Overview of Tympanostomy Tube Insertion
Tympanostomy tubes are tiny tube-like devices that doctors insert into the eardrum. This procedure lets fluid drain out from the middle part of the ear and balances the pressure between the middle ear and the outside. It’s a brief surgery and children usually get it done in an outpatient clinic while they’re under general anesthesia, meaning they’re asleep and don’t feel pain. In fact, this is one of the most common surgeries for kids. To put it in perspective, about 8% of all kids in the United States will have had this operation at least once by the time they turn 3. Moreover, nearly one in five children will need a second set of tubes put into their ears during their lives.
The main reasons for this procedure include recurrent acute otitis media (AOM), chronic otitis media with effusion (OME), and continuous middle ear infections that don’t get better with standard treatment. To break down these medical terms, otitis media is just a fancy name for an ear infection. It’s the second most diagnosed condition in kids, especially those younger than 7 years old as their immune systems not as strong and their eustachian tubes, which connect the middle ear to the back of the throat, don’t fully function yet. These tubes are designed to relieve symptoms, boost hearing, and fend off complications linked to long-term fluid build-up in the middle ear. These complications could include conductive hearing loss (a type of hearing loss where sound can’t get through the outer and middle ear) and the return of infections.
Anatomy and Physiology of Tympanostomy Tube Insertion
The external ear and the eardrum, also known as the tympanic membrane (TM), are important structures that doctors need to understand in order to insert a tube into the ear safely.
The external ear is made up of the pinna or auricle, which is the visible part of the ear that we can see on the side of our heads. This part of the ear is like a funnel and leads into the acoustic meatus and the external ear canal. The external ear canal in adults is around 2.5 cm long and is made of two parts: a bony segment towards the middle and a cartilage segment towards the outer side. The TM is situated inside the external ear canal and it plays a major part in forming the side wall of the middle ear space.
You can think of the TM as a thin, shiny, gray, and slightly curved piece. It has three layers: the outer skin layer, a middle fibrous layer, and an inner mucosal layer that is continuous with the lining of the middle ear cavity. The middle layer, which is made up of an outer radial layer and a deeper circular layer, supports the skin on one side and the middle ear mucosa on the other. This fibrous layer extends outwards to form the annulus. A part of the malleus, one of three tiny bones in the ear, attaches to the inside of the TM, and the tip of the malleus forms a small depression in the TM called the umbo. The TM has two parts: the thinner, upper part called the pars flaccida, and the thicker lower part called the pars tensa. The total surface area of the TM is about 85 mm2, but only 55 mm2 can move. The TM is about 8.5 to 10 mm up-and-down and 8 to 9 mm across.
The TM’s surface is nourished by blood supplied from the maxillary artery’s deep auricular branch, the occipital artery’s auricular branch and the maxillary artery’s anterior tympanic artery branch. Sensation in the TM is provided by certain nerves: the auriculotemporal branch of the nerve connected to the jaw, the facial nerve’s auricular branch, the vagus nerve’s auricular branch and the glossopharyngeal nerve. The glossopharyngeal nerve is also responsible for sensation on the inside of the TM.
Inside the TM is the middle ear space, which contains the ossicles: the malleus, incus, and stapes. The facial nerve passes through the middle ear space from front to back, right above the oval window and the stapes bone. The nerve then turns 90 degrees, runs downwards at what’s called the second genu, and travels through the mastoid part of the bone found near the ear, the temporal bone, before exiting this bone through a small opening known as the stylomastoid foramen. There is another nerve, a branch of the facial nerve that runs from back to front and exits through the petrotympanic fissure, which is called the chorda tympani. This nerve joins the lingual nerve and enables taste sensation in the front two-thirds of the tongue.
Why do People Need Tympanostomy Tube Insertion
The American Academy of Otolaryngology-Head and Neck Surgery suggested some guidelines in 2022 for inserting tiny tubes into a child’s eardrum. These tubes can help to drain out excess fluid and improve hearing. Here are the situations when a child might need these tubes:
- If both ears have had fluid behind the eardrum for three months or more, and the child has started having trouble hearing.
- If one or both ears have had fluid for this long and the child has issues that the doctor thinks are due to this, like balance problems, bad behaviour, not doing well at school, ear pain, or less enjoyment of life.
