Tympanostomy tube insertion is one of the most commonly performed surgical procedures in children. Otorrhea is a frequent complication of tympanostomy tubes, occurring in 6 to 68% some time after tube insertion.1–5 Persistent or recurrent otorrhea is reported in approximately 3 to 38% of patients.5, 6 Otorrhea may occur during the immediate postoperative period, or later, and persist for weeks or months. Measures useful in diminishing tympanostomy tube otor-rhea are widely discussed and debated among otolaryngologists. The safety and effectiveness of these measures are controversial. Factors considered, at least by some physicians, to decrease the incidence of postoperative tympanostomy tube otorrhea include control of environmental and behavioral risk factors for otitis media, antiseptic preparation of the ear during tympanostomy tube insertion, tube material, topical antibiotics at tube insertion, and perhaps for a few days later, and –water precautions” (i.e., keeping water out of the ear). Background Astley Cooper, an Englishman born in 1768, promoted myringotomy for indications that would be acceptable today. However, the challenge was maintaining the patency of the myringotomy. Before the 1860s, when Politzer introduced a hard rubber eyelet to keep a myringotomy open, catgut string, fishbone plugs, and lead wires had been tried. These techniques were abandoned because of –the high failure rate coupled with a high infection rate.”7 Thus, postoperative otorrhea was a problem long before Armstrong reintroduced tympanostomy tubes in 1954. Factors Related to Tympanostomy Tube Otorrhea The development of otorrhea after tympanostomy tube insertion is probably of multifactorial etiology. These factors can be considered to overlap those for otorrhea in chronic otitis media patients. Preoperatively recognizable patient characteristics and comorbidities, the surgeon’s operative findings, the surgeon’s operative choices, and the postoperative management may all influence the development of drainage through the tube. PATIENT CHARACTERISTICS, COMORBIDITIES, AND BEHAVIORS There is little doubt that some patients with tympanostomy tubes are susceptible to otorrhea. But why do some patients, operated and managed in each practitioner’s routine, have bothersome ear drainage, whereas other seemingly similar patients do remarkably well with their tympanostomy tubes? Age of Patient Infants have a greater propensity to develop post-tympanostomy otorrhea than do older children and adults. In addition, there may be a difference in the bacteriology of the otorrhea when comparing younger with older patients. Pathogens of acute otitis media seem to be more common in patients less than 3 years of age compared with those older than 3 years, where Pseudomonas aeruginosa and Staphylococcus aureus are more common.2 Cleft Palate Tympanostomy tube otorrhea in cleft palate children is such a problem (68% of patients with open clefts; otorrhea of at least 1 month’s duration in 38% of patients5) that some authorities prefer to ignore the otitis and delay tympanostomy tube placement until the cleft has been repaired.8 Even after palate repair, in comparison with noncleft –normal” children, these patients have an increased rate and severity of tympanostomy tube otorrhea. Tympanostomy tube placement is often done at age 2 or 3 months, with the intention of improved hearing and better speech and language development.9 Conversely, some advocate delaying the insertion of tympanostomy tubes until a few months after palate closure, arguing that (1) after cleft palate closure, the otitis may resolve so that tympanostomy tubes are not needed; and (2) those who receive tympanostomy tubes have less otorrhea.8 Immune Deficiency Immune problems, both congenital and acquired, humoral and T-cell mediated, are associated with an increased occurrence of tympanostomy tube otorrhea. Masin et al.10 report that in children who received tympanostomy tube placement because of recurrent otitis media, those with isolated IgG2 deficiency have a threefold increase in occurrences of otorrhea, in contrast to IgG2-competent controls. Anecdotal information supports the idea that patients with immotile cilia syndrome (e.g., Kartagener syndrome), or acquired immunodeficiency syndrome (AIDS), or who have had radiation to the ear, have a worse problem with tympanostomy tube otorrhea than do immune-competent patients. Dermatitis of External Ear Canal Eczematoid dermatitis involving the external ear canal is associated with such problematic tympanostomy tube otorrhea that many otolaryngologists prefer to manage the effusion with the combination of observation and amplification not requiring an ear mold (e.g., auditory trainer assistive listening device, or bone oscillator hearing aid). Bottle Feeding, Especially in the Supine Position The observation of middle ear fluid that resembles carbonated strawberry soda pop is convincing evidence of reflux from pharynx through the eustachian tube into the middle ear when the patient’s mother proceeds to exhibit a baby bottle containing such soda pop. Presumably the eustachian tube architecture that allows such reflux in noncleft palate patients is the same architecture that permits reflux in cleft patients. Day Care Children in day care are at increased risk of needing tympanostomy tube insertion (and reinsertion).11 This may be related to increased exposure to viral and bacterial pathogens. That children in day care have an increased