Version July 2025
INTRODUCTION —
This topic will provide an overview of tympanostomy tubes (TTs; also called "pressure-equalizing [PE] tubes" or "ventilation tubes"), including postoperative care of the child with newly inserted TTs and the diagnosis and management of TT complications. The indications for and efficacy of TTs in children with otitis media with effusion (OME) and recurrent acute otitis media (AOM) are discussed separately. The prevention and management of TT otorrhea is also reviewed in detail separately:
●(See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis".)
●(See "Otitis media with effusion (serous otitis media) in children: Management".)
●(See "Acute otitis media in children: Prevention of recurrence".)
●(See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)
EPIDEMIOLOGY —
TT insertion is among the most common operative procedures in childhood [1-5]. In the United States, approximately 400,000 pediatric TT insertion surgeries are performed each year and approximately 8 to 10 percent of children undergo TT insertion by age 17 years [3,6]. TT insertion rates are even higher in other parts of the world. For example, in Denmark, approximately 30 percent of children undergo at least one TT insertion procedure by their fifth birthday [7].
The rate of TT placement is higher in children who attend daycare. Children with autism spectrum disorder and/or developmental delay also undergo TT 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 [8,9]. 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 TT placement [10]. (See "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Language impairment' and "Eustachian tube dysfunction".)
The frequency of TT insertion in young children in the United States declined following the introduction of the pneumococcal conjugate vaccine into the routine childhood immunization schedule. (See "Acute otitis media in children: Prevention of recurrence", section on 'Pneumococcal conjugate vaccine'.)
During the height of the COVID-19 pandemic, the incidence of otitis media and other infectious respiratory conditions was reduced by increased hygiene and isolation. The frequency of TT insertion was considerably lower during the pandemic as well [11].
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). (See "Acute otitis media in children: Epidemiology, microbiology, 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 development of surgical techniques to provide middle ear ventilation via surgical perforation of the TM (myringotomy). The initial TT designs have been modified over time to achieve greater duration of function and lower rates of permanent perforation after extrusion.
The small, approximately 1 mm opening in the TT prevents the development of negative pressure in the middle ear. The TT does not "cure" otitis media but bypasses the child's immature and poorly functioning Eustachian tube to equalize middle ear and atmospheric pressures. TTs also allow administration of antibiotics to the middle ear topically. TTs are sometimes called "pressure-equalizing (PE) tubes" or "ventilation tubes." Relapse of AOM or OME when a TT extrudes or is obstructed reflects persistent inadequate function of the child's Eustachian tube and should not be interpreted as a surgical "failure" [12].
GENERAL CONSIDERATIONS FOR PATIENT SELECTION —
TTs provide long-term ventilation of the middle ear space [2]. They are used to control conductive hearing loss associated with middle ear effusion (MEE), reduce the risk of recurrent acute otitis media (AOM), and prevent acquired cholesteatoma due to a retraction pocket of the tympanic membrane (TM).
Decisions regarding the insertion of TTs are individualized based upon considering the following factors [2]:
●Efficacy – The first consideration is whether TT insertion has demonstrated efficacy for treating the child's specific middle ear disorder. Indications for TTs and data on the efficacy of TT insertion for these indications are discussed separately:
•Otitis media with effusion (OME) (see "Otitis media with effusion (serous otitis media) in children: Management", section on 'Tympanostomy tubes')
•Recurrent AOM (see "Acute otitis media in children: Prevention of recurrence", section on 'Tympanostomy tubes')
•Cholesteatoma (see "Cholesteatoma in children", section on 'Surgical treatment')
●Adverse effects – The potential complications of TT insertion are another important consideration. These include the risks of general anesthesia (GA), weakening of the TM related to surgery, and permanent perforation of the TM. Additional details are provided below. (See 'Complications and sequelae' below.)
These risks should be weighed against the downsides of alternative treatment options such as prophylactic antibiotic therapy or no treatment. Prolonged antibiotic therapy is associated with risks that include development of antibiotic-resistant pathogens, allergic reactions, diarrhea, and alteration of the gut microbiota. (See "Acute otitis media in children: Prevention of recurrence", section on 'Adverse effects'.)