- If a child has had middle ear infection multiple times (three or more in the last six months, or at least four in the previous year with at least one in the past six months), and there’s fluid behind the eardrum at the time the doctor is checking if tubes are needed.
Children who are at risk of not developing normally and have fluid in one or both ears for three months or more might also need these tubes. The children at risk include those with permanent hearing loss, delay in speech and language development, autism spectrum disorder, certain syndromes or craniofacial disorders, blindness or difficulty seeing that can’t be corrected, a cleft palate (a split in the roof of the mouth), intellectual disability, learning disorders, or attention-deficit hyperactivity disorder.
If a child needs the tubes and also has issues involving the adenoids (like infections or trouble breathing through the nose), doctors might remove the adenoids at the same time. This is especially a possibility for children who are at least four years old because it might help to prevent future ear infections or the need for more tubes.
For adults, however, there aren’t any clear rules about when tubes should be used. This can result in a delay in treatment. Generally, tubes might be considered for adults with ongoing problems with the eustachian tube (which connects the middle ear to the back of the nose), depending on how bad the symptoms are and whether they’re likely to improve.
When treating eustachian tube problems in adults, doctors often start with medications and run some tests to measure how well their patient can hear and how the eardrum is moving. It’s important to repeat these tests and check for any improvements after three to twelve months of treatment. If the treatment isn’t working well enough and the tests show this, surgery (like tubes) may be needed. This way, doctors can be sure the surgery is necessary based on objective measures.
In some cases, tubes might also be put in during a specific type of treatment with oxygen under pressure (hyperbaric oxygen therapy) to treat or prevent trauma due to changes in pressure (otic barotrauma).
When a Person Should Avoid Tympanostomy Tube Insertion
There are no strict reasons why a patient can’t have an ear tube placement surgery, medically known as a tympanostomy. However, patients with a persistent Ear Middle Inflammation (OME) or repeated Acute Middle Ear Infection (AOM) who don’t meet the required criteria for the ear tube surgery may just be monitored or given antibiotics, depending on their medical condition.
Still, an ear tube can be placed solely based on the decision of the surgeon after fully discussing the potential risks and benefits of the operation with the patient or their caretaker.
In some cases, certain uncommon variations in a person’s ear anatomy might make the ear tube surgery a bit risky. Such variations could include a close proximity between the facial nerve and the middle ear space, or an unusual or exposed location of the carotid artery (a major blood vessel) within the middle ear.
Equipment used for Tympanostomy Tube Insertion
If you need to have a procedure called a tympanostomy tube placement, doctors will use a number of special tools and equipment to carry out the treatment. These include:
- An operating microscope or an endoscope, which is a device used to look inside the body
- Ear specula, a tool to spread the opening of the ear for a better view
- Several types of forceps, which are like tiny tweezers, for gripping objects
- Cerumen loops, used to clean out ear wax
- Fraiser suction tubes of different sizes to clear out fluids
- A myringotomy knife for cutting into the eardrum
- Last but not least, a tympanostomy tube.
Tympanostomy tubes are small tubes that can be made from different materials like plastic, metal, a mineral called hydroxyapatite, or a flexible material called silicone. These tubes can be designed to stay in your ear for a short-term (6-12 months) or a long term (12 months or longer). The specific type or shape of the tympanostomy tubes can vary depending on the doctor’s preference, but all the types have shown good results.
Who is needed to perform Tympanostomy Tube Insertion?
During the process of placing tympanostomy tubes, which are special tiny tubes inserted into the eardrum to help drain fluid and improve hearing, different medical professionals are needed depending on where the procedure is done.
In an Operating Room:
- The Surgeon, who is a specialized doctor trained to perform this specific procedure.
- A Surgical Technician or Operating Room Nurse. These health professionals assist the surgeon during the procedure.
- A Circulating or Operating Room Nurse. They manage the operating room and make sure it’s clean, safe, and fully equipped.
- An Anesthesia Personnel. This person makes sure you’re comfortably sedated during the surgery so you won’t feel pain or discomfort.
In a Clinic:
- The Surgeon, who will do the procedure of inserting the tubes to treat your ear condition.
- A Medical Assistant or Nurse. This professional assists the surgeon and helps make sure your needs are met during the procedure.
