Ear tube placement surgery, also called tympanostomy, is the most common children’s outpatient surgery in the United States, according to the National Institutes of Health, with 3,372 performed in 2023 at Arkansas Children’s Hospital (ACH) in Little Rock. Though inserting a small tube into a child’s eardrum might sound invasive, the procedure is quick. It allows fluid to drain out, helping prevent continuous ear infections and restore hearing loss.
Graham Strub, M.D./Ph.D.
, a pediatric ear, nose and throat doctor (otolaryngologist) and clinician scientist at Arkansas Children’s Hospital (ACH) in Little Rock and associate professor in the department of otolaryngology-head and neck surgery at the University of Arkansas for Medical Sciences (UAMS), splits his time between clinical appointments and research, performing about 30 ear tube surgeries a month.
“It’s really common for kids to get fluid trapped behind their eardrums or get recurrent infections. Because it is such a fast procedure and so many kids have this problem, that’s likely why the surgery is considered the most common. It only takes about two minutes to do the procedure, so we’re able to have a high output in terms of the number of kids that we can treat,” Strub said. “I also think that we recognize now the importance of identifying hearing loss early, and that’s a lot of times how we discover that children need ear tubes. They either fail a hearing screen or parents are concerned about their speech development. Because we have such good early intervention from both community practitioners and our services here, I think that helps make parents aware of the problem and brings more kids to our attention.”
What Are Ear Tubes?
An ear tube, also called a tympanostomy tube, is a tiny, hollow cylinder typically made of silastic or titanium placed in the ear drum to allow airflow to the middle ear, allowing built-up fluid to drain.
“The middle ear is the space that exists between the eardrum and the Eustachian tube, which is the tube that drains into your nose. That enclosed space usually is ventilated by the Eustachian tube. When the Eustachian tube doesn’t work properly, fluid gets trapped in this little space,” Strub said. “The tube comes in and lets that fluid come out. As the air pressure changes, it lets air move between the eardrum space, or the middle ear, and then the atmosphere.”
Strub added that when that fluid drains out, it also allows sound to travel normally throughout the ear rather than being muffled by the fluid.
“If you ever plug your ears with your fingers and then try to listen to people talking, that’s kind of what it sounds like if you have fluid behind your eardrums. The tube gets the fluid out of there,” he said.
ACH otolaryngologists use three different styles of tubing. The bobbin is the most common. It resembles a dumbbell, with two circular ends on each side and a tunnel in the middle.
“Most research has shown that with regards to the shape of the tube, they still all function about the same; it just makes a difference in terms of how long they sit in the eardrum for,” Strub said.
The bobbin is the most cost-effective and stays in the ear drum for four to 12 months. If a child has fluid buildup again after one round of tubes has fallen out, most surgeons try the same design of tubes again. If that does not work, they may choose a design that lasts longer.
Why Do Children Need Them?
The top reasons a child may need ear tubes are recurrent ear infections, speech delay and hearing loss. If a child has three or more ear infections in a six-month period, parents should talk to their pediatrician about making an appointment with a pediatric ENT. A middle ear infection, known as otitis media, causes swelling, redness and fluid buildup behind the ear drum. A child is considered to have recurrent otitis media if they have six or more infections per year.
“Children that get six or more are much more likely to have complications from ear infections like requirements of recurrent antibiotics causing GI problems or hearing loss that’s temporary, but a lot of times they have fluid for an extended period, even between those infections,” Strub said.
The tube allows ear drops to enter the eardrum, directly targeting the infection topically versus oral medications that are absorbed in the bloodstream and can cause side effects.
“Ear drops are about 1,000 times more effective at killing the bacteria that cause ear infections than taking amoxicillin orally,” Strub said. “It’s a much more effective treatment to use ear drops, but without a tube there, you can’t use ear drops because the eardrum seals that compartment of infected fluid off, and the ear drops don’t work.”
A child does not always have to have recurrent ear infections to need ear tubes. If a child struggles to hear information around them, it can cause speech delay, which might indicate fluid buildup in their ears.
“If your child is supposed to be talking and is not talking, then that can be a reason to have their ears looked at,” Strub said.
Other common reasons a child may need ear tubes include:
- Enlarged adenoids
- Autoimmune conditions that make a child more prone to infections
- Abnormal craniofacial anatomy (the structure of bones and muscles in the face), like Down syndrome
What Is The Procedure And Aftercare?
Once an ENT determines a pediatric patient should receive ear tubes, following a hearing test and medical history evaluation, the surgery is usually scheduled within the month. The patient is put under for the procedure, but because it is quick, they receive inhalational anesthetic, or gas, versus general anesthesia through an IV.
“The child comes into the operating room, they get a flavored gas — they get to choose their flavor strawberry, chocolate or others — and then they pretty much fall asleep. Then once they’re asleep, if we’re not doing anything else, we don’t need to put an IV in because it’s such a fast procedure,” Strub said. “With the use of a microscope, we look in both ears, clean out any wax, cut a tiny hole in the eardrum, put the tube in and then switch to the other side and do the other side. It takes about 30 seconds per side.”