Opting for no treatment would leave the child at risk for the short- and long-term complications of AOM and OME (eg, recurrent painful episodes of AOM, hearing loss related to MEE during the period of rapid speech acquisition). (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Complications and sequelae' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'OME-associated hearing loss'.)
●Speech and language development – Another important factor to consider is whether the child is at risk for speech, language, or learning problems for other reasons (eg, cleft palate, Down syndrome, autism) [2,13]. These at-risk patients may benefit from earlier placement of TTs [14].
●Cost – In one cost-effectiveness analysis, the incremental cost of TT placement relative to medical management for recurrent AOM outweighed the small improvement in quality of life [15]. However, the results were sensitive to factors such as missed work, special childcare, the societal cost of antibiotic resistance. Placing a higher value on these factors tips the balance in favor of TT placement.
PROCEDURAL DETAILS
Setting
●Operating room (preferred) – TT insertion is typically performed in the operating room under general anesthesia (GA). Performing the procedure under GA ensures adequate patient comfort and prevents excessive movement during the procedure.
●In-office procedure without GA – For patients or parents/caregivers with a strong desire to avoid GA, some otolaryngologists offer the option of in-office TT placement without GA [16-18]. The success of in-office TT insertion may vary depending on the age of the child (success is less likely in young children), the clinician's experience with the procedure, and use of local anesthesia [19]. Topical anesthetic agents are generally ineffective for the tympanic membrane (TM), but iontophoresis has been used to deliver local anesthesia. Successful in-office placement of TTs without GA (with or without local anesthesia) is likely enhanced by employing behavioral techniques such as preparation, coaching, and distraction [20].
In addition to conventional grommet TTs, three different rapid-insertion TT systems are commercially available [21]. None has received wide acceptance. Information to support the safety and efficacy of these devices comes from industry-funded studies with modest sample sizes and often lacking a control group [17,22]. In a study describing the use of one rapid-insertion TT system in the OR setting (68 patients) or office setting (269 patients), TT retention rates at 18 months were similar in both groups (46 versus 38 percent, respectively). [23]. Families should understand that the devices do not make the procedure pain free.
In another long-term prospective study of children who underwent TT placement in the OR under GA (42 patients) or as in-office procedure with local anesthesia (42 patients), the TT retention rate at 15 months was higher in the GA group (72 versus 50 percent) [24]. However, quality of life scores and parental satisfaction ratings at two years were similar in both groups. In this study, an in-office procedure was more likely to be chosen by parents of younger children and those who indicated fear or distrust of health care professionals.
Choice of tympanostomy tube
Short versus long term — There are two general types of TTs: short-term TTs (grommet TTs) and long-term TTs (T-tubes).
●Short-term TTs – Short-term (grommet) TTs are appropriate for most children. They are intended to remain in the TM for 4 to 18 months. In theory, more prolonged ventilation would be desirable. However, only 15 to 30 percent of children initially treated with short-term TTs require second sets or additional surgery for otitis media [25]. Thus, short-term TTs are sufficient for most children and they may avoid some of the complications (eg, otorrhea, persistent TM perforation) that can occur with long-term TTs [26-28].
Grommet TTs have flanges on the inner and outer surfaces that span either side of the eardrum and hold the TT in place (picture 1). Grommet TTs with right angles or beveled flanges (Armstrong-type TTs) (picture 1) normally last approximately 13 months, with 95 percent extruding between 6 and 18 months [26] (see 'Tube extrusion' below). Shepard-type grommets with an hourglass shape extrude sooner, after a mean duration of approximately eight months [29]. The duration for second sets of grommet TTs (ie, placed after initial tube extrusion) is considerably shorter [30].
●Long-term TTs – Long-term TTs (T-tubes) are intended to remain in the TM for >15 months. They have large inner flanges and/or shafts that are too long to fit in the middle ear (picture 2). These tubes frequently require active removal [31] (see 'Tube removal' below). Implantation of TTs beneath the tympanic annulus provides even longer retention (median 35 months) [32]. However, subannular TTs are associated with high rates of infection and occlusion and so require frequent maintenance [33].
