Tympanostomy Tubes in Children
Key Points
Key Points
- Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States.
- Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy.
- All these conditions are encompassed by the term otitis media (middle ear inflammation), which is second in frequency only to acute upper respiratory infection (URI) as the most common illness diagnosed in children by health care professionals.
- When children receive surgery for OME (Table 1), insertion of tympanostomy tubes is the preferred initial procedure, with candidacy dependent primarily on hearing status, associated symptoms, and the child’s developmental risk.
- Risks and potential adverse events of tympanostomy tube insertion are related to both general anesthesia, usually required for the procedure, and the effects of the tympanostomy tube on the tympanic membrane and middle ear.
- When making clinical decisions, the risks of tube insertion must be balanced against the risks of chronic OME, recurrent otitis media, or both conditions, which include suppurative complications, damage to the tympanic membrane, adverse effects of antibiotics, and potential developmental sequelae of the mild to moderate hearing loss that is often associated with middle ear effusion.
Table 1. Abbreviations and Definitions of Common Terms
| Term | Definition |
|---|---|
| Myringotomy | A surgical procedure in which an incision is made in the tympanic membrane for the purpose of draining fluid or providing short-term ventilation |
| Tympanostomy tube insertion | Surgical placement of a tube through a myringotomy incision for purposes of temporary middle ear ventilation. Tympanostomy tubes generally last several months to several years, depending on tube design and placement location in the tympanic membrane. Synonyms include ventilation tubes, pressure equalization tubes, grommets (United Kingdom), and bilateral myringotomy and tubes |
| Otitis media with effusion (OME) | The presence of fluid in the middle ear without signs or symptoms of acute ear infection |
| Chronic OME | OME persisting for 3 months or longer from the date of onset (if known) or from the date of diagnosis (if onset unknown) |
| Hearing assessment | A means of gathering information about a child’s hearing status, which may include caregiver report, audiologic assessment by an audiologist, or hearing testing by a physician or allied health professional using screening or standard equipment, which may be automated or manual. Does not include the use of noisemakers or other nonstandardized methods |
| Acute otitis media (AOM) | The rapid onset of signs and symptoms of inflammation of the middle ear |
| Persistent AOM | Persistence of symptoms or signs of AOM during antimicrobial therapy (treatment failure) and/or relapse of AOM within 1 month of completing antibiotic therapy. When 2 episodes of otitis media occur within 1 month, it may be difficult to distinguish recurrence of AOM (ie, a new episode) from persistent otitis media (ie, relapse) |
| Recurrent AOM | Three or more well-documented and separate AOM episodes in the past 6 months or at least 4 well-documented and separate AOM episodes in the past 12 months with at least 1 in the past 6 months |
| Middle ear effusion (MEE) | Fluid in the middle ear from any cause but most often from OME and during, or after, an episode of AOM |
| Conductive hearing loss (CHL) | Hearing loss, from abnormal or impaired sound transmission to the inner ear, which is often associated with effusion in the middle ear |
| Sensorineural hearing loss (SNHL) | Hearing loss that results from abnormal transmission of sound from the sensory cells of the inner ear to the brain |
| Tympanostomy tube otorrhea (TTO) | Discharge from the middle ear through the tube, usually caused by AOM or external contamination of the middle ear from water entry (swimming, bathing, or hair washing) |
| Retraction pocket | A collapsed area of the tympanic membrane into the middle ear or attic with a sharp demarcation from the remainder of the tympanic membrane |
| Tympanogram | An objective measure of how easily the tympanic membrane vibrates and at what pressure it does so most easily (pressure-compliance function). If the middle ear is filled with fluid (eg, OME), vibration is impaired and the line will be flat. If the middle ear is filled with air but at a higher or lower pressure than the surrounding atmosphere, the peak on the graph will be shifted in position based on the pressure (to the left if negative, to the right if positive) |
Management
Manageme...
...y of Guideline Key Action Statements (...
...OME of Short DurationClinicians shoul...
...ing EvaluationClinicians should obtain a heari...
.... Chronic Bilateral OME with Hearing D...
.... Chronic OME with SymptomsClinician...
...ance of Chronic OMEClinicians should reevaluate...
...AOM without MEEClinicians should not perform tymp...
...current AOM with MEEClinicians should of...
...hildrenClinicians should determine if a child wit...
...Tubes in At-Risk ChildrenClinicians may perfor...
...erm TubesThe clinician should not plac...
...denoidectomyClinicians may perform...
...operative EducationIn the perioperative period, cl...
...ative Ear DropsClinicians should not rout...
...Acute Tympanostomy Tube OtorrheaClinici...
...ter PrecautionsClinicians should not e...
...pThe surgeon or designee should examine th...
...son of AOM With and Without a Tympanostom...
...4. Comparison of Short-term vs. Long-...
...line Washout (Irrigation) to Prevent Postoperat...
...isk Factors for Developmental Difficult...
...Validated Questions for Assessing Hear...
...igure 1. Relationship of the EarRelation...
...ubes(A) Size of tympanostomy tube compared to...
...earing LevelsAn average hearing level between 0 a...
...igure 4. AOM and Tympanostomy TubesAOM without a...
...5. Normal Type A Tympanogram ResultThe...
...e 6. Abnormal Type B Tympanogram Result...
...Tissue SpearsAdapted from Centre for Remote He...
...Flowchart Showing Key Action Statements and Proce...
Patient Information
...nt Information...
...uld I do if my child has frequent ear inf...
...Why am I receiving this information...
...at is middle ear fluid, also called effu...
...does it mean if my child has repeated ear infec...
...there any children who should still get...
...if my family doctor specifically sent me to...
...Tubes — A Caregiver's...
...e ear tubes recommended?Ear tubes are recommended...
2. How long will my child's ear tubes last?Mo...
...When does my child need to be seen again after t...
...possible complications, or problem...
...y child need ear plugs when exposed to wa...
...ar tubes and ear infectionsEar tubes will...
...e possible reasons why my doctor or health...
...call the Ear Doctor (Otolaryngologist...