The Medical Consumer's Advocate

Retained ventilation tube and a smelly, draining ear

 

Q: My oldest son had ear tubes placed twice, because the first ones fell out after a year. The problem? He still has a tube in his ear after 20 years! This causes a lot of problems for him, including a "smelly" ear. Also, he cannot go diving underwater because it hurts his ear. Does the tube need to come out? How big is the operation? Is the physician that originally put the tubes in under an obligation to take them out since he stated, specifically, that they would fall out in a "little while?"

A: Not everyone knows what these tubes are for, so please bear with me while I explain "ear tubes."

The space behind the eardrum is air-filled. Air gets into this space via the Eustachian tube, which is a muscular/cartilaginous tube extending from the middle ear space to the throat. These tubes open periodically, allowing air to reach the middle ear space.

Many children and adults suffer from Eustachian tube dysfunction. If the tube opens rarely or not at all, the air that is trapped in the middle ear space gradually gets reabsorbed by the tissue lining that space. The air pressure becomes very low, relative to the outside world. Fluid can build up in the middle ear space as a result. On the rare occasion when the tube does open, fluid in the throat (primarily saliva mixed with nasal mucus) can be sucked into the middle ear space. Since this saliva/mucus mixture is laden with bacteria, an ear infection may result.

Ventilation tubes are very small plastic tubes which are placed into the eardrum by a surgeon. The tubes allow air into the middle ear space, thus functionally replacing the Eustachian tubes. These tubes usually last 6 to 18 months and are then spontaneously extruded (ejected) by the eardrum. Occasionally, however, the tubes are not extruded, and must be removed by a surgeon.

I am certain that if your son’s surgeon is still in practice, he will be willing to remove the tube. He cannot be faulted for telling you they were temporary, since in the vast majority of cases, they do not stay in for over 20 years! Nevertheless, when I discuss tubes with parents, I usually do tell them, "Very rarely, one or both of the tubes will not fall out on its own. If the tube remains in place for two or three years, and in particular if the tube appears to be causing any problems, I will have to remove them."

It’s possible that the tube is causing your son’s smelly ear (a symptom which suggests your son is suffering from a chronic ear infection), in which case removal of the tube should be curative. Removal is very simple. In a teenager or adult, the tube can be removed in the office using only local anesthesia. Your son should be warned that a 20-year-old tube, once removed, may very well leave behind a chronic perforation, i.e. a non-healing hole in the eardrum. If I were your son’s surgeon, I would recommend performing a "fat patch" or "paper patch," which are fairly simple procedures (again, office procedures requiring only local anesthetic) which will encourage the hole to heal. I would do this immediately after removing the tube.

It’s also possible that the tube is not causing your son’s ear to be smelly. Chronic ear infection can cause a smelly ear, and it is very possible that the tube is only a distraction– it is not the real problem at all. Some chronic ear infections can be exceptionally serious, essentially "ticking time bombs" which, if allowed to fester for very long, can lead to permanent hearing loss, damage to the balance system, damage to the nerve which innervates the muscles of facial expression, and even spread of infection to the brain (e.g., meningitis or brain abscess.) Consequently, a chronically smelly ear is a potentially serious condition which must be evaluated by an ear, nose and throat surgeon. Unfortunately, a few primary care physicians will treat such infections with ear drops and antibiotics, not realizing the risk inherent to the situation.

Does the tube need to come out? I think so; twenty years is an awfully long time for a tube to remain in an ear. But much more important is that your son have his smelly ear examined by an ear, nose and throat surgeon.

 

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