Bilateral myringotomy and tube placement, or “placing PE tubes”, is the most common surgical procedure performed in the United States, and for good reason. Simply put, for the right child, it is a simple, safe procedure, which can help resolve chronic middle ear infections while preventing future infections and eliminating the need for numerous courses of antibiotics.
The question is how do we choose “the right child”. Generally, this decision is made along with the parents after carefully reviewing not only the patient’s physical examination, but also the history of ear infections, hearing loss, or persistent fluid in the ears. The following is a detailed description of what to expect if your child does undergo bilateral myringotomy and tube placement (BM & T).
How does the ear work?
The ear has three compartments: the external ear consisting of the visible ear or auricle, the ear canal which is a tunnel of cartilage and bone which leads and channels sound down to the ear drum, also called the tympanic membrane. Behind the ear drum is an air filled space called the middle ear. It is filled with air and allows the ear drum to vibrate. Bones behind the ear drum, called ossicles, are found in this space and they are important for amplifying and transmitting sound waves from the ear drum to the inner ear, which is the third compartment. The inner ear is the nerve center of the ear and will not be discussed in detail at this time as it is not relevant to the procedure in question.
The ear drum vibrates much like a stereo speaker when sound waves, which travel as vibrations through the air, hit it. A stereo speaker creates the vibrations which send the sound waves out, while the ear drum receives them, or is made to vibrate by the sound waves, but the physical actions are similar. In order for a speaker or ear drum to vibrate properly, there needs to be air on both sides of the membrane. You can imagine that if your stereo speaker were filled with honey that not much sound would come from it because the woofer or speaker membrane could not move freely. Similarly, the space behind the ear drum must be filled with air that is neither at higher nor lower air pressure than the air in the room. Imagine going up in an airplane or to the bottom of a pool. In each of these circumstances the pressure on one side of the drum is higher or lower than in the middle ear resulting in the ear drum being pushed in our made to bulge out, with resulting pain and decreased hearing. Eventually the pressure can be equalized by “popping the ears.” This is a process which can be learned, but which occurs naturally throughout the day in a healthy ear by the opening and closing of the Eustachian tube. This tube allows air in the back of the nose to enter or exit the middle ear and thus equalize the air pressure in the middle ear. When the Eustachian tube works properly, the middle ear is generally healthy. When it does not work properly for an extended period of days to weeks, the middle ear fills with mucus which is secreted by the lining of the middle ear and infection can then occur. Reasons for a Eustachian tube not working properly include viral infection, hereditary reasons, age related reasons, allergy, sensitivity to pollution, obstruction due to large adenoids, or environmental reasons.
Myringotomy and tube placement – what to expect
Myringotomy and tube placement is a very simple and low risk procedure designed to create a temporary but constant pressure release for the middle ear. It is not for all children or adults with ear infections. The decision to recommend tubes is a complex one made by your doctor based on years of experience and training, and with a full knowledge of all the relative risks and benefits in your particular case. We will summarize these risks and benefits here, but they are unique in each patient and your surgeon should be asked if they are not clear to you.
“It is very important to follow the postop instructions given to you to minimize the likelihood of complications such as a plugged tube.”
By placing tubes in the appropriate patient, the risk of recurring infection, extension of infection into the mastoid bone, permanent damage to the ear drum, erosion of the bones behind the ear drum, formation of erosive cysts in the ear, development of temporary and even permanent hearing loss can be diminished. The procedure itself takes about 3-5 minutes. While no procedure is perfect, this operation is almost ideal in that it is quick, painless, highly effective, and generally has few complications. During the procedure the patient is either asleep (in the case of children), or the ear drum is otherwise anesthetized in the office. No IV’s or breathing tubes are typically required if this is the only procedure being done. Under a microscope, the ear drum is carefully examined and then a small nick or incision is made with a special instrument. The middle ear fluid or mucus, if there is any, is sucked out from behind the drum, and a special tube (about the size of the tip of a lead pencil) is inserted through the incision. This is no more traumatic to the body than piercing ears, it is just more mysterious because you cannot see the tube. Once the tube is in position, your surgeon will usually ask you to put ear drops in the ears and to pump on the tragus (the small cartilage in front of the ear), to push the drops through the tubes. This helps fight the infection and also keeps the tubes from getting plugged with dried mucus. It is very important to follow the postop instructions given to you to minimize the likelihood of complications such as a plugged tube. The tubes we use in children and in some adults are designed to minimize the likelihood of complications while lasting 6-12 months, although that is highly variable. Please understand that we have no more control over what happens to the tubes after we place them than you do, but we can certainly assist with any issues that come up, such as infection, drainage or the tubes becoming plugged. For this reason we like to watch children with tubes by having them return to our office for a tube check about every 4-6 months. We also will typically want to verify normal hearing at the postop visit, and then yearly thereafter as long as we are treating the patient.
This procedure is usually but not always done on both ears, especially in children under age 4. Once completed the patient is typically awakened and sent home 30-60 minutes later. The surgeon will explain his findings in surgery and will explain what to look for and how to care for the patient. There is usually little or no pain involved, and often the ears immediately feel much better due to the release of pressure and fluid. Tubes stay in the ear drum until the drum heals and pushes them out, much like a splinter being pushed out of the skin.
Are there any potential problems to consider?
Problems can arise as with any foreign object in the body. The tubes can be pushed out too early, they can become plugged or the body may begin to react to them by forming what we call granulation tissue, or proud flesh, around them. Most of these problems can be resolved by proper treatment in the office, but sometimes the patient will require replacement of the tubes. In children, tubes are a temporary measure to prevent middle ear problems and infection until the child has outgrown the problem and the Eustachian tube function has returned to normal. Unfortunately, in some patients the need for tubes persists into adulthood, at which time a longer lasting tube is generally recommended.
In some cases, the ear drum may not have a strong enough blood supply to allow the strong healing that pushes the tubes out. This may cause the tubes to remain in place longer than normal, and may even result in the persistence of a small hole in the eardrum after the tubes are removed or come out. In these cases most of the time the drum will heal and close after the Eustachian tube function returns to normal. In the mean time the perforation or hole acts like a tube to prevent infection. If a hole in the ear drum persists until age 6-7 or is causing problems like hearing loss by getting too big, then a procedure called myringoplasty or tympanoplasty may be recommended to close the hole. Although this is an uncommon occurrence, it is why we recommend regular follow-up with your surgeon to monitor the tubes and the patient’s hearing after tube placement.
We are happy to answer your questions!
We hope that this discussion and presentation of issues regarding tube placement helps you in making an informed decision regarding your or your child’s health. Please feel free to call to schedule a consultation or reevaluation to any questions which may remain. We are resolved to providing you, the patient, with the highest quality care, and the most accurate information possible regarding your care, as well as to forming a strong partnership in achieving excellent health.