Pressure equalization tubes are commonly placed in patients, especially children, who are experiencing recurrent acute otitis media or chronic otitis media with effusion. While these tubes effectively alleviate middle ear pressure and reduce infection frequency, managing tube-related ear drainage—otorrhea—remains a challenge for both clinicians and patients.
"Otorrhea occurs when fluid, either mucus or pus, drains from the middle ear through the tube and is usually indicative of an acute ear infection," says pediatric otolaryngologist Eileen Raynor, MD. "Most of the time, this is managed using antibiotic ear drops and resolves within a few days. However, in some cases, the problem is recurrent or recalcitrant and may require other management strategies."
A Challenging Condition
One primary challenge is that the drainage can be quite thick, obstructing the tube and making visualization of the eardrum difficult. This obstruction can prevent antibiotic drops from reaching the middle ear, hindering effective treatment.
"Frequently, parents report their child was seen at urgent care or in their primary care office and were told the 'tube is out' when, in fact, it is obstructed by the ear drainage," Dr. Raynor says. "In those situations, we will suction out the drainage so we can see the tube and allow for placement of the drops."
Occasionally, otorrhea may signal a more serious underlying condition such as cholesteatoma, chronic granulation tissue, chronic rhinosinusitis, or an immune disorder. Identifying these conditions requires thorough evaluation and sometimes additional workup.
Improving Patient Outcomes Through Education
To improve outcomes in managing tube drainage, Dr. Raynor says, clinicians should maintain adequate visualization of the ear canal and have access to suction equipment or culture swabs in the office setting. The involvement of child-life specialists or additional nursing personnel can help calm the child and family, facilitating a more effective examination and treatment.
Training and mentorship are crucial in equipping trainees with the skills needed to manage drainage issues confidently. At Duke, hands-on experience in the operating room and temporal bone lab allows trainees to become familiar with the use of microscopes and ear instrumentation under ideal conditions.
"This experience is directly translatable to the office or clinic setting," Dr. Raynor says. "Patient positioning is important to success. Trainees can practice using the operating microscope and ultimately become comfortable using it in the office."
Education is also important for primary care providers and urgent care clinicians. Through its Choosing Wisely® campaign, the American Academy of Otolaryngology–Head and Neck Surgery promotes the use of ototopical antibiotic drops instead of oral antibiotics as first-line management for ear drainage. This has helped decrease side effects and the risk of antibiotic resistance.
At the recent American Academy of Pediatrics National Conference and Exhibition, Dr. Raynor presented a session on tube otorrhea and co-directed an otoscopy workshop for pediatricians, highlighting the importance of proper management strategies.
By focusing on thorough evaluation, appropriate treatment strategies, and comprehensive training for clinicians, the challenges associated with otorrhea can be significantly mitigated.
"Otorrhea is a common problem, but it can be perplexing in refractory cases," says Dr. Raynor. "Through proper management and education, we can improve patient care and outcomes."