Back To Search Results

Tympanostomy Tube Insertion

Editor: Macario Camacho Updated: 3/5/2024 6:40:26 PM

Introduction

Tympanostomy tubes are small, cylindrical devices inserted into the eardrum to facilitate fluid drainage from the middle ear and equalize pressure between the middle ear and the external environment. This minor surgical procedure, often performed as an outpatient procedure under general anesthesia, is 1 of the most frequently performed surgeries in children. In the United States (US), tympanostomy tube insertion is the most common ambulatory surgery performed on children younger than 15 years, with nearly 667,000 cases performed in 2006.[1] More than 8% of all children in the US will undergo tympanostomy tube placement at least once by age 3 years; approximately 20% will require the insertion of a second set of tympanostomy tubes during their lifetime.[2][3] 

Tympanostomy tube insertion is primarily indicated for conditions such as recurrent acute otitis media (AOM), chronic otitis media with effusion (OME), and persistent middle ear infections that fail to respond to conservative management. Otitis media is the second-most common ailment diagnosed in children and is more prevalent in children younger than 7 years of age due to their comparatively underdeveloped immune systems and compromised eustachian tube function.[4] Tympanostomy tubes aim to alleviate symptoms, improve hearing, and prevent complications associated with prolonged middle ear fluid accumulation, such as conductive hearing loss and recurrent infections.

Anatomy and Physiology

Register For Free And Read The Full Article
Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed. Earn CME/CE by searching and reading articles.
  • Dropdown arrow Search engine and full access to all medical articles
  • Dropdown arrow 10 free questions in your specialty
  • Dropdown arrow Free CME/CE Activities
  • Dropdown arrow Free daily question in your email
  • Dropdown arrow Save favorite articles to your dashboard
  • Dropdown arrow Emails offering discounts

Learn more about a Subscription to StatPearls Point-of-Care

Anatomy and Physiology

A comprehensive understanding of the anatomy of the external ear and a detailed familiarity with the tympanic membrane (TM) and its adjacent structures are essential to safely inserting a tympanostomy tube.

External Ear

The external ear comprises the auricle or pinna, a funnel-shaped cartilaginous structure contiguous with the acoustic meatus and external auditory canal. The external auditory canal, measuring approximately 2.5 cm in length in adults, has a lateral cartilaginous and a medial bony segment. The TM is positioned at the medial aspect of the external auditory canal and forms a significant portion of the lateral wall of the middle ear space.

Tympanic Membrane

The TM is concave, thin, semitransparent, and pearly gray. It comprises 3 layers: an outer epithelial or ectodermal layer, a middle fibrous layer, and an inner mucosal or endodermal layer; the inner mucosal layer is continuous with the squamous lining of the middle ear cavity. The middle fibrous layer, comprised of an outer radial layer and a deeper circular layer, supports the skin of the external auditory canal laterally and the middle ear mucosa medially. The fibrous layer integrates laterally to form the annulus. The manubrium of the malleus is attached to the medial aspect of the TM; the tip of the malleus forms a small depression in the TM called the umbo. The thinner, superior portion of the TM is the pars flaccida, and the thicker inferior area is the pars tensa. The pars flaccida comprises the upper posterior quadrant of the TM, and the pars flaccida comprises its remainder. The total surface area of the TM in adults is approximately 85 mm2; only 55 mm2 is mobile. The TM measures about 8.5 to 10 mm vertically and 8 to 9 mm horizontally.[5]

The lateral surface of the TM receives blood supply from the deep auricular branch of the maxillary artery. The medial surface is supplied by the auricular branch of the occipital artery and the anterior tympanic artery branch of the maxillary artery. Sensory innervation to the lateral surface of the TM is provided by the auriculotemporal branch of the mandibular nerve (cranial nerve [CN] V, V3), the auricular branch of the facial nerve (CN VII), the auricular branch of the vagus nerve (CN X), and the glossopharyngeal nerve (CN IX). The medial aspect of the TM is innervated by the glossopharyngeal nerve (CN IX).[6] 

Middle Ear

Medial to the TM is the middle ear space housing the ossicles: the malleus, incus, and stapes. The tympanic segment of the facial nerve traverses the middle ear space from anterior to posterior above the oval window and stapes. The nerve turns 90 degrees, runs inferiorly at the second genu, and runs through the mastoid portion of the temporal bone before exiting the temporal bone through the stylomastoid foramen. A branch of the facial nerve known as the chorda tympani runs from posterior to anterior behind the TM between the malleus and incus, exiting through the petrotympanic fissure. The chorda tympani joins the lingual nerve and gives a taste sensation to the anterior two-thirds of the tongue.