Preparing for Tympanostomy Tube Insertion
When children have to go through a procedure, where a small tube is placed in their ear drum to help with recurring ear infections, they are typically given general anesthesia through a mask. This means they’re completely asleep and won’t feel anything during the procedure. However, if the child has to go through additional procedures, like removal of the adenoids (glands located in the roof of the mouth) or repair of the cleft palate (a condition where the roof of the mouth contains an opening into the nose), then the doctors use endotracheal anesthesia. This is a different type of anesthesia where a tube is placed into the windpipe to help with breathing while the child is asleep.
On the other hand, teenagers and adults can often tolerate this ear tube placement procedure in a doctor’s clinic under local anesthesia. This means that they’re awake, but the area being operated on is numbed. This is typically achieved with the help of numbing medicines like lidocaine or phenol. In some cases, lidocaine is also injected to numb the area effectively.
How is Tympanostomy Tube Insertion performed
The doctor will first examine the inside of your ear using a microscope and a small tool called an ear speculum or an endoscope – which is a long, thin instrument with a light and a camera on its tip. This helps check for any earwax or dead skin cells that may need to be removed for a clear view and easy access to the eardrum, which is the thin layer of tissue separating your ear canal from your middle ear.
Once the eardrum is clearly visible, a knife, designed especially for this procedure, is used to make a very small cut (about 2mm in size) at the lower front area of the eardrum. If there is any fluid built up in the middle ear, it may be suctioned out with a tool known as 5F or 3F Fraiser tip suction. If the fluid is too thick, it can be washed out with a saltwater solution.
Next, a tiny tube known as a tympanostomy tube is inserted into the small cut in the eardrum using a special type of pliers called alligator forceps. Another instrument, a pick or right-angle clamp, is used to adjust the tube’s position to ensure that the inner surface of the middle ear can be clearly seen through the tube.
Usually, any bleeding that may occur stops on its own. If it doesn’t, the doctor can apply a medication such as oxymetazoline or a solution with a drug called epinephrine directly to the area to help stop bleeding.
Antibiotic drops are placed in the ear during surgery and typically continued for several days after the procedure. This helps to keep the tube open and helps to reduce the risk of a possible ear infection after surgery.
Possible Complications of Tympanostomy Tube Insertion
After surgery to place a tube in your eardrum, sometimes known as a tympanostomy, it’s normal to see changes in the structure of the eardrum, such as hardening or scarring. These changes don’t usually need to be treated.
However, there can be some minor complications after tympanostomy tube placement.
One of the most common issues is that a fluid called otorrhea might start to drain from your ear. This happens in about 16% of kids within a month of surgery and 26% of kids over the entire time the tube is in place. To help prevent this, doctors usually give antibiotic ear drops right after surgery. It’s important to keep water out of your ears to stop the fluid from draining.
Another problem, affecting 6-12% of patients, is that the tube might get blocked. Doctors can treat this by manually removing the blockage or prescribing ear drops.
Around 4% of patients might develop something called granulation tissue where the tube is placed. If this happens, you’ll likely be given antibiotic-steroid drops. However, sometimes the tube might need to be removed if the tissue continues to grow.
Sometimes the tube might fall out too soon, typically within a few months of placement. If this happens, your doctor will see if a new tube needs to be put in.
In a small number of cases, 1-6% of the time, a hole might form in the eardrum after the tube falls out. In rare instances, this might need to be repaired with surgery.
Even rarer, the tube might move into the middle ear. This affects about 0.5% of patients and might need to be treated if the ear becomes inflamed.
Lastly, the tube might stay in place for too long, over 2-2.5 years. If the tube doesn’t fall out by itself, it can cause infection, chronic eardrum hole, tissue growth, and a skin growth called cholesteatoma. These issues can be treated with drops if they aren’t severe or persistent, otherwise the tube might need to be removed and the eardrum repaired.
What Else Should I Know About Tympanostomy Tube Insertion?
The act of placing a small tube in the eardrum, called a tympanostomy, is the most common outpatient surgery performed on children in the US. This procedure has been proven to enhance the quality of life for children. In patients suffering from ongoing fluid buildup in the middle ear (also known as chronic OME), the frequency of this troublesome fluid is reduced by 33%, and their hearing shows an average improvement ranging from 5 to 12 decibels. Thanks to the tympanostomy tubes, medicated ear drops can be applied straight into the middle ear at higher concentrations. This also reduces the need for children to take antibiotics through the mouth or via injections.
