2 percent).

Tube type − The rate was higher in children who received long-term tubes compared with those who received short-term tubes (15 versus 2 percent).

Number of tube placements − The rate was higher in children with ≥2 compared with one previous tube placements (14 versus 3 percent).

Episodes of otorrhea − The rate was higher in children with ≥3 compared with no episodes of postoperative otorrhea (11 versus 2 percent).

The diagnosis of persistent perforation is made clinically with otoscopy (picture 11). Pneumatic otoscopy demonstrates an immobile TM. Tympanometry that demonstrates a flat (type B) tympanogram (figure 2) with a large volume measurement confirms the diagnosis.

A 6- to 12-month observation period is recommended before surgical closure of persistent perforation, because most postintubation perforations close spontaneously [75,76]. If left untreated, large perforations may cause slight to moderate conductive hearing loss [77]. In addition, perforations allow contaminated water to penetrate into the middle ear during swimming and frequently lead to infection and otorrhea.

Persistent, small central perforations may be plugged with adipose tissue harvested from the posterior aspect of the lobule (80 to 90 percent success) [78,79]. The best results are achieved when the child has been free of active middle ear disease for one year, to avoid having to reintubate a TM that has been grafted successfully [80-82].

Tympanosclerosis (myringosclerosis) — Tympanostomy tubes are associated with structural changes of the TM [83,84]. Approximately 32 percent of TMs (range 7 to 64 percent) develop asymptomatic whitish plaques of calcium and phosphate crystals (tympanosclerosis) after tube extrusion (picture 12) [69]. For every 3.3 children who receive tubes, one additional case of tympanosclerosis occurs compared with children with recurrent otitis media who do not receive tympanostomy tubes. The plaques may be localized or diffuse and are of uncertain etiology. Boys are affected more often than girls [85] and larger plaques are associated with multiple intubations [86].

The diagnosis of tympanosclerosis is made clinically. Otoscopy demonstrates whitish plaques on the TM (picture 12). Pneumatic otoscopy may demonstrate decreased or absent mobility. The plaques are firm and contained within the middle layer of the drum, unlike cholesteatomas, which are soft and occupy the middle ear space. Otomicroscopy with palpation or computed tomography may be necessary to differentiate these disorders.

Tympanosclerosis associated with tympanostomy tube placement rarely requires treatment. Although the plaques that occur after tube extrusion may theoretically cause hearing loss if they involve the ossicles, this phenomenon has not been reported. The hearing impairment caused by tympanosclerosis is less than 0.5 dB, which is inconsequential [83].

Focal atrophy of TM — After a tympanostomy tube has extruded, the resultant perforation (about 1 to 2 mm diameter) heals as a dimer composed of only the squamous and mucosal layers of the TM (the middle fibrous layer of the TM does not regenerate) [87]. This potential area of weakness is more susceptible to subsequent retraction or perforation (picture 4).

Focal atrophy or retraction at the site of a prior tube occurs in approximately 25 percent of ears (range 2 to 75 percent), and pars tensa retraction pockets in approximately 3 percent of previously intubated ears (range 0 to 23) [69]. (See 'Cholesteatoma' below.)

Focal weakening of the TM is usually nonprogressive and tympanoplasty is rarely required. Generalized atrophy or TM collapse (atelectasis) (picture 13) is caused by poor eustachian tube function, not by prior intubation.

Cholesteatoma — A cholesteatoma is an accumulation of desquamating epithelium within the middle ear that may grow to envelop the ossicles and result in conductive hearing loss and destruction of the ossicular chain. The placement of tympanostomy tubes may have an overall protective effect on cholesteatoma formation in children with recurrent AOM, because acquired cholesteatoma is a complication of recurrent AOM [88]. (See "Cholesteatoma in children".)

However, acquired cholesteatoma also can occur as a complication of tympanostomy tube placement [89-93]. The risk of cholesteatoma formation is increased with long-term tubes compared with short-term tubes. In one meta-analysis of tympanostomy tube sequelae, cholesteatoma occurred in 0.8 percent of children with short-term tubes and 1.4 percent of children with long-term tubes [69]. In a large retrospective cohort, cholesteatoma occurred in 1 percent of children who underwent tympanostomy tube insertion. The risk of cholesteatoma was increased in children who underwent multiple tympanostomy tube insertions [93].

Retraction pockets are the first step in the genesis of an acquired cholesteatoma (picture 10) [94]. If squamous debris begins to collect in a deep- or narrow-mouthed retraction pocket and egress of the material is obstructed, granulation tissue and secondary infection ensue. Enlargement of the collection may result in erosion of the ossicular chain, mastoid air cells, and external auditory canal. (See "Cholesteatoma in children", section on 'Acquired'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute otitis media and otitis media with effusion in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Ear tubes (The Basics)")


The placement of tympanostomy tubes permits adequate ventilation of the middle ear, circumventing the child's immature and poorly functioning eustachian tube. (See 'Background' above.)

Tympanostomy tubes are indicated when long-term ventilation of the middle ear space is desired. Tympanostomy tubes are used to control conductive hearing loss associated with middle ear effusion (MEE), control recurrent acute otitis media (AOM), and prevent acquired cholesteatoma due to a retraction pocket. (See 'General considerations for patient selection' above and "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes'.)

Otolaryngology follow-up after tympanostomy tube placement typically occurs at four- to six-month intervals. Otolaryngology follow-up continues until at least one year after extrusion or removal of tubes and healing of the tympanic membrane (TM), normal eustachian tube function, and normal hearing have been established. (See 'Follow-up schedule' above.)

Referral to the otolaryngologist earlier than regularly scheduled follow-up is indicated for (see 'Referral indications' above):

Chronic, recurrent, or bloody otorrhea (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Tympanostomy tube otorrhea')

Persistent ear pain, deterioration in hearing, or problems with balance

Structural disease or suspected structural disease of the TM

Children with symptoms in whom the tube is obstructed or cannot be visualized (see 'Blocked tubes' above)

An extruded tube that cannot be removed from the ear canal

A tube that has migrated into the middle ear space

The tube has been retained for more than two years (see 'Tube removal' above)

Proper function of a tympanostomy tube is assured if it is seen to span the eardrum, its lumen is unobstructed, and no MEE is present (picture 5). (See 'Assuring tube function' above.)

Complications and sequelae of tympanostomy tubes include tube otorrhea, persistent perforation of the TM (picture 11), tube obstruction (picture 5), tympanosclerosis (picture 12), focal atrophy of the TM (picture 4), and cholesteatoma. (See 'Complications and sequelae' above.)

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