Indications

In 2022, the American Academy of Otolaryngology-Head and Neck Surgery published guidelines for tympanostomy tube insertion in children.[7] These guidelines are:

  • Bilateral chronic OME for 3 months or longer AND documented hearing loss.
  • Unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable, all or in part, to OME, including, but not limited to, balance (vestibular) problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life.
  • Recurrent AOM with unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy. Recurrent AOM is defined as 3 or more well-documented and separate AOM episodes in the last 6 months OR at least 4 well-documented and separate AOM episodes in the previous 12 months with at least 1 in the last 6 months.
  • At-risk children with unilateral or bilateral OME that is likely to persist as reflected by a type B (flat) tympanogram or a documented effusion for 3 months or longer. Children with OME who are at risk for developmental delays or disorders are those with permanent hearing loss independent of OME, speech and language delay, developmental disorders including autism spectrum disorder, syndromes or craniofacial disorders which include cognitive, speech or language delays, blindness or an uncorrectable visual impairment, cleft palate, developmental delay, intellectual disability, learning disorder, or attention-deficit hyperactivity disorder.

Adenoidectomy may be performed as an adjunct to tympanostomy tube insertion for children with symptoms directly related to the adenoids, such as adenoid infection or nasal obstruction, or in children aged 4 years or older to potentially reduce future incidence of recurrent otitis media or the need for repeat tube insertion.[7][8][9] 

Unlike children, there are no set guidelines for tympanostomy tube placement in adults, which can slow referrals and delay definitive treatment. The indications for tympanostomy tubes in adults with eustachian tube dysfunction vary and depend upon the severity of symptoms and the likelihood of improvement. Indications for adult tympanostomy tube placement are less well-defined but include chronic eustachian tube dysfunction leading to chronic OME, a systemic infection of unknown etiology with fluid within the mastoid or middle ear space, or an atrophic, retracted, and flaccid drum.[10] 

Primary care practitioners should initiate medical management and obtain a preliminary baseline audiogram and tympanogram when treating chronic eustachian tube dysfunction in adults. After 3 to 12 months of maximal medical therapy, subsequent studies should be conducted to assess symptom severity and improvement. Surgical intervention becomes necessary if medical management fails to alleviate symptoms and follow-up studies indicate insufficient improvement. This approach ensures appropriate escalation to surgical intervention when indicated based on objective measures of treatment response.

Occasionally, a tympanostomy tube is needed during hyperbaric oxygen therapy to treat or prevent otic barotrauma.[11]

Contraindications

There are no absolute contraindications to tympanostomy tube placement. Patients with chronic OME or recurrent AOM who do not meet the indications for tympanostomy tube placement should be observed or treated with antibiotics as medically indicated. However, a tympanostomy tube may be placed based on the surgeon’s judgment only after thoroughly discussing the risks and benefits of the procedure with the patient or their caregiver.

Several anatomic variants may be considered relative contraindications to tympanostomy tube placement. These variants include but are not limited to the dehiscence of the facial nerve within the middle ear space or a dehiscence or aberrant course of the internal carotid artery within the middle ear cleft.[12]

Equipment

The equipment for tympanostomy tube placement typically includes:

  • Operating microscope or 0° endoscope
  • Ear specula
  • Cup forceps
  • Cerumen loops
  • 3F, 5F, and 7F Fraiser suction tubes
  • Myringotomy knife
  • Alligator forceps
  • Curved forceps
  • Tympanostomy tube(s)
    • tympanostomy tubes are typically made of plastic, metal, hydroxyapatite, or silicone and are classified as short-term (6-12 months) or long-term (12 months or longer). Selecting a particular tympanostomy tube type or shape is a matter of preference, as numerous short- and long-term tympanostomy tube types exist with well-established results.[7]

Personnel

The personnel typically required for tympanostomy tube placement will vary with the procedural setting.

