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Donna, 52, had difficulty hearing speech in a noisyroom,
especially womens speech, and wanted her hear-ing aid turned up.
Adjusting a hearing aid is easy withthe necessary software and
should make an improve-ment, 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. Thefirst
rule of intervention is, Do no harm.
Donna has been wearing hearing aids for years, andwas hearing
well when she was initially fit. I used an
otoscope to look into her ears to ensure excessive waxwas not
the problem. She has small ear canals, limitingthe ability to see
the canal and to view the eardrumfrom different angles. Initial
inspection of her right earshowed a green circle surrounded by ear
wax. (Figure 1.)What is the green circle in Donnas right ear,
andshould the ear be cleaned?
What is your diagnosis? See p. 10.
THROUGH THE OTOSCOPE
Symptoms: Ear Wax, a Green Circle, and
Small Ear CanalsBy Michael J. Rensink, MD
8 THE HEARING JOURNAL Through the Otoscope MAY 2012 VOL. 65 NO.
5
Figure 1.Donnas right ear.Medrex
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10 THE HEARING JOURNAL Through the Otoscope MAY 2012 VOL. 65 NO.
5
Continued from p. 8
A clearer view of Donnas ear reveals why her ear should notbe
cleaned: a ventilation tube passes through the eardrum.(Figure 2.)
This raises other questions for audiologists andhearing 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?
HOW YOU CAN HELP
Patients are told to keep water out of their ears because it
isimperative to keep the ear dry when inserting a ventilation
tube.Water can move pathogens into the middle ear and cause
aninfection. I recommend well-fitted, custom-made otoblocks,but use
caution when making the impression to avoid drivingthe tube into
the middle ear. Inspect the otoblock packagingcarefully for
blow-by, the leaking of harmful material.
HOW LONG SHOULD A TUBE STAY IN THE EAR?
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 Eustachiantube
function improves. Remember, the ventilation tube hastwo functions:
draining fluid out of the middle ear, and pro-viding air to the
tissues in the middle ear, a crucial role if theEustachian tube is
functioning poorly.
The tube should be removed once the ear is healthybecause the
perforation will heal on its own more quicklythe sooner it is
removed. Cases of tubes remaining in placefor years have been
reported, and the tube should remain ifthe condition persists.
Ventilation tubes are naturally expelledfrom the ear in most cases
by the tissues in the eardrum.
Straw-shaped, longer T-tubes (Figure 2) tend to stay in theear
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
aspossible. Hearing aid use depends on the condition of the
ear.Typically, most of the fluid is removed from the middle ear
afterthe tube is inserted, and a hearing aid may be worn if there
isno drainage within in a few days. Some ears do take several
daysto drain through the tube. It makes no sense to use a
hearingaid during heavy drainage.
Hearing aid use can resume if the condition is resolved atthe
patients two-week follow-up. Some cases are difficult andheal
slowly, and that requires more follow-ups and a variety of
treatments to help the ear heal. Refer the patient back to
hisENT as soon as possible if there is new drainage at this
time.
OTHER CONSIDERATIONS
Patients with ventilation tubes should not use cotton
swabsbecause they may dislodge the tube or harm the eardrum.
Theyshould never use an over-the-counter wax solvent, such as
Debroxor Cerumenex. Wax removal can be especially tricky because
ofthe risk of dislocating the tube or getting water in the ear.
Use caution if you see a dislodged ventilation tube restingin
the ear canal. Do not take out the tube because it may beattached
to debris or residual skin protruding from the ear-drum. Pulling
the tube can cause damage to delicate tissue, sorefer the patient
back to his ENT if you accidentally remove it.Some tubes, such as
the tall T-tube, extrude from the eardrumand appear incorrectly
inserted but are not. (Figure 1).
The drainage in Donnas ear stopped, and her earimproved. I
reinstalled her hearing aid use after two weeks,and her audiologist
adjusted it. The tube will be removed ina few months if her ear
continues to improve.
Dr. Rensinkis a member of ENT Associates of San Diego, and has
been a practicing ENT
specialist for more than 35 years.
Diagnosis: Ventilation TubeBy Michael J. Rensink, MD
THROUGH THE OTOSCOPE
Figure 2.Ventilation tube with a longer T-tube.Medrex
Figure 3.Ventilation tube with a shorter grommet tube.Med
rex