occurrence of tympanostomy tube otorrhea is anecdotal. Mastoid Opacification Valtonen et al.12 report that in children aged 5 to 16 months, early postoperative otorrhea correlates more (P < 0.001) with radiographically determined opacification of the mastoid air cell system than with finding a pathogenic bacteria (P < 0.01). As the mesotympanum connects via the epitympanum to the mastoid air cell system, radiographically normal mastoids are to be expected in patients with rather minimal otitis media. OPERATIVE FINDINGS Middle Ear Fluid The presence of middle ear fluid and the type of effusion at tympanostomy may be indicative of whether postoperative otor-rhea will develop.3, 12 Patients with effusions of any type seem to have a higher rate of postoperative otorrhea than do those with dry middle ears, 21.1% vs 6%.12 Patients with mucoid and puru-lent effusions at surgery seem to have an even higher rate of otorrhea during the early postoperative period than that of patients with serous fluid.13–15 Middle Ear Mucosa The intraoperative findings of edematous or granular middle ear mucosa are probably important in predicting postoperative otorrhea.3, 15 Although an increased proportion of patients with inflamed middle ear mucosa have bacterial pathogens in the middle ear fluid, Giebink3 found inflamed mucosa and mesotympanic pathogens independently to increase the risk of postoperative otorrhea approximately twofold. Eustachian Tube Caliber The caliber (internal diameter) of the eustachian tube can be measured intraoperatively by sounding with increasingly larger bougies through the myringotomy into the eustachian tube. Ears with bougie-determined large caliber eustachian tube lumens (i.e.,≥4 Fr) are more likely to have persistent otitis. The bougie-determined caliber of a normal eustachian tube is 2 Fr (0.67 mm). Otitis patients have calibers as large as 6 Fr (2.0 mm). Eustachian calibers are bilaterally symmetric and apparently do not change with patient age or growth. Intraoperative bouginage of the eustachian tube may provide useful information.16 OPERATIVE CHOICES OF THE SURGEON Antiseptic Preparation of the Ear Canal It has been suggested that bacteria within the ear canal may contribute to postoperative otorrhea. Antiseptic preparation of the external ear canal has been advocated to decrease postoperative otorrhea. Baldwin and Aland15 reviewed 111 children who underwent canal preparation of one ear, with the contralateral ear acting as a control. Postoperative otorrhea (by report on postoperative days 3 through 6 and by otolaryngologist’s observation on day 7) developed in 6.3% of the treated ears and in 10% of the control ears—not a statistically significant difference. These investigators concluded that preparing the ear canal with povidone-iodine had no demonstrable effect on early postoperative otorrhea.15 Interestingly, all patients with otorrhea had had either mucoid or puru-lent fluid in the middle ear: 19% who had mucoid fluid, 29% who had pus. None of the patients who had dry middle ears or serous fluid had otorrhea. Giebink et al.3 performed a prospective study preparing the ear canal with 70% alcohol or povidone-iodine and found again that there was no difference in early postoperative otorrhea. Scott and Strunk17 similarly reported no difference in early postoperative otorrhea in children with and without canal preparation with povidine-iodine and alcohol. Benefits other than perhaps reducing early postoperative tympanostomy tube otorrhea may prompt antiseptic preparation of the ear canal. These benefits may include (1) a better view of the tympanum to identify vexations (e.g., cholesteatoma, retraction pocket, dehiscent jugular bulb); (2) minimizing the dilemma of deciding whether a microorganism identified at culture was of external ear canal origin; and (3) minimizing the question of iatrogenic infection. Middle Ear Irrigation Middle ear irrigation with saline at tympanostomy tube insertion reduces postintubation otorrhea by one-half.18 The irrigation presumably decreases the microbial burden in the mesotympanum. Intraoperative Cultures There are conflicting data in the literature regarding the usefulness of intraoperative culture results and postoperative otorrhea.The overall incidence of positive cultures at surgery is probably 2013 to 35%.3 Reports are contradictory as to whether patients with positive middle ear cultures at tube insertion do not13 or do3, 12, 19 have a higher rate of immediate postoperative otorrhea. These reports are not comparable due to differing durations of otitis, ages of patients, external ear canal preparations, and topical antimicrobial prophylaxis. The early postoperative otorrhea rates, for patients with middle ear pathogens versus sterile ear cultures, ranged from 5.4% versus 2.919 to 37 versus 17%.12 Choice of Tube Material A wide variety of tympanostomy tubes are available for insertion. Tubes for short-term and long-term use are manufactured from various biocompatible materials, including stainless steel, titanium, plastics such as silicon elastomer (Silastic), polytetrafluoroethylene (Teflon), and hydroxyapatite. The type of tympanostomy tube chosen may influence postoperative otorrhea. A study of the scanning electron microscopic characteristics of fluorocarbon versus silicon tubes showed that fluorocarbon tubes had a smoother surface and a lower rate of early postoperative otorrhea.20 Hester et al.19
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