Operating Room

  • Surgeon
  • Surgical technician or operating room nurse
  • Circulating or operating room nurse
  • Anesthesia personnel

Clinic

  • Surgeon
  • Medical assistant or nurse

Preparation

For children undergoing tympanostomy tube placement as the only procedure, general anesthesia with mask ventilation alone is typically used. Conversely, general endotracheal anesthesia is used for children undergoing additional procedures, such as adenoidectomy or cleft palate repair.

In adolescent and adult patients, the procedure is often well tolerated in the clinic under local anesthesia, facilitated by topical lidocaine, phenol, or lidocaine injection.

Technique or Treatment

The ear canal and TM are visualized using an operating microscope with an appropriately sized ear speculum or 0° endoscope. Cerumen and squamous epithelium are removed to facilitate visualization and access to the TM. A myringotomy knife is used to make a 2-mm radial incision in the anteroinferior portion of the TM. A middle ear effusion, if present, may be aspirated using a 5F or 3F Fraiser tip suction. Saline irrigation can effectively remove thick mucoid effusions from the middle ear space.

The tympanostomy tube is placed through the myringotomy using alligator forceps. Proper positioning is ensured with a pick or right-angle clamp to enable visualization of the middle ear mucosa through the tube. Bleeding typically ceases spontaneously; oxymetazoline or a 1:1000 epinephrine solution can be topically applied to achieve hemostasis. Antibiotic drops are administered intraoperatively and continued for several days to maintain tube patency and minimize the risk of postoperative otorrhea.

Complications

Myringosclerosis, tympanosclerosis, and other TM changes are common following tympanostomy tube placement and do not require intervention.[13]

Complications

The complications following tympanostomy tube insertion tend to be mild and easily managed. These complications include but are not limited to:

Tympanostomy tube otorrhea: is the most common complication of tympanostomy tube placement and is seen in 16% of children within 4 weeks of surgery and 26% of children during the entire period the tube is in place.[13] Prompt administration of antibiotic ear drops following tube placement has demonstrated efficacy in averting tympanostomy tube otorrhea.[14] Ciprofloxacin or ofloxacin formulations are typically used and are comparable to combination antibiotic-steroid ear drops.[14] Notably, adherence to water precautions has been efficacious in preventing otorrhea following tympanostomy tube placement.[15]

Tympanostomy tube obstruction: occurs in 6% to 12% of patients. The management of obstructed tympanostomy tubes primarily involves empirical methods, including manual removal of the blockage or treatment with ear drops. Formulations include 5% sodium bicarbonate, 3% hydrogen peroxide, 0.33% acetic acid, or 0.9% sodium chloride drops; hydrogen peroxide is the least efficacious.[16]

Granulation tissue: occurs in approximately 4% of patients. The recommended initial treatment is antibiotic-steroid drops. However, contemplating tube removal is advisable to mitigate foreign body reactions in cases of persistent obstruction.[13]

Premature tube extrusion: typically occurs within a few months of tube placement. Patients should undergo reassessment to determine their eligibility for tube replacement.[13]

Tympanic membrane perforation after tympanostomy tube extrusion: occurs in 1% to 6% of patients but has been reported to be as high as 10%. This complication may require myringoplasty or a formal tympanoplasty.[17]

Tube displacement into the middle ear: is a rare complication that affects approximately 0.5% of patients. The tube may be left in situ, and the patient observed, or the tube can be removed if an inflammatory reaction ensues. The development of a perilymphatic fistula has been reported following tube displacement into the middle ear.[18] 

Retained tympanostomy tube: is characterized by its persistence in situ beyond 2 to 2.5 years following placement. Retained tubes are associated with otorrhea, chronic TM perforation, granulation tissue formation, and cholesteatoma development. Patients with retained tympanostomy tubes may be observed; granulation tissue or otorrhea may be treated with topical drops, provided they are not required persistently. Alternatively, tympanostomy tube removal with or without myringoplasty may be considered to prevent persistent TM perforation.[19]

