Information on Ear, Nose and Throat Surgeries     
Ear Tube Surgery - Myringotomy and Tubes
Ear Tubes, M & T, Myringotomy Tubes
Ear Tube Surgery - M & T
         
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Ear Tube Surgery (Myringotomy Tubes) - Indications            
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Middle Ear Fluid Found During Ear Tube Insertion

WHY DOES A CHILD NEED TUBES ?   Indications for Ear Tubes
"Tubes", also called, "PE Tubes", "PETs", or "Pressure Equalizing Tubes", allow air to get into the middle ear space behind the eardrum.  Air is needed in this space to allow the eardrum to move.  Normally, a tube (
eustachian tube) at the back of the throat does this, but in many children, the eustachian tube is immature or temporarily not fully grown, preventing the air from getting into the middle ear.  If air is not present in the ear, either fluid builds up, or infections start, or both.  With the buildup of fluid or an  infection, a temporary or permanent hearing loss may develop.  If a trial of medication has not worked, PE tubes may be recommended to prevent future problems.  Prediction of which children will develop complications from chronic serous otitis media is difficult.  Measurement of the ability to aerate the middle ear using the forced response test, the sniff test and the pressure equilibration test has been found to be of little value in the prediction of chronic serous otitis media or the development of serious complications.   
View Abstract   Click on Pictures to Enlarge
Chronic Serous Otitis Media  Ear (Myringtomy) Tube and Tympanosclerosis
 
 



Take a Self Test On Ear Disease and Hearing Loss !!!!        

Take a Test on Ear Anatomy !!!!

Other treatments for chronic serous otitis media (ear fluid)   

     
Another reason for the placement of ear tubes is recurrent ear infections.  Recurrent
middle ear infections may be treated with either long term antibiotics (prophylactic antibiotics) or ear tubes.  Because of developing bacterial resistance to antibiotics, many ear doctors are returning to ear tube placement as one of the first line treatments for recurrent infection.  Does exposure to tobacco smoke cause ear infections ?   (Arch OL-HNS July 1999)   View Abstract
         
Eustachian Tube Opening in the Nasopharynx


Eustachian Tube opening into the nasopharynx.
                    
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To the right is a slide show of eardrums with chronic middle ear disease pre and post ear tube (myringotomy tube) placement.



 
 

 

     

 
  • 1.  Severe Atelectasis of the EardrumThe eardrum on the promontory and the middle ear obliterated from adhesive otitis media.
  • 1.  Severe Atelectasis of the Eardrum - Post Op
  • 2.  Chronic Serous Otitis Media
  • 2.  Chronic Serous Otitis Media - Post Op
  • 3.  Otitis Media & Attic Retraction PocketThere is scutal erosion with exposure of the head of the malleus and impending cholesteatoma formation.
  • 3.  Otitis Media & Attic Retraction Pocket - Post Op
  • 4.  Chronic Serous Otitis MediaThe middle ear is filled with fluid and there is a shallow attic retraction pocket.
  • 4.  Chronic Serous Otitis Media - Post Op
  • 5.  Severe Eardrum AtelectasisThere is erosion of the long arm of the incus, an attic retraction pocket with exposure of the head of the malleus, & middle ear space obliteration.
  • 5.  Severe Eardrum Atelectasis - Post Op
  • 6.  Deep Anterior Superior Retraction PocketThere is a very deep retraction pocket with impending cholesteatoma formation.
  • 6.  Deep Anterior Superior Retraction Pocket - Post Op
  • 7.  Deep Posterior Retraction PocketPosterior retraction P\pocket with myringoincudopexy and impending cholesteatoma formation.
  • 7.  Deep Posterior Retraction Pocket - Post Surgery
  • 8.  Chronic Serous Otitis Media
  • 8.  Chronic Serous Otitis Media - Post Surgery
  • 9.  Chronic Serous Otitis MediaThe eardrum has eroded the long arm of the incus and formed a myringostapediopexy.
  • 9.  Chronic Serous Otitis Media - Post Surgery
  • 10.  Chronic Serous Otitis MediaThis eardrum has a shallow attic retraction pocket.
  • 10.  Chronic Serous Otitis Media - Post Op
  • 11.  Chronic Serous Otitis MediaThis eardrum is retracted with mild tympanosclerosis. Note the thin area in the inferior eardrum from a prior tube placement.
  • 11.  Chronic Serous Otitis Media - Post Surgery
  • 12.  Severe TympanosclerosisThis eardrum has severe tympanosclerosis with middle ear fluid and a myringoincudopexy.
  • 12.  Severe Tympanosclerosis - Post Surgery
  • 13.  Chronic Serous Otitis Media
  • 13.  Chronic Serous Otitis Media - Post Surgery
  • 14.  Deep Attic Retraction PocketThis eardrum is retracted with tympanosclerosis and middle ear fluid. Note the severe scutal erosion and huge attic retraction pocket.
  • 14.  Deep Attic Retraction Pocket - Post Surgery
 
Ear (Myringotomy) Tube Surgery - Technique:

WHAT ABOUT COMING TO THE HOSPITAL?    Click on Pictures to Enlarge

Ear Tube InsertionIt is VERY IMPORTANT on the day of surgery, that your child have an empty stomach. If anything has been put into the mouth or stomach, because of SAFETY for your child, the surgery must be cancelled. Even chewing gum will cause the cancellation of surgery. DO NOT let your child eat or drink ANYTHING on the day of surgery. Please tell someone if you think your child has eaten or has drank anything on the day of surgery. If there is food or liquid in the stomach at the time of surgery, there is a chance your child could choke while asleep.

