Tympanostomy Tubes Insertion: Definition, Purpose & Procedure

Tympanostomy or ear tube insertion is a surgical procedure that involves the insertion of a tiny tube into the eardrum. It is a common procedure performed to release air pressure and prevent fluid buildup in the middle ear. The tiny tubes inserted are called grommets, pressure equalization tubes, ventilation tubes or tympanostomy tubes. These tubes are small, hollow, and cylindrical. They are made of plastic, metal, teflon, or silicon.

Anatomy and Physiology of the Ear

The human ear is an organ of hearing as it detects and analyses sound by converting sound waves into electrical impulses. The ear has three distinguishable parts: the outer, middle and inner ear.

1. The outer ear comprises of:

   1. Pinna or auricle: Pinna or auricle is the outermost part and collects the sound waves.

   2. External auditory canal: It connects the outer ear to the eardrum.

2. The middle ear comprises of:

   1. Tympanic membrane: It is also called the eardrum and is made of connective tissue.

   2. Ear bones: It contains a chain of three tiny bones, malleus, incus, and stapes. The stapes are the smallest bone attached to the cochlea's oval window.

   3. Eustachian tube: It helps equalize the pressure between the middle ear and the atmosphere.

3. The inner ear comprises of:

   1. Labyrinth: It consists of interconnected canals and sacs. It is surrounded by a liquid called perilymph.

   2. Cochlear: cochlear is the coiled portion of the labyrinth, which helps balance.

The sound waves or vibrations are collected by the pinna, which reaches the tympanic membrane through the auditory canal. The collected sound waves vibrate the eardrum and transmit the vibration to three bones in the middle ear. The earbones amplify the sound waves which reach the perilymph through the oval window. Finally, the vibration reaches the cochlear, which converts these vibrations to electrical impulses. These electrical impulses are later sent to the brain, translating into sound.

Generally, tympanostomy is done to to release air pressure and prevent fluid buildup in the middle ear. However, tympanostomy also helps treat other conditions such as:

1. Excessive fluid buildup (acute otitis media) in the middle ear
2. Frequent ear infections
3. Chronic middle ear infection
4. Retracted eardrum (pulling of the eardrum to the middle of the ear)
5. Ear injuries
6. Certain ear conditions such as barotrauma (a painful condition caused due to change in air pressure)
7. Abnormal shape of the Eustachian tube (a thin tube that connects the middle ear with the upper pharynx and equalizes air pressure) 
8. Hearing problems

Tympanostomy is generally performed in children of age one to three years. The procedure is also performed in adults who have:

1. Frequent ear infections
2. Excessive fluid buildup (acute otitis media) in the middle ear
3. Retracted eardrum
4. Pain in the ear due to changes in air pressure

Ear tube surgery is a safe procedure. The procedure usually takes about 15 to 20 minutes to complete depending on the patient's age, medical condition of the patient and the complexity of the case. The procedure is done under general anaesthesia to keep the patient comfortable. However, in some cases, local anaesthetics can also be used. ENT specialist along with specialised medical staff performs this procedure. The following steps are involved in the procedure:

1. The surgeon will administer general anaesthesia to the patient.
2. A small laser or scalpel will be used to make a tiny incision in the eardrum.
3. Using a vacuum, the doctor will remove all the excess fluid from the middle ear, cleaning the area and relieving the pain which is known as the aspiration of the middle ear.
4. Once done, the doctor inserts a tympanostomy tube into the hole of the eardrum. The doctor may place a single larger tube that may stay in place for a long time. The patients may also have short-term tubes, which are smaller in size and stay in the ear for almost six to twelve months.
5. Finally, the doctor will finish the surgery by removing all the surgical instruments from the ear. The incision will heal automatically and close within a few days.
6. The patient will then be moved to the hospital ward so that he/she can recover.