Clinical Significance

Tympanostomy tube placement is the most frequently performed ambulatory surgery in children in the US. Tympanostomy tube insertion has been shown to improve the quality of life in children.[17] In patients with chronic OME, the prevalence of middle ear effusion is reduced by 33%, and average hearing is improved by 5 to 12 decibels.[20] Tympanostomy tube placement allows topical drops to be administered directly into the middle ear at higher concentrations and limits the use of systemic antibiotics in children.[4]

Enhancing Healthcare Team Outcomes

With tympanostomy tube placement being the most frequent ambulatory surgery performed in children, an interprofessional team approach is imperative to obtaining optimum outcomes for patients. Clinicians, including physicians, advanced practitioners, and specialists like otolaryngologists, play key roles in identifying, referring, and performing the procedure. Primary care practitioners are pivotal in recognizing patients eligible for tympanostomy tube placement and referring them to specialists. Enhancing awareness of clinical practice guidelines and indications for the procedure can facilitate improved interdisciplinary patient care and consistent expectations for patients and their caregivers when transitioning from primary care clinicians to otolaryngologists.[21][22]

Nurses play a central role in coordinating activities among various clinicians, assisting during the procedure, and providing counseling to patients and caregivers. Audiologists are essential in conducting necessary assessments like audiograms and tympanograms to identify candidates for tympanostomy tube placement or those requiring surveillance before referral to specialists. Following the procedure, close observation by all team members is vital to monitor for complications, tube extrusion, and the potential need for repeat tube placement. Collaborative efforts and open communication channels among healthcare professionals ensure comprehensive care delivery and optimal patient outcomes throughout the entire process.

References


[1]

Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. National health statistics reports. 2009 Jan 28:(11):1-25     [PubMed PMID: 19294964]


[2]

Bhattacharyya N, Shay SG. Epidemiology of Pediatric Tympanostomy Tube Placement in the United States. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2020 Sep:163(3):600-602. doi: 10.1177/0194599820917397. Epub 2020 Apr 14     [PubMed PMID: 32284005]


[3]

Kogan MD, Overpeck MD, Hoffman HJ, Casselbrant ML. Factors associated with tympanostomy tube insertion among preschool-aged children in the United States. American journal of public health. 2000 Feb:90(2):245-50     [PubMed PMID: 10667186]


[4]

Bluestone CD. Role of surgery for otitis media in the era of resistant bacteria. The Pediatric infectious disease journal. 1998 Nov:17(11):1090-8; discussion 1099-100     [PubMed PMID: 9850004]


[5]

Volandri G, Di Puccio F, Forte P, Carmignani C. Biomechanics of the tympanic membrane. Journal of biomechanics. 2011 Apr 29:44(7):1219-36. doi: 10.1016/j.jbiomech.2010.12.023. Epub 2011 Mar 3     [PubMed PMID: 21376326]


[6]

Widemar L, Hellström S, Schultzberg M, Stenfors LE. Autonomic innervation of the tympanic membrane. An immunocytochemical and histofluorescence study. Acta oto-laryngologica. 1985 Jul-Aug:100(1-2):58-65     [PubMed PMID: 2411101]

Level 3 (low-level) evidence

[7]

Rosenfeld RM, Tunkel DE, Schwartz SR, Anne S, Bishop CE, Chelius DC, Hackell J, Hunter LL, Keppel KL, Kim AH, Kim TW, Levine JM, Maksimoski MT, Moore DJ, Preciado DA, Raol NP, Vaughan WK, Walker EA, Monjur TM. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2022 Feb:166(1_suppl):S1-S55. doi: 10.1177/01945998211065662. Epub     [PubMed PMID: 35138954]

Level 1 (high-level) evidence

[8]

Schupper AJ, Nation J, Pransky S. Adenoidectomy in Children: What Is the Evidence and What Is its Role? Current otorhinolaryngology reports. 2018:6(1):64-73. doi: 10.1007/s40136-018-0190-8. Epub 2018 Mar 2     [PubMed PMID: 32226659]


[9]

Rosenfeld RM, Shin JJ, Schwartz SR, Coggins R, Gagnon L, Hackell JM, Hoelting D, Hunter LL, Kummer AW, Payne SC, Poe DS, Veling M, Vila PM, Walsh SA, Corrigan MD. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2016 Feb:154(1 Suppl):S1-S41. doi: 10.1177/0194599815623467. Epub     [PubMed PMID: 26832942]

