Ear infections represent one of the most common reasons children are seen by physicians. Nearly 75% of children under the age of 7 will have at least one ear infection, but most children outgrow ear infections as their immune systems and eustachian tubes mature. Still, many children continue to have recurrent and chronic ear infections.
Ear Nose and Throat (ENT) surgeons place ear tubes which save thousands of children every year from severe ear pain, hearing loss and use of antibiotics. Common ear tube questions and ear tube myths have been discussed in previous posts to allow parents to better understand their potential value. Nevertheless, ear tube complications remain possible.
Parents gain knowledge about the expectations for ear tubes when they speak with their child’s surgeon. Common events which occur while ear tubes are in place are not considered complications. Mucous leaking out of tubes is NOT an ear tube complication. The need for more ear tubes after they successfully fall out is also NOT an ear tube complication.
True ear tube complications typically arise after the tubes have been in place for an extended period of time. All surgeons inform parents that the tubes should fall out; however, the process for following the ear tubes varies.
After I place ear tubes, I personally follow my patients every 6-12 months until the tubes have fallen out. If the tubes remain in place after 2 years, I discuss the need for removal because the risk of these undesirable ear tube complications increases over time.
Some surgeons do not routinely follow patients after ear tubes are placed. These patients are followed by their pediatricians who refer patients back to the ENT physician if a problem arises. Parents should make sure they fully understand the followup plans after ear tubes are placed. I believe it is a good idea to return to the ENT surgeon if tubes have been in place for 2 years, even if no problems have yet occurred.
This blog addresses ear tube complications that frequently require additional surgery. Thus, these are true undesirable complications that result from the insertion of ear tubes.
7 Undesirable Ear Tube Complications
1. Ear tube blockage
During surgery, a small incision is made in the eardrum in order to insert the tube. Ear drops are typically prescribed after surgery to treat any remaining infection behind the eardrum and also to rinse away fresh blood so it does not clot and block the tube.
Many children resist ear drops being inserted into their ears (READ: wildly fight and reject drops for reaching their target!). Parents may then be unsuccessful at putting in drops as directed. When the child is checked after surgery, dried blood or mucous may block the tube. Sometimes the tube can be opened but other times, new tubes need to be placed.
When an ear tube become blocked many months after placement, different treatment options are available. Most of the time, nothing needs to be done as this type of blockage may be part of the process of the tube falling out. When air is noted to be in the middle ear, this means that the eustachian tube has begun to work well; therefore, the tubes simply need to be monitored to be sure they fall out.
If the tube is blocked and there is air in the middle ear, this indicates that the eustachian tube has begun to work well and the tubes simply need to be monitored to be sure they fall out.
If the tube is blocked and there is fluid trapped in the middle ear again, further evaluation is needed. Over time, the eustachian tube should be working better; consequently, fluid in the middle ear suggests a potential chronic nasal problem. Allergies, enlarged adenoid and sinus problems are common problems that need to be addressed to improve the natural drainage of fluid from the middle ear.
2. Ear tube remains in eardrum too long
Tubes are temporary and need to come out of the eardrum. If the tubes do not fall out on their own, they will need to be removed. These are called retained ear tubes.
Depending upon how old the child is and how much of the tube has already started to come out, some tubes can be removed in the office. However, because the tube is still lodged in the eardrum, it may be very painful.
Tubes that do not fall out on their own sometimes require ENT surgeons to remove the tube in the operating room.
3. Chronic infection and irritation around the ear tube
Our immune systems are designed to attack substances that are recognized as foreign. This works well for viruses and bacteria. Tubes and other surgically implanted medical devices are often recognized as foreign objects.
If tubes do not fall out, the body increases the immune system attack, and the tissues around the tube become extremely inflamed. Eventually, swelling and irritation turn into infected granulation tissue. As more time goes by, this tissue matures into a granuloma which can actually grow and completely cover the ear tube.
Antibiotics and ear drops are useful in treating this inflamed tissue but the main treatment option would include removing the ear tube to stop the foreign body reaction.
4. Hole in ear drum (Perforation)
Most ear tubes successfully fall out of the eardrum into the ear canal while the eardrum closes. However, if tubes stay in the eardrum too long, scar tissue may form around it. This scar tissue then allows the ear tube to simply fall out of the eardrum without the slow growth to close the hole. A chronic hole in the eardrum (perforation) can then occur.
If the perforation is small, it may slowly continue to heal and close on its own. But many chronic eardrum perforations require a more extensive surgery to rebuild the eardrum and close the hole with a graft.
5. Ear tube falls out of eardrum into the middle ear
Extrusion is the process of the ear tube being slowly pushed out of the eardrum into the ear canal. In rare cases, the tube falls into the middle ear, and the eardrum heals over the tube. This process is called intrusion.
The tube trapped in the middle ear can stimulate a foreign body reaction and lead to middle ear infections, or fluid collection.
Surgery is required to remove the tube from the middle ear.
6. Eardrum scarring
Any chronic irritation of the eardrum, including recurrent ear infections or ear tubes, can cause eardrum scarring. This scarring occurs when white, hard calcium deposits collect on a normally thin eardrum.
In most cases, the scarring causes no problem with hearing and does not need any treatment; however, the scar tissue can replace a large part of the eardrum or extend into the middle ear space. This more aggressive scarring may cause significant hearing loss and need surgery to correct it.
7. Cholesteatoma (KO-less-TEA-uh-TOE-muh)
You may or may not have noticed, but many ear tube complications can also occur as a complication of recurrent ear infections. One of these severe complications that can occur, even if a child never requires ear tubes, is the dreaded cholesteatoma.
The process for cholesteatoma formation around the ear tube occurs because the tube can trap skin under its edges where it may not be easily seen. The skin from the outer ear can then grow into the middle ear and can cause severe damage to hearing structures or lead to life-threatening infections.
Potential trapped skin that may not be visible; consequently, this represents one of the reasons that ear tubes must be removed if they do not fall out.
The eardrum is not supposed to have a permanent connection from the outer ear to the middle ear. Close monitoring of ear tubes can often prevent these complications.
Make sure your ENT surgeon or pediatrician has clearly told you that the tubes have fallen out of your child’s eardrum to avoid these undesirable ear tube complications.
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