Before the tympanostomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Tympanostomy

Before undergoing the tympanostomy procedure, the ENT specialist will:

1. First, review the medical history of the patient and evaluate the signs and symptoms.
2. Perform tests, such as blood tests, to check for overall health and to test hearing before the procedure. 
3. Explain the procedural approach in detail and mentions its potential risks. 
4. Provide precautionary measures that a patient needs to take before the surgery.
5. Prescribe some medicines that the patient needs to take on the day of the surgery. The patient should take these medicines with a sip of water.
6. Advise the patient to stop certain medications, such as blood thinner, that may increase the risk of complications during or after surgery. 
7. Advise not to eat or drink anything from midnight before the day of the procedure.
8. The patient should also inform the doctor about any medication and supplements he/she is taking.

On the day of Tympanostomy

1. The patient should reach the hospital before the scheduled time.
2. The patient must leave all the valuables, wearables, and piercings at home before leaving for the hospital.
3. The patient will be asked to sign the consent form before the surgery.
4. The staff will take the patient to the pre-operative area. There, the patient will be given a surgical gown to change into.
5. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
6. The vitals of the patient will also be monitored.
7. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone tympanostomy can expect the following after the surgery:

The recovery process at the hospital

1. After the surgery, the staff will shift the patient to the recovery room. The patient may feel sleepy or dizzy for the first few hours, and the noise that he/she hears may seem louder than normal.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. In case the procedure is performed in the afternoon, and if the patient requires medical observation, they will be advised to remain in the hospital for one night.
4. The doctor may prescribe antibiotics and other ear drops to the patient to prevent ear infections and manage pain.
5. The patient is discharged from the hospital after the doctor checks and ensures he is fit for discharge. 
6. The doctor will also give some instructions for home care.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. The patient may also experience bleeding or ear discharge for a day or two, which is completely normal.
3. The patient should take the medications and the ear drops as directed by the doctor.
4. The doctor may also recommend earplugs during certain activities like showering or swimming. 
5. If there is a pus-like discharge from the ear, consult the doctor. 

First follow-up appointment

1. The patients will have the first follow-up with the doctor within two to four weeks after tympanostomy tube insertion surgery. 
2. Afterwards, they will have regular checks with the doctor every few months. 
3. The doctor will monitor the tubes and side effects to ensure everything is functioning. 
4. The patient may also be recommended a hearing test and can return to work and do regular activities from the next day.
5. The ENT specialist might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.

Tympanostomy is a simple and safe procedure with several benefits that helps improve the quality of life of an individual. Below mentioned are some of the benefits of tympanostomy.

1. Improved hearing
2. Reduction in the frequency of recurrent otitis media
3. Reduced fluid accumulation
4. Reduced need for oral antibiotics during ear infections
5. Less pain or lower fevers during ear infections
6. Improved speech development.
7. Reduced risk of sleep problems related to chronic ear infections

Like any surgical procedure, tympanostomy also has some risks and complications. These include:

1. The hole in the eardrum which doesn’t close after the tube comes out.
2. Scarring of the eardrums, caused by multiple ear infections or by the ear tube surgery itself.
3. Repeated ear infections, even after ear tube surgery.
4. The ear tubes either fall out early or don’t come out at all.
5. A condition called otorrhea (continuous drainage of fluid from the ear).
6. The eardrum may shrink or harden after several ear tube surgeries.
7. Ear tubes may become clogged due to earwax buildup.

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she experiences:

1. Persistent fluid, mucus, or other discharge from the ear
2. Weakening or scarring of the eardrum
3. Falling out of ear tubes
4. Bleeding
5. Ear infection
6. Increased pain
7. Reaction to anaesthesia
8. Hearing problems 
9. The eardrum does not close even after removing the tubes
10. Blockage in the inserted tubes due to mucus or blood

Delaying a tympanostomy procedure can increase the severity of the pain and discomfort in the ear, leading to reduced quality of life. Below mentioned are some of the common risks of delayed tympanostomy:

1. Persistent otitis media with effusion.
2. Structural abnormalities of the tympanic membrane or middle ear are suspected.
3. Blockage of ear tubes from blood, mucus, or other secretions.
4. In severe cases, the infection spreads to other areas of the head and may lead to permanent hearing loss or holes in the eardrum.
5. Delays in learning, speech, and developing social skills. 
6. Impairment in the psychological development. 

The cost of tympanostomy ranges from ₹35,000 to ₹60,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.