Strub said the primary issue children deal with after the surgery is crankiness from anesthesia. Typically, they do not have pain after an ear tube surgery unless they have an ear infection. That tube drains pus; parents may see mucus and some blood drainage at the ear for the first few days. But most children are back to their usual selves the next day, he said.
Strub recommends applying ear drops for two to three days following the surgery to help stop bleeding or prevent infection. If the child already has an infection at the time of surgery, he recommends ear drops for a week.
As far as activity restrictions, Strub said that varies by surgeon. He recommends children not swim underwater for the first few days after surgery.
“For the most part, you can do everything that you would normally do with your tubes in place,” Strub said. “They can shower, they don’t need to wear earplugs, they can get water in there. The only thing that you can’t do with ear tubes is scuba dive. The pressure can make you dizzy, and if you get dizzy while you’re 30 meters underwater, it can be a disaster.”
Strub said they want to see patients back at least once following surgery to ensure the tubes are open and there wasn’t another reason for hearing loss beyond fluid buildup.
The tube stays inserted for about four to 12 months, depending on the tube’s shape and size. As the eardrum heals, it pushes the tube out, causing it to fall out of the child’s ear. A child will not usually notice when the tube falls out because it’s so small. If a tube gets stuck, it might cause itching and drainage.
“I always just tell parents if you run into problems, call us and let us look in the ear because if there’s a tube sitting in the ear canal, we can just take it out in the clinic,” Strub said.
What Are The Risks?
In most cases, the cut to the eardrum will close. If it does not, surgery to repair the hole may be needed, depending on the size. Strub said for the patients he has operated on, it’s usually about a one percent risk.
The number one problem Strub said children run into after an ear tube surgery is the tubes getting clogged. Using ear drops helps prevent clogging, but sometimes, if they develop another ear infection, even ear drops can’t always prevent the hardening of the infected mucus.
“Then the tube becomes dysfunctional, and it won’t work anymore. That can cause fluid to build up behind the eardrum again because it can’t get out. Then you can get an ear infection and need oral antibiotics unless we can unplug that tube,” Strub said. “We will usually try to use drops. In the clinic, sometimes we can suction out a tube to try to unplug it.”
A child with this issue will show the typical symptoms of an ear infection.
Sometimes, as the eardrum heals, the tissue can grow over the tube rather than push it out, forming granulation tissue with blood vessels. The sign of this is pus drainage.
“It’s kind of like if you scrape yourself and that red, beefy tissue grows in has all these new little blood vessels that will start to grow over the tube. And when that happens, it can trap bacteria. Then it usually will get infected and then drain,” Strub said. “For that complication, we use an ear drop with a steroid in it, which will usually shrink that tissue away, and the tube will then be functional again.”
Sophia Rabb’s Journey with Ear Tubes
On Jan. 8, Sophia Rabb, 17 months, underwent ear tube surgery by Graham Strub, M.D., at Arkansas Children’s Hospital (ACH) in Little Rock, following months of continuous ear infections. Sophia, the second child of parents Dillon and Sarah Rabb of Pottsville, was born Aug. 7, 2022. Her family makes the roughly three-hour round trip each month for Sophia to see ACH specialists, including the ear, nose and throat care team, since being diagnosed with failure to thrive following weight loss around seven months old.
Sarah Rabb said Sophia has passed her hearing tests but has had about 10 ear infections since birth. She had an appointment with ACH ENT specialists in December and was told she’d need ear tubes.
“I had a lot of questions because they put them under anesthesia, considering it’s a surgery, even though it’s about a five-minute long surgery. So that was my first question — how long will she be put under? Why does she have to be put under? I asked what the positive sides of getting tubes are, so what would be our reasoning for moving forward with this? What are going to be the benefits of her having tubes?” Rabb said, praising the care team for their thorough answers to all her questions. “I was really encouraged because they said we won’t have to go to the doctor anymore for ear infections; we can treat them at home. We were going about every month or month-and-a-half for ear infections. So that was huge for us. She no longer has to be put on antibiotics for infections.”
Rabb said the team was “absolutely incredible,” including the receptionist, nurses, anesthesiologist and Strub on the day of Sophia’s ear tube surgery.
“They all introduced themselves to me and promised that they would take good care of her; the best they could do, they would offer it to her. And it was sincere, you can tell,” Rabb said.
Rabb said Sophia has been healing normally.
“The first day, you wouldn’t have even noticed she had it done. She slept the entire night through, and she’s just been great,” she said.
Rabb recommends ACH’s ENT medical experts for other parents considering ear tubes for their child.
“Handing your kids over into someone else’s care is hard. But if they’re at Arkansas Children’s, trust these doctors know what they’re doing. They care greatly, which can put you at ease,” Rabb said. “Your kids pay attention to how you feel. They pay attention to how you’re encountering situations. If you can be at peace and show that you’re confident and that your kids are in safe hands, it will help so much more.”