Level 1 (high-level) evidence

[10]

Llewellyn A, Norman G, Harden M, Coatesworth A, Kimberling D, Schilder A, McDaid C. Interventions for adult Eustachian tube dysfunction: a systematic review. Health technology assessment (Winchester, England). 2014 Jul:18(46):1-180, v-vi. doi: 10.3310/hta18460. Epub     [PubMed PMID: 25029951]

Level 1 (high-level) evidence

[11]

Fernau JL, Hirsch BE, Derkay C, Ramasastry S, Schaefer SE. Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function. The Laryngoscope. 1992 Jan:102(1):48-52     [PubMed PMID: 1731157]

Level 3 (low-level) evidence

[12]

Wadhavkar N, Goldrich DY, Roychowdhury S, Kwong K. Laceration of Aberrant Internal Carotid Artery Following Myringotomy: A Case Report and Review of Literature. The Annals of otology, rhinology, and laryngology. 2022 May:131(5):555-561. doi: 10.1177/00034894211028468. Epub 2021 Jul 1     [PubMed PMID: 34192882]

Level 3 (low-level) evidence

[13]

Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2001 Apr:124(4):374-80     [PubMed PMID: 11283489]

Level 2 (mid-level) evidence

[14]

Alvi SA, Jones JW, Porter P, Perryman M, Nelson K, Francis CL, Larsen CG. Steroid Versus Antibiotic Drops in the Prevention of Postoperative Myringotomy Tube Complications. The Annals of otology, rhinology, and laryngology. 2018 Jul:127(7):445-449. doi: 10.1177/0003489418776669. Epub 2018 May 28     [PubMed PMID: 29807438]


[15]

van Dongen TMA, Damoiseaux RAMJ, Schilder AGM. Tympanostomy tube otorrhea in children: prevention and treatment. Current opinion in otolaryngology & head and neck surgery. 2018 Dec:26(6):437-440. doi: 10.1097/MOO.0000000000000493. Epub     [PubMed PMID: 30234663]

Level 3 (low-level) evidence

[16]

Uppal S, Sharma R, Nadig SK, Back G, England RJ, Coatesworth AP. A blinded in-vitro study to compare the efficacy of five topical ear drops in clearing grommets blocked with thick middle ear effusion fluid. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2005 Feb:30(1):29-34     [PubMed PMID: 15748186]


[17]

Hellström S, Groth A, Jörgensen F, Pettersson A, Ryding M, Uhlén I, Boström KB. Ventilation tube treatment: a systematic review of the literature. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011 Sep:145(3):383-95. doi: 10.1177/0194599811409862. Epub 2011 Jun 1     [PubMed PMID: 21632976]

Level 1 (high-level) evidence

[18]

Hajiioannou JK, Bathala S, Marnane CN. Case of perilymphatic fistula caused by medially displaced tympanostomy tube. The Journal of laryngology and otology. 2009 Aug:123(8):928-30. doi: 10.1017/S0022215108003873. Epub 2008 Oct 17     [PubMed PMID: 18925998]

Level 3 (low-level) evidence

[19]

Michel M, Nahas G, Preciado D. Retained Tympanostomy Tubes: Who, What, When, Why, and How to Treat? Ear, nose, & throat journal. 2020 Aug 31:():145561320950490. doi: 10.1177/0145561320950490. Epub 2020 Aug 31     [PubMed PMID: 32865460]


[20]

Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical practice guideline: Tympanostomy tubes in children. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2013 Jul:149(1 Suppl):S1-35. doi: 10.1177/0194599813487302. Epub     [PubMed PMID: 23818543]

Level 1 (high-level) evidence

[21]

Harvey M, Bowe SN, Laury AM. Clinical Practice Guidelines: Whose Practice Are We Guiding? Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2016 Sep:155(3):373-5. doi: 10.1177/0194599816655145. Epub 2016 Jun 21     [PubMed PMID: 27329423]

Level 1 (high-level) evidence

[22]

Ryan MA, Leu GR, Boss EF, Raynor EM, Walsh JM. Adherence to American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2020 Oct:163(4):626-644. doi: 10.1177/0194599820922155. Epub 2020 May 26     [PubMed PMID: 32450772]

Level 1 (high-level) evidence