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TH ROUG H TH E O T O S CO P E

Symptoms: Ear Wax, a Green Circle, and


Small Ear Canals
Donna, 52, had difficulty hearing speech in a noisy
room, especially womens speech, and wanted her hearing aid turned up. Adjusting a hearing aid is easy with
the necessary software and should make an improvement, but you need to make sure the ear canal is clear.
Audiologists in some states are licensed to clean ears,
but sometimes cleaning the ear is contraindicated. The
first rule of intervention is, Do no harm.
Donna has been wearing hearing aids for years, and
was hearing well when she was initially fit. I used an
otoscope to look into her ears to ensure excessive wax
was not the problem. She has small ear canals, limiting
the ability to see the canal and to view the eardrum
from different angles. Initial inspection of her right ear
showed a green circle surrounded by ear wax. (Figure 1.)
What is the green circle in Donnas right ear, and
should the ear be cleaned?
What is your diagnosis? See p. 10.

THE HEARING JOURNAL

Medrex

By Michael J. Rensink, MD

Figure 1. Donnas right ear.

T h ro u g h t h e O t o s c o p e 

MAY 2012 VOL. 65 NO. 5

T HRO UGH TH E OTOSC OP E

Diagnosis: Ventilation Tube


By Michael J. Rensink, MD

A clearer view of Donnas ear reveals why her ear should not
be cleaned: a ventilation tube passes through the eardrum.
(Figure 2.) This raises other questions for audiologists and
hearing aid dispensers:

Is there anything I can do to help?

How long should the tube stay in the ear?
How long after the tube is inserted can the patient wear
a hearing aid?

What should be done if there is drainage in the outer ear?
How often does the patient need to follow up with
an ENT?

Medrex

Continued from p. 8

Figure 2. Ventilation tube with a longer T-tube.

HOW YOU CAN HELP

Patients are told to keep water out of their ears because it is


imperative to keep the ear dry when inserting a ventilation tube.
Water can move pathogens into the middle ear and cause an
infection. I recommend well-fitted, custom-made otoblocks,
but use caution when making the impression to avoid driving
the tube into the middle ear. Inspect the otoblock packaging
carefully for blow-by, the leaking of harmful material.
The answer depends on the ears health. The ear returns to
normal quickly in some cases. Middle ear fluid drains out,
the ear is aerated through the ventilation tube, and Eustachian
tube function improves. Remember, the ventilation tube has
two functions: draining fluid out of the middle ear, and providing air to the tissues in the middle ear, a crucial role if the
Eustachian tube is functioning poorly.
The tube should be removed once the ear is healthy
because the perforation will heal on its own more quickly
the sooner it is removed. Cases of tubes remaining in place
for years have been reported, and the tube should remain if
the condition persists. Ventilation tubes are naturally expelled
from the ear in most cases by the tissues in the eardrum.
Straw-shaped, longer T-tubes (Figure 2) tend to stay in the
ear longer than shorter grommet tubes. (Figure 3.)
WHEN CAN THE PATIENT WEAR A HEARING AID?

The goal is to return the patients ear to normal as quickly as


possible. Hearing aid use depends on the condition of the ear.
Typically, most of the fluid is removed from the middle ear after
the tube is inserted, and a hearing aid may be worn if there is
no drainage within in a few days. Some ears do take several days
to drain through the tube. It makes no sense to use a hearing
aid during heavy drainage.
Hearing aid use can resume if the condition is resolved at
the patients two-week follow-up. Some cases are difficult and
heal slowly, and that requires more follow-ups and a variety of
10

THE HEARING JOURNAL

Medrex

HOW LONG SHOULD A TUBE STAY IN THE EAR?

Figure 3. Ventilation tube with a shorter grommet tube.


treatments to help the ear heal. Refer the patient back to his
ENT as soon as possible if there is new drainage at this time.
OTHER CONSIDERATIONS

Patients with ventilation tubes should not use cotton swabs


because they may dislodge the tube or harm the eardrum. They
should never use an over-the-counter wax solvent, such as Debrox
or Cerumenex. Wax removal can be especially tricky because of
the risk of dislocating the tube or getting water in the ear.
Use caution if you see a dislodged ventilation tube resting
in the ear canal. Do not take out the tube because it may be
attached to debris or residual skin protruding from the eardrum. Pulling the tube can cause damage to delicate tissue, so
refer the patient back to his ENT if you accidentally remove it.
Some tubes, such as the tall T-tube, extrude from the eardrum
and appear incorrectly inserted but are not. (Figure 1).
The drainage in Donnas ear stopped, and her ear
improved. I reinstalled her hearing aid use after two weeks,
and her audiologist adjusted it. The tube will be removed in
a few months if her ear continues to improve.
Dr. Rensink is a member of ENT Associates of San Diego, and has been a practicing ENT
specialist for more than 35 years.

T h ro u g h t h e O t o s c o p e 

MAY 2012 VOL. 65 NO. 5