One of the most common and simple procedures that Otolaryngologists (ear, nose, and throat specialists) perform is that of putting “tubes” in children’s ears. General and pediatric otolaryngologists alike perform thousands of these simple and quick procedures every year, often several times in a single hour! Most children who need and get “tubes” in their ears are toddlers and those in preschool age. What continues to surprise me is how often parents and caretakers are not explained to clearly about what to do once a child has ear tubes in and then develop a wet or draining ear. Yes, I am talking about yellow, green, white, brown, stinky (the smell can fill up a room!), sticky, nasty stuff that not only runs out your child’s ear canal, but then crusts around their ears and worse, perhaps down their cute cheeks!
I have believed it is critical that every ENT surgeon take the time to explain to parents why and how tubes decrease “ear infection”, which is when there is buildup of pus in the middle ear space, pushing on the eardrum from the “inside”. Every time I recommend ear tubes, I make sure that parents understand the simple “plumbing” logic that is involved once there is a small opening created in the eardrum so that oxygen and air can go from the world into that tiny space behind the eardrum (middle ear space), and of course, when there is “infection” or pus which develops from that space now it can drain out through the tube directly out of the ear canal and be seen by parents. The whole point of tubes is that parents and caretakers can tell when a child actually has an ear “infection”. Instead of pain from pus trapped and pushing on eardrum and fever that results from trapped pus, there should be no pain or fever... just nasty stuff coming out the ear. I realized early in my career that unless I explain in detail how a wet ear should be treated once a tube has been placed and is working, parents go first to an urgent care, or their primary doctor’s office, and then are usually prescribed oral antibiotics (almost always unnecessary as well as ineffective), instead of using antibiotics in the form of ear drops which primary and ENT doctors should prescribe.
You see, the beauty of the ear tubes is that now just as air can go through that tiny 1.2 mm round ‘hole” in your child’s ear drum, so can ear drop which contain antibiotics (and steroid, an important component of ear drop therapy in my experience). The strength of the antibiotics in those few drops from that expensive bottle is likely 300 times stronger than what the human body can safely eat. Since the drops are getting absorbed into our blood stream and system which is what happens when we eat/drink it, it works by simply making contact with the infected surfaces of the middle ear space, the mucosal lining with living cells which produce the pus or mucus in the first place (when it is inflamed by viral and bacterial infection along with the irritation that goes with every infection).
A nasty draining ear is easily treatable – the junk is all removed from the canal, tube is checked to ensure it is still in the eardrum and “working” (hole is open), and then topical ear antibiotic and steroid drops are prescribed. I emphasize the importance of aural toileting, that means taking toilet paper or KleenexTM, twirling it into tiny 1-2 cm “wicks”, and putting that gently into the canal for a few seconds so that the nasty drainage is absorbed onto the tissue. Twirl another area of tissue and repeat, and repeat, until not much nasty wet stuff is coming out. THEN, and ONLY THEN, do they start putting the few ear drops into the ear canal. It is also critical to perform the “tragal pump”, meaning to gently push on the little “nubbin” just in front of the opening of the ear canal to make sure that trapped air bubbles come out and drops make it all the way deep into the canal to where the tube and “hole” is to have a chance to get into the middle ear space where the infection is.
Of course, there may be other problems. Sometimes the child is having this issue because it’s been 2 or 3 years since the tubes were put it, but not one knows if it’s still in the ear drum or has “fallen out”. Often the tube is no longer in the drum, the hole has healed itself, but the tube is “stuck” on the drum or ear canal which is lined by skin. The body gets irritated with this “foreign body” that is stuck there and then angry tissue called granulation tissue forms. This angry reddish mass is full of blood vessels and is most likely cause of blood coming out of any child’s ear if that child has had tubes placed. Thankfully, the treatment is the same. As I tell parents every clinic day, it doesn’t matter what is coming out of the ear canal, using the antibiotic and steroid ear drops is the way to go. The steroid component will calm the anger, reduce inflammation, shrink the angry tissue, stop the drainage and pain associated with this, and then the tube can be removed from the canal in the office most likely.
If families are informed of how tubes work, and techniques for good aural toileting, as well as immediate use of ear drops whenever there is draining ear in a child with tubes, then they can be empowered to stop going to urgent care, their primary physicians, save time from work and school missed, save money on oral antibiotics, and most importantly, spare their child from yet another course of oral antibiotics.
I must mention that while perhaps 95% of draining ears should respond to a solid week of using ear drops containing antibiotics and steroid, currently we do have another cause of persistent draining ears in healthy kids. That is the issue of methicillin-resistant staphylococcus aureus (MRSA) infection, even in the ear. I find that many daycare aged toddlers will show up in the office, after using drops as I have intensely preached, and in these children often the culture will prove they have MRSA as the bacteria causing this problem. Thank goodness MRSA in this setting is almost universally susceptible to a class of antibiotics that are “sulfa” based, like “Bactrim” (trimethoprim/sulfamethoxazole), because we the medical professions have not used this drug much in the past decade or two since we have many “newer” antibiotics, it is actually useful to fight MRSA. If your child’s ears are still draining after a week of the antibiotic and steroid ear drops, you should call the surgeon who put the tubes in, ask to be seen, for a culture to be done of the nasty drainage, and if it is MRSA positive, then the best treatment is to switch to a “sulfa” based drop , 10% sulfacetamide, used 3 times daily for next 7 days, as well as put mupirocin ointment in the child’s nostrils twice a day for 10 days, and finally your child should also be given oral Bactrim for 10 days. The idea is to try to eradicate the MRSA living in their nasopharynx which is connected to the middle ear space through the Eustachian tube – details worthy of a separate blog.
If the MRSA drainage does not clear up, I will make the tough but proactive and effective decision to take those tubes out and let the ear drum heal. Thankfully, these children do not necessarily go back to having a bunch of ear infections or trap fluid causing mild hearing loss. Thanks to time, sunshine, love, and nourishment, little heads and bodies grow and they often do well without the tubes.
Sometimes I joke with parents that I am just a glorified plumber. There is a great deal of truth in that. If the plumbing is blocked, much goes wrong in the house. You would certainly contact the plumber, and as such, do contact your child’s ENT sooner rather than later if a draining ear does not stop, AFTER you’ve done what I have described. May you and all parents out there whose children have tubes save money and time live better lives as promised by your child’s ENT.
By the way, stop plugging your child’s ears from bath and swimming, unless they complain of pain every time water gets in. Ten years of a handful of studies show that children whose ears are plugged from water are no better than those who plug and there is no difference….but everyone is much happier without those plugs. Yes, even if your child is swimming in a lake (again, another blog worthy topic). I am a mother first, and believe that your child deserves more than opinions, but information based on science.
by Dr. Julie Wei, MD, FAAP
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