Indications for long-term TTs include:
•Weakened or atelectatic TMs
•Previous early extrusion of grommet TTs
•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 TTs during the summer swimming season. (See 'Tube otorrhea' below and 'Persistent perforation' below.)
Earlier extrusion of all types may occur when TTs are inserted into TMs that have been previously intubated or have been weakened focally by atrophy or atelectasis [34].
Tube materials — TT materials are selected for maximum biocompatibility and resistance to clogging and extrusion. TTs are available in various materials (plastic, metal, ceramic). 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. The materials include plastics (polytetrafluoroethylene [fluoroplastic or Teflon], silicone elastomer [Silastic]), and metals (stainless steel, titanium, gold).
A variety of modifications have been proposed that are of uncertain value. Silver-oxide impregnated silastic tubes slightly reduce postoperative otorrhea [35], 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 [36-38]. Organoselenium coating on silicone tubes also decreased S. aureus, Haemophilus influenzae, and Moraxella catarrhalis biofilm formation in vitro [39]. 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 [40].
Insertion site — Most TTs 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 one-half of the drum is generally chosen, location does not correlate with duration of intubation [41]. Routine placement in the anterosuperior quadrant, for example, does not prolong intubation compared with placement in the anteroinferior quadrant [42-44].
POSTOPERATIVE CARE —
Follow-up care with the operating otolaryngologist, in conjunction with primary care clinicians, is required after TT insertion to assure that the TTs are functional, hearing loss has been corrected, and any potential complications are properly recognized and managed [2,13,45,46]. The planned schedule for follow-up visits should be communicated with caregivers. 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 TTs is essential for optimum outcomes [45-47]. The initial postoperative follow-up visit should be performed by the otolaryngologist within four weeks of TT placement to verify the patency and functional status of the TT [46]. Subsequent follow-up is 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 [46-48].
Referral indications — Referral to the otolaryngologist earlier than regularly scheduled follow-up is indicated for [45-47]:
●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 TT site) (picture 4)
●Symptomatic children with TT obstruction, particularly if they have preexisting sensorineural hearing loss, or language or developmental delay (see 'Blocked tubes' below)
●Symptomatic children in whom the TT cannot be visualized
●Children with an extruded TT that cannot be removed from the ear canal
●Children in whom the TT has migrated into the middle ear space
●Children in whom the TT 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 [46,49,50]. 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 loss in children: Screening and evaluation".)
Rarely, the TT itself may cause a mild conductive hearing loss (approximately 10 to 20 decibels, typically in the lower frequencies), which resolves if the TT is occluded temporarily with a paper patch [51]. Extended follow-up of children with TTs, however, shows no evidence of persistent hearing loss directly attributable to intubation [52].
Assuring tube function — Proper function of a TT is assured if it is seen to span the eardrum, its lumen is unobstructed, and no middle ear effusion (MEE) is present (picture 5) [53]. When these three features are observed, ventilation of the middle ear through the TT lumen will maintain good hearing and reduce the frequency, duration, and severity of subsequent otitis media episodes [54].
Visualization of a TT may be difficult if the child is struggling during the examination, cerumen obstructs the external canal, a long-shafted TT has been used, the TT is oddly angulated, or the TT 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 TT or perforated eardrum. (See "Cerumen", section on 'Cerumen removal' and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)
When TT 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 TT is probably functioning. A flat (type B) tympanogram (figure 2) with a large volume measurement (static compliance) confirms that a functioning TT (or a perforation) connects the ear canal and middle ear. A peaked (type A or C) tympanogram (figure 2) suggests a clogged or extruded TT without MEE. A flat tympanogram with small volume measurement indicates a nonfunctioning TT with MEE [55].
Blocked tubes — The lumen of a TT 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 [56]. TT blockage may occur in the immediate postoperative period or after an initial period of patency.
