Greg Smith: It is the most common procedure done for children in the United States. Children are often candidates for this procedure if they have recurrent ear infections so these would be recurrent acute ear infections or they have chronic ear infection, which is called chronic otitis media with fluid behind the eardrum. This can affect everything from balance, to speech, and hearing prolonged.
Nishant Reddy: Hello everyone. Welcome to the We Knows Noses Podcast where we discuss anything ENT. Here we’ll talk about a variety of topics for anyone wanting to learn anything about ENT or ear, nose, and throat related. The three of us make up NJ ENT. We’re a newly formed private practice ENT group based in central New Jersey. My name is Dr. Reddy and I’m joined here with Dr. Undavia and Dr. Smith. For today’s topic, we’re going to first discuss a common question that we get asked from our patients which is, should I get ear tubes?
Now, the medical term for ear tubes is called tympanostomy tubes and first we’ll go over some of the indications for ear tubes and some background as well as some potential alternatives to tubes. Then we’ll touch a little bit on the procedure itself and what to expect for postoperative care. I’m going to turn it over to Dr. Smith first and he’ll talk about some of the background and the indications for ear tubes.
Greg Smith: Sure. As Dr. Reddy alluded to, the medical term for ear tubes are tympanostomy tubes, and so the procedure to put those in would be a myringotomy with tympanostomy tube insertion. What this does is it allows a ventilation between the middle ear space, which is essentially a sinus, and the outside world through your ear canal. It is the most common procedure done for children in the United States and children are often candidates for this procedure if they have recurrent ear infections. These would be recurrent acute ear infections or they have chronic ear infection, which is called chronic otitis media with fluid behind the eardrum. This can affect everything from balance, to speech and hearing prolonged. Typically, there are indications for this, like how frequently and how many, and that’s what you come see an ENT specialist for.
The basic gist is about three infections in six months in a child or four infections in a year but there’s obviously a lot of other factors that the ENT or the specialist who you see may weigh in to determine whether or not your child may need ear tubes. Now, for adults, adults often get this procedure as well. Certainly it’s much more common in children but, as I said, that tube is to try to ventilate that middle ear space because it’s not getting adequately ventilated.
In children, that’s just because their anatomy is not developed, their eustachian tube is narrower and flatter, it’s pitch, and so it tends to get obstructed more easily. Kids also have a lot more viral and upper respiratory infections as their immune systems are generating, and so they often get these infections over and over and over again. Now, in adults that’s not very common but adults can get this procedure for things like that, chronic otitis media or fluid within the middle ear space because that vent is not ventilating very well and the fluid is maintaining in that space.
Sometimes we do them for eustachian tube dysfunction. That eustachian tube dysfunction, that eustachian tube is that vent that I was talking about, the natural vent that goes between that middle ear sinus all the way into the back of the nose. And so, if that eustachian tube’s not working often adults get complaints of ear pressure, fullness, popping, and usually difficulty in handling altitude changes, whether that be flying or diving. And so, there are a lot of different strategies we can talk about in patients who have eustachian tube dysfunction as well as what type of examinations and things we do. Dr. Undavia can talk a bit about what we do in a normal exam and ENT visit concerning things that might necessitate ear tubes.
Samir Undavia: Yeah, so the first thing we always want to do is we get the history like Dr. Smith talked about. We then start with looking at the ear. Obviously, the first thing we look at is for ear wax and if there’s some ear wax we want to take that out so we can get a good look at the eardrum. When we look at the eardrum, we want to see if we can see through it and you should be able to see through it and see the internal structures. The middle ear space has the three tiniest bones in the whole body and we want to see if we can see parts of those.
If we can see parts of them, that usually is a pretty good indicator that there is not any fluid in there. If you look at as many ears as we do, you’ll realize if the eardrum looks like this or if it looks sucked in like that, that typically means that there’s a negative pressure inside the ear. Sometimes we can actually see yellow fluid, sometimes it looks bright red like there’s an infection. Sometimes all we see are these little bubbles inside the ear indicating that there’s air bubbles within fluid so we’re really looking to see the quality of the eardrum itself, plus behind the ear.
Now, if this is an adult and we’re paying attention to only one ear, that heightens our alertness to the back of the nose which, as Dr. Smith said, connects the nose and the ear through the eustachian tube so we want to see if there’s anything blocking the back of the nose. In an adult, we’re looking for a mass so we want to look at the nose, we want to see is the septum crooked, are the turbinates swollen, and is there something blocking the opening to the eustachian tube. You should be able to see that with a camera called an endoscope that we can do right in the office. It’s uncomfortable for about five seconds, maybe 10 seconds, but it gives us a whole ton of information that we need to decide about patient care.
