Tympanostomy – Insertion of a Ventilation Tube into the Eardrum
Tympanostomy is an ENT procedure in which a small opening is made in the eardrum and a ventilation tube, also known as a tympanostomy tube or grommet, is inserted. It helps ventilate the middle ear and equalise pressure, as well as prevent prolonged fluid accumulation behind the eardrum. If the problem affects both ears, the ENT specialist may recommend bilateral tympanostomy. The procedure is particularly common in children with persistent otitis media with effusion (OME), or fluid in the middle ear, and associated hearing loss. Ventilation tubes may also be considered in certain cases of recurrent middle ear infections.
What is a tympanostomy?
The eardrum separates the middle ear from the outer ear. Under normal conditions, the middle ear is ventilated through the Eustachian tube, which connects the middle ear with the nasopharynx. If the Eustachian tube does not function effectively for a prolonged period, negative pressure may develop in the middle ear and fluid may accumulate. This may cause:
a feeling of a blocked ear;
pressure in the ear;
hearing loss;
recurrent middle ear infections;
in children – difficulty hearing speech and sounds;
in some cases – speech, language or learning difficulties if hearing impairment persists for a long time.
The tympanostomy tube temporarily performs part of the ventilation function of the Eustachian tube, allowing air to enter the middle ear.
How is a tympanostomy performed?
During the procedure, the ENT specialist:
makes a small opening in the eardrum under microscopic control – a procedure known as myringotomy;
removes fluid from the middle ear, if present;
inserts a small ventilation tube into the opening in the eardrum.
The tube helps maintain ventilation of the middle ear and equalise pressure on both sides of the eardrum.
In children, the procedure is most commonly performed under general anaesthesia. In adults, it may in some cases be performed under local anaesthesia. The most appropriate type of anaesthesia is determined by the doctor. In children, insertion of ventilation tubes is usually a short procedure. Duration of the procedure: the procedure itself usually takes approximately 10–20 minutes, although the overall time spent at the medical facility is longer because of anaesthesia and postoperative observation.
When is tympanostomy indicated?
An ENT specialist may consider tympanostomy if the patient has:
persistent fluid in the middle ear, or otitis media with effusion;
hearing loss caused by middle ear fluid;
a feeling of pressure or blockage in the ear;
Eustachian tube dysfunction;
recurrent acute middle ear infections in selected cases;
retraction of the eardrum or other changes associated with prolonged negative pressure in the middle ear;
a need for prolonged middle ear ventilation following assessment by an ENT specialist.
For children with middle ear fluid that persists for three months or longer, international guidelines recommend an age-appropriate hearing assessment. Ventilation tubes are particularly considered when persistent fluid is associated with hearing impairment or other significant symptoms.
Are ventilation tubes needed for every middle ear infection?
No. Many acute middle ear infections and episodes of middle ear fluid resolve without surgery. Particularly in children, fluid accumulation often resolves spontaneously during the first few months. Tympanostomy is not recommended solely because a child has experienced several ear infections. For example, in children with recurrent acute otitis media but no middle ear fluid present at the time of examination, guidelines do not routinely recommend ventilation tubes. The decision is made by the ENT specialist, taking into account:
the frequency of infections;
how long the fluid has been present;
hearing status;
changes in the eardrum;
the patient’s age;
speech and language development in children;
other individual risk factors.
Tympanometry and hearing assessment before surgery
Before tympanostomy, the ENT specialist may perform or recommend additional examinations.
Tympanometry
Tympanometry helps assess the mobility of the eardrum and pressure in the middle ear. It may provide information about the presence of middle ear fluid or Eustachian tube dysfunction.
Audiometry
If hearing loss is suspected, an age-appropriate hearing assessment – audiometry – may be performed. In children with persistent otitis media with effusion, hearing assessment is an important part of the evaluation before deciding on surgery.
Tympanostomy in children
Insertion of ventilation tubes is particularly common in paediatric ENT practice because the anatomy and function of the Eustachian tube in children differ from those in adults, making middle ear fluid and infections more common. Persistent middle ear fluid, or otitis media with effusion (OME), may reduce sound transmission and impair hearing. The National Institute for Health and Care Excellence (NICE) recommends considering ventilation tubes for children with hearing loss caused by OME, with the treatment choice discussed with the child’s parents or carers. In selected cases, the ENT specialist may recommend combining tympanostomy with adenoidectomy if there are also indications for treatment of enlarged adenoids.
Tympanostomy in one or both ears?
If fluid, hearing impairment or other changes are detected in only one ear, unilateral tympanostomy may be required. If the problem affects both ears, the doctor may recommend inserting ventilation tubes into both eardrums during the same procedure. The decision to perform a unilateral or bilateral procedure is made after examining both ears and assessing hearing.
Preparing for surgery
Before tympanostomy, a consultation with an otorhinolaryngologist (ENT specialist) is required. The doctor may assess:
the frequency of ear infections;
how long the middle ear fluid has persisted;
the condition of the eardrum and middle ear;
hearing changes;
tympanometry and audiometry results;
other ENT conditions, such as enlarged adenoids.
If the procedure is performed under general anaesthesia, the preoperative examinations prescribed by the doctor and anaesthetist are required.
The patient or the child’s parents will receive individual instructions regarding eating, drinking and the use of medicines before surgery.
After tympanostomy
After a short period of observation, the patient can in many cases go home on the same day.
During the first few days, the following may occur:
mild discomfort in the ear;
a small amount of bloody or clear discharge;
temporary sensitivity to sounds.
If hearing loss was caused by fluid in the middle ear, hearing may improve relatively quickly after the fluid is removed and ventilation is restored. However, the individual outcome depends on the underlying cause of the hearing impairment. The doctor will also determine when follow-up visits and hearing assessments are required. For patients who have undergone tympanostomy because of otitis media with effusion, postoperative follow-up is important to ensure that the ventilation tube is functioning and that the middle ear fluid has resolved.
How long does the ventilation tube remain in the ear?
A ventilation tube is not intended to remain in the eardrum permanently. Short-term tubes usually come out of the eardrum spontaneously after several months, and the opening generally closes by itself. The exact duration depends on the type of tube used and the individual healing process. Many standard tubes remain in place for approximately 6–12 months, although the period may be shorter or longer. In some patients, middle ear fluid accumulation or Eustachian tube dysfunction may recur, and repeat tympanostomy may occasionally be required.
Can you swim with a ventilation tube?
International guidelines do not recommend routinely imposing permanent water restrictions or requiring all children with tympanostomy tubes to use earplugs. Water protection may be appropriate in individual situations, for example if ear discharge repeatedly occurs or if the child swims in untreated water. After surgery, the instructions provided by the treating ENT specialist should be followed, as recommendations may vary depending on the type of ventilation tube and the individual situation.
Possible risks and complications
As with any surgical procedure, complications may occur after tympanostomy. These may include:
ear discharge, or otorrhoea;
middle ear infection;
blockage of the ventilation tube;
premature extrusion of the tube;
prolonged retention of the tube;
scarring of the eardrum, or tympanosclerosis;
persistent perforation of the eardrum after the tube comes out;
the need for repeat insertion of a ventilation tube.
NICE particularly recommends discussing the risks of perforation, tympanosclerosis, local changes to the eardrum and infection with the patient or the child’s parents before surgery. If severe pain, persistent or purulent discharge, fever, bleeding or a significant deterioration in general health occurs after surgery, the treating doctor should be contacted.