Blocked TTs can sometimes be cleared by applying ototopical drops, although none are approved by the US Food and Drug Administration for this purpose. The ability of ear drops to clear blocked TTs was demonstrated in a trial in which 110 obstructed TTs in children ≥27 months of age were randomly assigned to active treatment or observation for 14 days [57]. Patients in the treatment groups filled the ear canal with ear drops (5% sodium bicarbonate or 3% 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 TTs treated with hydrogen peroxide and sodium bicarbonate, respectively, and in none of the TTs 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 otologic pick instrument through the TT lumen using the binocular microscope for visualization [53]. This procedure should not be attempted without magnification and is usually unsuccessful with metal or long-shafted TTs.
Prophylactic ear drops — The use of prophylactic ear drops (including antibiotic drops) to prevent TT 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 acute otitis media — TTs reduce the frequency of acute otitis media (AOM) but do not prevent all episodes. The average child has at least one episode of AOM in the year after TT insertion, and some children have numerous episodes [58]. Episodes of AOM typically cause purulent drainage from the TT. This often presents as visible otorrhea emanating from the ear canal, but it may be subtle, apparent only on otoscopy. Some of these episodes may be associated with ear pain, though many have minimal discomfort. Most occur on the third or fourth day of a cold [59]. In older children, otorrhea may follow repeated water contamination without an antecedent upper respiratory infection [60]. Treatment of acute TT otorrhea is discussed in detail separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Treatment'.)
Water precautions — We concur with the American Academy of Otolaryngology-Head and Neck Surgery guidelines that recommend against routine, prophylactic water precautions in children with TTs [2]. Exceptions are made in certain situations (eg, swimming in a lake, pond, river, or ocean; submerging in a bath; deep diving) and for certain patients (eg, those with active, recurrent, or prolonged otorrhea; those with a prior history of problems with water exposure).
In meta-analyses of prospective studies and randomized trials of swimming in children with TTs, the rates of otorrhea were similar in swimmers and nonswimmers, in children who swam with and without ear protection, and in children who used ear drops after swimming and those who used ear protection [61-63]. These findings suggest that water precautions do not prevent otorrhea. However, the impact of the type and location of water activity on TT otorrhea is not well defined [46]. The lack of benefit of water precautions may be related to the relatively low concentration of bacteria in well-chlorinated swimming pools (compared with lakes, ponds, rivers, oceans, bath water) or the failure of ear plugs to exclude water from the ear canal during submersion [64-67].
Little water probably enters the middle ear during bathing (unless the head is dunked), showering, or surface swimming, but it may enter the ear if the head is submerged (eg, swimming under water at a depth of more than four to six feet, diving, head dunking in a bath) [68-72]. The risk of water entry into the middle ear is theoretically increased when the water is mixed with soap or shampoo because these agents decrease the surface tension of water [68,73].
TUBE EXTRUSION AND REMOVAL
Tube extrusion — Extrusion of short-term TTs is initiated by the continual shedding of squamous debris from the epithelium of the tympanic membrane (TM) [44]. The migrating keratin from the TM accumulates between the surface epithelium and the outer flange of the TT. As debris accumulates under the outer flange of a short-term (grommet) TT, the pressure causes the flange to lift up from the surface of the TM (picture 6). The inner flange of the TT becomes visible as it presses against the eardrum and begins to extrude as the TT tips posteriorly. When both flanges are clearly in view, extrusion is complete (picture 7).
Small amounts of keratin debris adjacent to a functioning TT are a normal and expected finding. The debris requires no attention unless it obstructs the TT lumen or causes a local inflammatory response (granulation tissue).
Long-shafted TTs (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 — Approximately 3 to 5 percent of short-term TTs and many long-term TTs do not extrude spontaneously and require surgical removal [74]. A child with bilateral tympanostomy TTs who retains one TT has an increased risk of nonextrusion of the other TT. 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 [75].
Nonextruded, uncomplicated short-term (grommet) TTs are usually removed by two to three years [47,76,77]. The likelihood of persistent perforation is approximately two- to three-fold higher when TTs are left in place for longer than three years compared with TTs that are removing electively before three years [78]. (See 'Complications and sequelae' below.)