Search PubMed for Myringotomy Tubes

    

This is a slide of the ear.  Note the carotid artery next to the eustachian tube.  This is the reason there is no safe way to surgically open the eustachian tube to aerate the middle ear.

Click on Pictures to Enlarge

Temporal Bone and Ear Anatomy

Temporal Bone and Ear Anatomy

 
 
WHAT ABOUT USING A LASER?

Laser assisted myringotomy for recurrent acute otitis media and chronic serous otitis media  in children has been associated with a high failure and persistence of the disease and with eardrum perforation.  View Abstract   Koopman et..al. found that the eardrum hole from a laser myringotomy stayed open an average of 2.4 weeks compared to 4 months for a myringotomy tube.   The success rate for laser myringotomy was only 48% compared to 78% for ear tube placement.  Laser myringotomy was found to be safe but less effective than ear tube placement. View Abstract
 

T-Tubes are often called "permanent tubes".  However, between 3.0% and 47% (mean 8.8%) of T-Tubes will eventually come out (1).  Kalcioglu found that T-Tubes will say in an average of 16.3 months compared to 7.3 months for grommet tubes (2).  When T-Tube do come out they often leave a hole in the tympanic membrane.   This is significantly higher than the 0.5% to 2.0% perforation rate found in short-term tubes (1) .  Placing a T-Tube in a damaged eardrum or one that is markedly retracted can produce perforation rates up to 21% (1).  
                      
(1)  Goode, R.L.  Long-term middle ear ventilation with T tubes:  The perforation problem.  Otolaryngology-Head and Neck Surgery  1996;115:500-501.
(2)  Kalcioglu MT, et.al. Follow-up of 366 ears after tympanostomy tube insertion Otolaryngol Head Neck Surg 2003 Apr;128(4):560-4   
View Abstractct
ear_t_tube2.jpg (27638 bytes)   ear_t_tube.jpg (25855 bytes)
This picture to the right shows a T-Tube coming out of the eardrum and a perforation forming around the tube.
   
The picture to the right shows various types of ear tubes.

Ear (Myringotomy) Tube Plastic Bobbin    Ear Tube Reuter Bobbin
Click on Pictures to Enlarge

 
Different Types of Ear Tubes

   
Ear (Myringotomy) Tubes - After The Surgery:
  
Will an ear tube need to be inserted if my child's tube comes out ???       Click on Pictures to Enlarge

The reinsertion rate for ear tubes is between 15.9 % (Age over 18 months)  to 26.3 % (age 18 months or younger.)   The greatest risk factor for reinsertion is a patient whose age is less than 18 months (3).   It is very important that your child has checkups every 3 to 6 months after the tubes are put in so the tubes can be checked to determine it they are still working.

Plugged Ear (Myringotomy) TubeThe picture to the right shows an ear tube which is starting to fall out of the eardrum.  The inner layers of the eardrum have healed behind the ear tube and are pushing it off the eardrum.  This usually takes place without problems.  However, sometimes a reaction occurs which produces excessive serous fluid.  When the fluid hardens in the center of the tube it is slowly pushed out, causing the formation of a long rod shaped structure.  The tube shown in this picture was removed in the office without difficulty.

(3) Boston, M, McCook, J, and Derkay, C   Incidence of and risk factors for additional tympanostomy tube insertion in children.   Arch Otolaryngol Head and Neck Surg.  2003 Mar 129(3): 293-296.     View Abstract

  
HOW LONG WILL TUBES STAY IN?
  

Most tubes stay in place for 3 to 18 months, average is 9 months, however, they can come out sooner or stay in longer.  However, this varies widely between patients. View Article  They usually come out on their own and the drum usually heals. The first sign that the tube is coming out is that it becomes plugged.  This is caused by the eardrum healing behind the tube. The tube will then be slowly pushed out.  


Click on Pictures to Enlarge

  
Ear Tube Retension Graph
   

   
Can my child get water in his ears ???

Many ENT Doctors feel that non-chlorinated water getting into the ear can cause middle ear infections.  Because of this many ENT Doctors will recommend wearing water ear plugs when bathing or swimming.  In a recent article Goldstein et. al. supports the use of water precautions in children who have have had ear tube placement.  View Article
 
Click on Pictures to Enlarge


 
Ear (Myringotomy) Tube Surgery - Complications:

  
Sometimes bleeding occurs when the tubes are coming out.  The use of ear drops usually stops the bleeding and allows the tubes to come out naturally. If the tubes stay in for 3 years your doctor may want to remove them by taking your child back to the operating room. Rarely (1%), a hole is left in the eardrum when the tubes come out.  This hole will act as a tube, but at some point the child will have to be taken back to the operating room and have the hole patched.  This procedure may be postponed until the child is 6 to 8 years of age.