We look in the back of the nose. For kids, we don’t typically do that because, for the most part, we’re not worried about a big mass growing there. They have adenoids, the adenoids can contribute to things but, for most kids, if they’re not complaining about things in the nose like snoring or nasal obstruction or if their parents aren’t saying that they’re snoring or having trouble breathing through the nose, we really just focus on the ear, so we do that. Then we have a couple of tests that we can do in the office to either confirm that their hearing is okay or to confirm that there’s fluid in the ear.
The first thing we can do is a tympanogram. Either we can do it or the audiologist does it. We hold an instrument up to the ear and it puffs air into the ear canal and then that air creates a sound wave that reflects back onto our machine. We get three different types of waves. If it’s a type A, it means there’s a very nice response of the eardrum to the puff of air and there’s nothing holding its mobility back. If it’s a type B, it means that there is something holding the mobility back and typically that is fluid in the ear. Type C means that it’s restricted. It’s moving but it’s not moving as well as it could and usually that means that there’s a negative pressure in the ear.
As Dr. Smith said, that you usually feel full or you feel like you have pressure in the ear. It’s uncomfortable, sometimes it can hurt. People typically feel that when they’re descending on an airplane, not typically ascent but descent. Finally, in kids who aren’t really able to verbalize whether they are having trouble hearing or what their symptoms are, we can do an Oto-Acoustic Emissions Test. While there’s a lot of physics and physiology involved with this, the basic gist of this is that when you send a signal into the ear it travels to the eardrum, it gets amplified by 17.1 times to go into the cochlea.
As it goes into the cochlea, it creates this wave pool where the water rushes in and then the energy comes out. But it creates a little wave in these inner hair cells which, as they flap and they interpret that sound, they send another sound out. This really refined machine can actually hear that sound coming back. It tells us if the inner hair cells heard that sound and flap back they are hearing that message and that tells us whether that ear has at least 40 decibels of hearing or not. Those are the tests that we typically do. If an adult wants a little bit more specific hearing test, we can get a full hearing test which will give us all the frequencies and their word recognition score and give us a good idea of how well they hear.
Nishant Reddy: Great. I’m going to touch base a little bit on alternatives to tubes prior to even considering getting tubes. The first thing you try is some type of medication and the medications that we use to try to improve your eustachian tube is what we’re trying to aim for. Those typically include things like decongestants, either topical or oral decongestants such as Sudafed or Afrin. You can consider steroids, either nasal sprays or oral steroids. If you have an underlying allergy that might be contributing to the eustachian tube issue, addressing the allergy either with avoidance or with anti-allergy therapy may be helpful for improving your ear function.
If none of that stuff works, another useful technique is something called auto insufflation and that’s basically just popping your ears repeatedly and equalizing the pressure in your ears. This is done a lot of times for people that are flying or for scuba divers, for example. But essentially, what you do is you just close your nose like this and then you breathe out through a closed nostril and you’re trying to force air up into your ears to gently pop your ears and equilibrate your ears. If you do that multiple times a day, it may be enough where your symptoms are relatively well controlled.
Finally, if none of that’s working, the only other alternative that’s FDA approved currently, other than tympanostomy tubes, is something called eustachian tube balloon dilation. Now, this is a relatively newer procedure that’s been FDA approved just for a few years. There’s not significant long term data on this but there is randomized clinical trial data that does show that it’s effective. Essentially what it is, is you’re inserting a small balloon catheter through your nose, inserting it up into the eustachian tube, dilating the eustachian tube in an effort to try to make your natural eustachian tube function better. I’m going to turn it over to Dr. Smith and he’ll talk a little bit about what are tubes exactly and some of the details of the actual procedure.
Greg Smith: Great. Ear tubes, as we mentioned, or tympanostomy tubes, are these tiny, little hollow cylinders that essentially equalize the pressure in the middle ear space for you. And so, they sit and saddle across the ear drum and connect the middle ear space to the outside world, as I mentioned before. People often ask about how big are these because they imagine some big thing kind of hanging out of their ear that they’ll be able to see. Truly, they’re about the size of a half a grain of rice so they really are teeny, teeny tiny. They’re usually made out of something that’s inert, meaning your body doesn’t see it as foreign, and that’s usually made out of material called fluoroplastic which is a type of plastic or silicone-like material.
Ear tubes can be done with or without general anesthesia. Typically, in the past all children were done with anesthesia and now there are some centers and studies being done with doing ear tubes without general anesthesia. Adults often can be done without general anesthesia comfortably in the office with just a local medication to numb the eardrum, and allows us to make a small, little incision in the eardrum and insert that tube through the eardrum. As I said, it sits like a little spool across the eardrum and so after you make a small little incision you can kind of slide this little tube in between and it kind of helps keep that little incision spot open so there’s a tiny little vent hole there.