Flexible silicone TTs may occasionally be removed in the office setting. However, general anesthesia (GA) is usually necessary for removal of TTs 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 TT removal include:
•Failure of spontaneous TT extrusion after three years for grommet type TTs
•Retained bilateral TTs in a child with normal Eustachian tube function, resulting from growth, medical therapy, or surgery (adenoidectomy or cleft palate repair)
•Chronic otorrhea, unresponsive to topical and systemic antimicrobials (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Tympanostomy tube otorrhea')
•TT-associated granulation tissue or granuloma that does not respond to topical therapy or debridement
•Evolving perforation around a functional TT (picture 9)
Children aged ≥6 years are the best candidates for TT 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 TTs that have been in place for longer than two to three years [79]. (See 'Complications and sequelae' below.)
●Myringoplasty – Myringoplasty at the time of TT removal has frequently been performed in an attempt to improve perforation closure, especially after long-term intubation (picture 10) [80]. Myringoplasty can be performed with a paper-patch, Steri-Strip tape [81], silastic sheeting [82], or collagen matrix [83]. A 2022 systematic review of tympanic membrane intervention versus no intervention at the time of TT removal showed no difference in perforation rates [78]. Additionally, no difference in perforation rates was identified when the types of TM interventions were compared, including freshening of tympanic membrane edges and/or patching with various materials.
COMPLICATIONS AND SEQUELAE —
A child with middle ear disease severe enough to require TT insertion remains at risk for recurrent infection, persistent middle ear effusion (MEE), and for several late complications of TT placement [84-86]. In a meta-analysis of >60 randomized trials and 70 case series, the pooled incidence rates of complications and sequelae of TTs were as follows [84]:
●TT otorrhea – 16 percent within the initial two weeks after placement; 26 percent at >2 weeks after placement (see "Tympanostomy tube otorrhea in children: Causes, prevention, and management")
●Occlusion of TTs – 7 percent (see 'Blocked tubes' above)
●Premature extrusion – 4 percent
●Medial displacement of TTs (picture 11) – 0.5 percent
●Persistent tympanic membrane (TM) perforation – 2 percent with short-term TTs; 16 percent with long-term TTs
●Tympanosclerosis or myringosclerosis – 32 percent
●Focal atrophy of the TM at the site of insertion (this finding increases the risk of retraction pockets and cholesteatoma) – 25 percent
●Retraction pocket (picture 12) – 3 percent
●Cholesteatoma – 0.8 percent with short-term TTs; 1.4 percent with long-term TTs (see "Cholesteatoma in children")
In a cohort study using an administrative dataset with >14,000 children who underwent TT placement at a large multihospital health system (Intermountain Healthcare), 14 percent of patients required a second set of TTs within five years and 5 percent required three or more sets; 3 percent required removal of a TT at an average interval of 34 months postplacement; and 5 percent required myringoplasty to address TM perforation after TT extrusion or removal [74].
Although most serious complications of TT placement are uncommon, early detection and management are necessary to reduce long-term morbidity.
Tube otorrhea — The prevention and management of TT otorrhea are discussed separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)
Persistent perforation — Most postintubation perforations close spontaneously (picture 13) [87,88]. Persistent TM perforation (picture 14) after TT extrusion occurs in 2 to 6 percent of cases when short-term TTs are used and approximately 15 percent when long-term TTs are used [84,89]. Persistent perforation is also related to duration of intubation and baseline structural integrity of the TM [28,84,89,90].
The diagnosis of persistent perforation is made clinically with otoscopy (picture 14). Pneumatic otoscopy demonstrates an immobile TM. The diagnosis can be confirmed with tympanometry, which typically demonstrates a flat (type B) tympanogram (figure 2) and a large volume measurement.
Postintubation perforations should initially be observed for a period of 6 to 12 months before proceeding with surgical closure since most perforations close spontaneously (picture 13) [87,88]. If left untreated, large perforations may cause slight to moderate conductive hearing loss [91]. 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) [92,93]. 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 [94-96].
