How Do Pressure Equalizing Tube Bypassing the Eustachian Tube?
It is important to remember that the tube does not "fix" the underlying problem (immature Eustachian Tube function and poor ear ventilation). No surgical intervention can fix this problem except growth and development. While some children take longer to out grow ear disease than others, very few children still have this problem past age 8. The tubes simply act as a "way to buy time" as the child grows or in adults to allow swelling to resolve in adult patients. Ear tubes work by bypassing the problem and ventilating the ears through the eardrum. Therefore ear infections and ear fluid are reduced or prevented. By the time the tubes come out, most children have grown enough to ventilate their ears on their own - approximately 10 % of children may need to have tubes placed more than once.
There are two basic types of tubes- short acting and long acting. Although there are dozens of styles and brands, most fall into one of these two categories. Each surgeon has his or her own preferences regarding tube selection. Generally, short acting tubes are used in children without other underlying problems (see below) for their first or second set of tubes. These tubes reliably fall out of the eardrum within 6 months to a year after placement.
Long acting tubes are used with children suspected of having severe, long-term Eustachian tube problems. Such problems may be seen in children with cleft palate, Down syndrome, various head and neck syndromes, or older children who have had longstanding ear problems and severe collapse of the eardrum. While the long-term tubes make replacement surgery less likely, they have a greater chance of leaving a persistent hole in the eardrum after they fall out or are removed, which would then require more extensive surgery to repair. For this reason, I rarely recommend long term tubes in children and only recommend long term tubes in adults if their problems are persistent.
For children ear tubes are placed under general anesthesia through the ear canal using a microscope. After cleaning out the wax from the ear canal, a tiny hole is made in the eardrum with a small knife, and any fluid is suctioned from the ear. The tube is then inserted into the hole, where it stays in place due to its flared ends (it is shaped like a spool of thread). No skin incision or sutures are used, nothing is visible from the outside, and the entire operation usually takes less than ten minutes for each side. Most parents are very concerned about the anesthesia, but this is extremely safe. For adults who can withstand the discomfort of the procedure tubes are placed in the office with a topical anesthesia applied to the ear drum. This can be a rather uncomfortable procedure so I rarely recommend placement of ear tubes in the office in children.
In some cases removal of the adenoids will be recommended when tubes are placed. The theory behind this practice is that the adenoids sit at one end of the Eustachian tube (in the back of the nose), and may contribute to ear infections and fluid . There are several theories as to why the adenoids have this effect. One of which is that they physically block the Eustachian tube, interfering with its function. Another theory is that they provide a place for bacteria to grow which then inflames the Eustachian tube, or bacteria from the adenoids travel up the eusthacian tube into the ear causing infections.
Adenoidectomy adds a small amount of time and risk to the surgery, and like all operations, should not be done unless there is a good reason. Adenoidectomy may be recommended if your child has required a previous set of ear tubes or has symptoms which suggest blockage of the nose by the adenoids such as snoring, mouth breathing or recurrent infections.
What are the benefits of inserting pressure equalizing tubes?
In children who have persistent ear fluid, the benefit is immediate. Once the fluid is suctioned from the ear, hearing is improved. Many parents of children with speech delay related to hearing loss will report a quick improvement in language and socialization after surgery. Sometimes, especially if the fluid is thick, drainage from all the small spaces throughout the middle ear may continue for a few days. The ventilation that the tube provides prevents the fluid from coming back, as long as the tube is open.
For children with recurrent ear infections, the tubes make it less likely that the ear will become infected in the future, reducing the need for antibiotics. However, it is still possible to get an ear infection, especially during a cold. In this case, the ventilation tube serves to drain the infected fluid out of the ear. Therefore, the child experiences less pain and fever than they would if the tubes were not in place. I will ususally recommend the use of ear drops instead of oral antibiotics if your child does develop ear infection or drainage after tubes are placed. The ear drops are antibiotics and avoid, in most cases, the use of oral antibiotics.
What are the risks of inserting pressure equalizing tubes?
