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Through the Otoscope: Symptoms: Ear Wax, a Green Circle, and Small Ear Canals

Rensink, Michael J. MD

doi: 10.1097/01.HJ.0000414379.97740.a4
Through The Otoscope

Dr. Rensink is a member of ENT Associates of San Diego, and has been a practicing ENT specialist for more than 35 years.

Donna, 52, had difficulty hearing speech in a noisy room, especially women's 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 Donna's right ear, and should the ear be cleaned?

What is your diagnosis? See p. 10.

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Diagnosis: Ventilation Tube

By Michael J. Rensink, MD

A clearer view of Donna's 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?

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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.

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The answer depends on the ear's 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.)

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The goal is to return the patient's 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 patient's two-week follow-up. Some cases are difficult and heal slowly, and that requires more follow-ups and a variety of 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.

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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 Donna's 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.

© 2012 Lippincott Williams & Wilkins, Inc.