In a review of 2604 ears in which TTs were placed for recurrent acute otitis media (AOM) or otitis media with effusion (OME), the overall rate of persistent TM perforations was 3 percent [89]. The rate of persistent TM 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 TT placement – The rate was higher in children with recurrent AOM compared with those with OME (16 versus 2 percent)
●TT type – The rate was higher in children who received long-term TTs compared with those who received short-term TTs (15 versus 2 percent)
●Number of TT placements – The rate was higher in children with ≥2 compared with one previous TT 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)
Retrospective cohort studies suggested that patients treated with fluoroquinolone ear drops may be at greater risk of persistent perforation than those treated with aminoglycoside drops [97,98]. However, the observational study design and source of the data (Medicaid encounter and pharmacy billing data) limit the certainty of this finding. Animal studies also suggest that fluoroquinolone drops may delay TM healing [99].
Myringosclerosis — TTs are associated with structural changes of the TM [100,101]. Approximately 32 percent of TMs (range 7 to 64 percent) develop asymptomatic whitish plaques of calcium and phosphate crystals (myringosclerosis) after TT extrusion (picture 15) [84]. For every 3.3 children who receive TTs, one additional case of myringosclerosis occurs compared with children with recurrent otitis media who do not receive TTs. The plaques may be localized or diffuse and are of uncertain etiology. Boys are affected more often than girls [102], and larger plaques are associated with multiple intubations [103].
The diagnosis of myringosclerosis is made clinically. Otoscopy demonstrates whitish plaques on the TM (picture 15). 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.
Myringosclerosis associated with TT placement rarely requires treatment. Although the plaques that occur after TT extrusion may cause hearing loss if they involve the ossicles, this phenomenon is not common in the United States and Europe. The hearing impairment caused by myringosclerosis involving the ear drum alone is <0.5 decibels, which is inconsequential [100].
Focal atrophy of the tympanic membrane — After a TT has extruded, the resultant perforation (approximately 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) [104]. 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 TT 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) [84]. Generalized atrophy or TM collapse (atelectasis) (picture 16) is caused by poor Eustachian tube function, not by prior intubation. (See 'Cholesteatoma' below.)
Focal weakening of the TM is usually nonprogressive, and tympanoplasty is rarely required. However, because of this focal weakening, a history of TT placement is associated with an increased risk of re-perforation of the ear drum at the old TT site following minor barotrauma (slaps, diving, etc.) [105].
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 TTs may have an overall protective effect on cholesteatoma formation in children with recurrent AOM because acquired cholesteatoma is a complication of recurrent AOM [106]. (See "Cholesteatoma in children".)
However, acquired cholesteatoma also can occur as a complication of TT placement [107-111]. The risk of cholesteatoma formation is increased with long-term TTs compared with short-term TTs. In one meta-analysis of TT sequelae, cholesteatoma occurred in 0.8 percent of children with short-term TTs and 1.4 percent of children with long-term TTs [84]. In a large retrospective cohort, cholesteatoma occurred in 1 percent of children who underwent TT insertion. The risk of cholesteatoma was increased in children who underwent multiple TT insertions [111].
Retraction pockets are the first step in the genesis of an acquired cholesteatoma (picture 12) [112]. 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".)
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, otitis media with effusion, and external otitis".)
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 email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Ear tubes (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Common indications for TT insertion – Tympanostomy tubes (TTs; also called "pressure-equalizing [PE] tubes" or "ventilation tubes") are placed when long-term ventilation of the middle ear space is desired. TTs 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'.)
●Follow-up after TT insertion – Otolaryngology follow-up after TT placement typically occurs at four- to six-month intervals. Otolaryngology follow-up continues until extrusion or removal of TTs and healing of the tympanic membrane (TM), normal Eustachian tube function, and normal hearing have been established. (See 'Follow-up schedule' above.)
●Indications for earlier referral – 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 TT is obstructed or cannot be visualized (see 'Blocked tubes' above)
•An extruded TT that cannot be removed from the ear canal
•A TT that has migrated into the middle ear space
•The TT has been retained for more than two years (see 'Tube removal' above)
●Assessing tube function – Proper function of the TT 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 – Complications and sequelae of TTs include TT otorrhea, persistent perforation of the TM (picture 14), TT obstruction (picture 5), myringosclerosis (picture 15), focal atrophy of the TM (picture 4), and cholesteatoma. (See 'Complications and sequelae' above.)