The most common problem after tube placement is persistent drainage of liquid from the ear. Although the tube is placed to allow for drainage as well as ventilation, sometimes the drainage continues for weeks and may cause symptoms such as itching or foul odor. In this case, it may require specific treatment such as the use of ear drops. If drainage from the ears does not improve within three days of starting ear drops then a child should be seen in our office for an evaluation.
In rare cases, the hole in the eardrum will not close as expected after the tube comes out. This is very uncommon with short acting tubes, but I recommend that no tube stay in place for more than three years. After three years, the chance of persistent perforation increases and removal of the tube is recommended.
Many parents are concerned about "scarring" of the eardrum. This can be seen after tube placement, or simply after many ear infections. In most cases, scar tissue on the eardrum does not cause any problem at all, and hearing is generally normal once the fluid is gone. Serious injury to the middle or inner ear mechanism during surgery is extremely uncommon.
The surgery to insert tubes is done under general anesthesia. This is usually the most frightening part of the whole process for parents. However, it is extremely safe. While the operation only takes a few minutes, it is vital that the child be absolutely still, as even a small amount of movement could cause damage to the ear to occur. Although tubes can be placed in adults with local anesthesia, it is simply not possible to do this safely in most younger patients.
Doesn't the hole in the eardrum that occurs when tubes are placed cause a hearing loss?
In most cases hearing is improved by removing the fluid and allowing sound to travel through the middle ear. The size of the hole is so small compared to the overall size of the ear, that it does not significantly reduce the surface of the eardrum. Even with a tube in place, the drum vibrates well enough for normal hearing to occur.
What do I have to do after the tubes are placed?
There is little care that is required after tubes are placed. You or your child will be seen in follow up three weeks after the surgery and then every three to four months so that I may check the ear to assure that no problems with the tubes are developing. You or your child will have a hearing test performed after the tubes are placed and hearing test will be performed intermittently while the tubes are in place to assure that there is no decrease in hearing.
What happens when the tubes fall out?
The tube is pushed out as the eardrum grows. As this happens, the tube is designed to fall outward, into the ear canal. Once it is there, it does not cause any harm. In most cases it will work its way out of the canal and fall out of the ear entirely.
Once the tube is out and the hole in the eardrum has closed, the child is once again dependant on his or her own natural ear ventilation to prevent ear infections and the accumulation of fluid. Tubes are placed to "buy time" and allow for ventilation while the child's ears mature; ideally, by the time the tubes are out, the child has outgrown the ear problem that required the operation. However, this is not always the case.
About 10% of children will need a second set of tubes, and a smaller number will need a third set. Such children may have underlying problems which make them take a long time to grow out of their ear disease (such as cleft palate), while others are otherwise normal but just take longer to develop good Eustachian tube function. Long acting tubes make the chances of a second operation less likely, but this benefit must be balanced against the greater possibility of persistent perforation (especially if they are not removed before three years). In each child, a number of factors go into the decision as to what type of tubes to place and whether or not they need replacement.
Can my child swim with tubes in place?
Yes they may swim. No special precautions are needed for routine water exposure such as bathing and swimming. If your child is an "aggressive" swimmer such as diving head first into a pool or swimmming to the bottom of the pool (ie. deeper than three feet) than ear plugs are recommended. The danger of "aggressive" swimming with ear tubes in place is that water will be forced through the tube by water pressure and an ear infection could develop. Approximately 2% of children who are not "aggressive" swimmers will be sensitive to water with ear tubes in place. You will know whether your child is sensitive as they will complain of ear pain when exposed to water. These children should wear ear plugs when exposed to water. Ear plugs can be purchase at most pharmacies or custom ear plugs can be made in our office by appointment.
Can my child travel by airplane with tubes in place?
One of the additional advantages of tube placement is that the ear pain of takeoff and landing will be eliminated. This pain is caused by the ear's inability to rapidly equalize air pressure between the pressure level in the cabin and the pressure level behind the ear drum. With tubes in place, the pressure equalizes instantly, and no pain should be felt unless the tube has become clogged.