It is very important that your child has checkups every 3 to 6 months after the tubes are put in so the tubes can be checked to determine it they are still working.


Plugged Ear (Myringotomy) Tube with Acute Otitis MediaPlugged Ear (Myringotomy) Tube with Acute Otitis MediaWhen tubes stop working it is usually because they have become plugged or the eardrum has healed behind the tube.  If the ear tube is plugged it often can be unplugged in the office.  However, if the eardrum has healed behind the tube and the tube is still needed, then tube reinsertion may have to be performed.  

The pictures to the right shows plugged ear tubes with an acute otitis media (middle ear infections).

      Click on Pictures to Enlarge

   
Pus Draining From an Ear TubeThis picture shows an ear tube with pus draining out of it in a child with an
acute otitis media (middle ear infection).  Up to one third of infections in ears with ear tubes is due to a bacteria called pseudomonas.  This bacteria is resistant to almost all oral antibiotics which can be given to children.   If ear drops do not clear the infection, the child may rarely have to be placed on IV medications through home health.   Treatment with ear drops containing neomycin have the potential for ototoxicity, but have been used for many years with few adverse effects.  View Abstract   A new generation of ear drops which contain fluoroquinolone antibiotics ( cipro and floxin ear drops ) are also effective against pseudomonas and are not ototoxic View Abstract   Heslop et. al reported that topical ciprofloxacin had a 23% failure rate which was lower than that found in patients treated with oral amoxicillin or with saline rinses.   View Abstract

   
Rarely an ear tube does not fall out into the ear canal but instead falls into the
middle ear.  Usually, this does not cause a problem and the tube does not have to be removed.

The two pictures on the right shows ear tubes which have migrated into the middle ear. 

 

Click on Pictures to Enlarge


Ear Tube Granuloma - Granulation TissueThis picture shows an infected ear tube with pus draining out of the tube and an
infectious granuloma above the ear tube.

   

Click on Pictures to Enlarge


   
 

Ear Tube Granuloma - Granulation TissueThis picture is of a 12 year old who had ear tubes placed six years ago.  Granulation tissue has completely grown over and enveloped the tube.  The ear had chronic drainage from the granulation tissue.  The eardrum was mobile and the ear tube was plugged with tissue.   Surgical tube removal will probably be required. 
 
 
 
 
Click on Pictures to Enlarge
 
 
 


  
Acute Otitis Media with a Plugged Ear TubeEar Tube Granuloma and Eardrum HoleThe picture on the right shows a picture of an ear with an
acute otitis media ( middle ear infection ) with an extruded ear tube, laying in the ear canal.

The picture on the left shows a perforation and a granuloma which formed from an ear tube
  
  
  
   
    


 

 
Perforation of the inferior eardrum caused by an ear tube. The picture on the far right shows a perforation from a
myringotomy tube.  The near right picture shows an inferior perforation with an anterior area of tympanosclerosis and an extruded ear tube in the superior ear canal.  Eardrum perforations occur in about 2% of ears.  View Abstract

    

     Click on Pictures to Enlarge

    
 
 
 

Eardrum Cholesteatoma from Myrnigotomy Tube Placementcholesteatoma is a rare complication of myringotomy tube placement, but can occur.  To the right is a picture of a child two years after myringotomy tube placement.  A white round cholesteatoma can be seen in the area where the tube resided.
 

 

 

 


 

 
Eardrum with a Monolayer and TympanosclerosisEardrum with a Monolayer and TympanosclerosisThis picture shows an eardrum with
tympanosclerosis or white plaques of the eardrum which form from prior infections.     The plaques are surrounding a "monolayer" or thin portion of the eardrum.  Not how through the hand held otoscope the monolayer mimics a perforation but the close up view clearly shows the intact eardrum.  A monolayer is sometimes occurs when an eardrum perforation heals.  In this patient the monolayer formed after an ear tube extruded.    Click on Pictures to Enlarge


 
This pictures below are of a child who was referred to our practice with a very rare complication.  The ear (
myringotomy ) tube fell into the
middle ear and down the eustachian tube.  The child developed a cholesteatoma.  Treatment consisted of a canal wall down mastoidectomy and removal of the myringotomy tube from the eustachian tube.

Ear Tube In Eustachian Tube - CT Scan   Ear Tube In Eustachian Tube  
   

The picture to the right shows an 80 year old patient had a nasopharyngeal (back of the nose) mass which presented with blockage of the eustachian tube and serous otitis media ( ear fluid ).  The mass was a benign cyst (Tornwaldt's Cyst) but could have been a cancer.  Older patients that present with persistent ear fluid should have an examination of the nasopharynx.

  

    Click on Pictures to Enlarge
 
  
 
 
 
     

  
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