Depending on the type of condition with the middle ear space, it often depends on what type of tube your ENT or physician may end up using. Certainly, there are ones made out of steel and there are ones made out of plastic and silicone. There are some that have longer flanges that stay into the middle ear space and help maintain the tube in there longer but, by and large, all of those kind of decisions are made by the physician and the clinician. As far as how long these tubes lay in that space is typically variable. We typically quote that these tubes last anywhere from six months to a year and a half.
Sometimes they last a little bit longer, sometimes they fall out a little bit sooner, and that typically is the biggest risk is that it may last too long, it may fall out too soon, and may either necessitate another tube going in or may even require going back in there and retrieving the tube. The biggest concern is that when the tube falls out or we retrieve that tube, sometimes you could be left with a small little hole or a perforation in the eardrum. 99% of the time this will close up on its own but sometimes these eardrum perforations don’t close up on their own. Some of that depends on the age of the patient, the health of the patient, et cetera, as well as the health of the middle ear.
A hole in the eardrum would be the most concerning risk of doing a procedure like this but, as I said, the vast majority of these fall out on their own and heal up without you even knowing most of the time that the tube even fell out. And so, often with children, we’ll talk about post-procedural care and maintenance of what you need to do with the tubes and I’ll turn that over to Dr. Undavia.
Samir Undavia: Depends on if you’re a child or an adult, but for kids and the parents who want to manage what their kids are doing afterwards, for most kids I tell the family that the kid can go back to school or back to their daycare the next day. They’re going to be groggy for the rest of the day as they get their tubes. They’re probably going to cry for the first couple hours. Totally normal. They’re disoriented from the anesthesia. It will go away. They can have a regular diet, they can run around the house and stuff. Then the next day they can resume all normal care. They can bathe as they normally do. If we’re a little worried about infections, we can have the parents put a cotton ball with some Vaseline or just a cotton ball in the ear so that not a lot of fluid gets inside the ear and then they resume their activities as normal.
It’s pretty tough to manage a young kid and tell them to restrict what they’re doing and how they do things so we just leave them alone. The one thing that we do care about is going into water like a pool or the ocean. I think if you polled all three of us we might have different rules about what the patients and the kids can do afterwards. In general, we want to restrict how dirty the water is and the exposure to the ear so we don’t want them to be in the ocean or a lake and be dunking their heads in. In that case, I would rather have them put an earbud in or something to block the water going. Yeah, a plugin. For kids, we want to do that, especially for the first week, but throughout the life of the ear tube we do want to restrict dirty water getting in there.
If they’re going to a pool and it’s relatively clean, again, we probably have three different rules here but, in general, it’s not as big of a risk. I’m of the opinion that they could swim without ear plugs in so long as they don’t go under five feet of water because some studies have shown that there’s just not enough water pressure for the water to get into the ear canal and then through the tube into the middle ear space. But if you do get chlorinated water into the middle ear space some kids can complain of burning in that region and then they’re not having a great time at the pool.
For adults, it’s a little bit different but, in general, the same. They usually get their tubes right there in the office. They go home or they go back to work, we do it at lunchtime, and they don’t have many restrictions. They’re pretty good about washing their hair and stuff so not worried about getting water into their ear, but if they are or if they have a history of a lot of infections with draining ears, then we definitely want to keep the water out of the ear and we use earplugs in the shower. Same thing goes for the pool. Don’t want them to go into dirty water like a lake or the ocean for the life of the tube.
We definitely have had patients who go swimming in the ocean and come back and there’s sand in the ear canal and they get ear infections so want to keep the ear tube clean. For pools, again, that are clean, you want to try and stay above five feet of water. If you are an avid scuba diver, you do not want to get tubes, you got to tell us if you’re going to be doing that. Then finally, I like to tell patients for the first week not to blow their nose or try and auto equilibrate your ear like Dr. Reddy was talking about because you could pop the tube out of place for the first year. After the first week or so, the eardrum has kind of made the tube very snug and we’re not too worried about that afterwards.
Nishant Reddy: Great. Well, thank you Dr. Undavia and Dr. Smith. That’s our show for today. Thank you all so much for listening. If you haven’t already, please make sure to subscribe and rate our podcast five stars, we need all the help we can get. For more information, please visit us at www.njent.com or call us at 609-710-NOSE. That’s 609-710-6673. Take care, guys.
Greg Smith: Take care, guys.