Ventilation Tube Placement Surgery

What is ventilation tube placement surgery?

Ventilation tube placement surgery, also known as tympanostomy with insertion of an ear drain, is a minimally invasive procedure performed to restore proper ventilation of the middle ear. This small device, popularly called a grommet, little tube, or drain, represents one of the most frequent surgical interventions in modern otolaryngology.

Indications for the Procedure

Insertion of a ventilation tube is indicated in different clinical situations, the main ones being:

• Persistent Otitis Media with Effusion: When there is a buildup of fluid in the middle ear that persists for more than three months, even without active infection. This condition can cause significant hearing loss and, in children, impair the development of speech and language.
• Recurrent Otitis Media: Patients who experience frequent episodes of middle ear infection, defined as three or more episodes in six months or four or more episodes in one year, benefit from the procedure to prevent new infections.
• Conductive Hearing Loss: When the buildup of secretions in the middle ear causes a decrease in hearing, compromising the patient’s quality of life.
• Eustachian Tube Dysfunction: In cases where the eustachian tube cannot adequately equalize the pressure between the middle ear and the external environment, resulting in symptoms such as a sensation of aural fullness, tinnitus, or imbalance.

Surgical Technique

The surgical procedure is performed through the external ear canal, using a microscopic or endoscopic technique. Dr. José Eduardo Marcondes prefers the endoscopic technique, which is more modern and faster. In adults, it can be performed in the medical office under local anesthesia, while in children it generally requires general anesthesia in a hospital setting.

Steps of the Procedure:

1. Preparation: The patient is positioned appropriately and the surgical field is prepared with rigorous antisepsis.

2. Visualization: A surgical microscope or endoscope is used for precise visualization of the eardrum (tympanic membrane).

3. Myringotomy: A small incision is made in the eardrum (tympanic membrane), preferably in the anterior quadrants.

4. Drainage: The fluid accumulated in the middle ear is completely aspirated through the incision.

5. Tube Insertion: The ventilation tube is carefully positioned in the tympanic incision, creating a permanent communication between the middle ear and the external ear canal.

The procedure has an average duration of 15 minutes per ear, and can often be combined with other procedures, such as adenoidectomy or tonsillectomy, especially in children.

Types of Ventilation Tubes

There are basically 3 types of ventilation tubes:

• Short-Term Tubes: They generally remain in the ear for 6 to 12 months. They are smaller and have edges that facilitate their natural extrusion when the eardrum (tympanic membrane) heals. This is the most commonly used tube.
• Medium-Term Tubes: Drainage tubes that have an intermediate duration, able to remain in the ear for 2 to 3 years. They are rarely used. They are reserved for specific cases of recurrence or failure of treatment with the short-term tube.
• Long-Term Tubes: They can remain for years or for an indefinite period. They have larger edges that keep them fixed in the eardrum (tympanic membrane) for prolonged periods. They are normally used in permanent alterations of the eustachian tube, such as in patients with malformations and those who have undergone surgery and/or radiotherapy in the nasopharynx region.

Postoperative Care

After the procedure, some specific precautions are essential:

• Protection against water: It is essential to avoid water entering the ears during the entire period the tube remains in place. During bathing, it is recommended to use cotton soaked in mineral oil or liquid petroleum jelly for ear protection.
• Aquatic activities: Swimming in pools, the sea, or rivers should be avoided, as should diving. When allowed, only some time after the surgery and with the use of an ear plug.
• Medication: The proper use of prescribed medications, including topical antibiotics when indicated.
• Medical follow-up: Regular appointments are essential to monitor the position and function of the tube, as well as to assess hearing recovery.

Possible Complications

Although it is a safe procedure, some complications may occur:

• Otorrhea: It is the most frequent complication, occurring in approximately 47% of cases. It manifests as drainage of secretion through the tube.
• Tube obstruction: It can occur due to a buildup of earwax or secretion, compromising its function.
• Residual perforation: In 2% to 3% of cases, a small perforation in the eardrum (tympanic membrane) may persist after the tube comes out.
• Tympanosclerosis: Formation of calcareous plaques on the eardrum (tympanic membrane), observed in about 23% of patients. They normally do not cause any impairment to hearing. They constitute a scarring process.
• Tube migration: Rarely, the tube may migrate into the middle ear, requiring surgical removal.

Results and Benefits

The placement of ventilation tubes offers immediate and significant benefits:

– Substantial improvement in hearing, often noticed right after the procedure
– Dramatic reduction in the frequency of ear infections
– Relief from the sensation of fullness and pressure in the ear
– Prevention of long-term hearing complications
– In children, improvement in the development of speech and language

Ventilation tube placement surgery represents a highly effective intervention for the treatment of middle ear conditions that do not respond to conservative treatment. With proper technique and appropriate postoperative care, it offers excellent functional results with a low rate of complications, providing a significant improvement in patients’ quality of life.