Why does an adult still experience pressure, bloody drainage, and pulsatile tinnitus after myringotomy (surgical incision in the eardrum) tube placement?

Post-Myringotomy Tube Symptoms: Pressure, Bloody Drainage, and Pulsatile Tinnitus in Adults

Persistent symptoms after myringotomy tube placement in adults may indicate underlying vascular abnormalities, inadequate tube function, or post-surgical inflammation that requires further evaluation and management.

Causes of Persistent Symptoms After Tube Placement

1. Pulsatile Tinnitus

Pulsatile tinnitus after tube placement warrants particular attention as it may indicate:

• Vascular abnormalities: Pulsatile tinnitus relates to rhythmic noise synchronized with the patient's heartbeat and may indicate an underlying vascular condition that was not addressed by the tube placement 1
• Retrotympanic vascular lesions: The presence of a vascular retrotympanic lesion leads to different differential considerations that require specific imaging 1
• Incomplete resolution: The tube may not have adequately addressed the underlying cause of symptoms

2. Persistent Pressure Sensation

Pressure sensation despite tube placement may be due to:

• Tube dysfunction: The tube may be blocked or not properly ventilating the middle ear
• Eustachian tube dysfunction: Underlying issues with eustachian tube function that persist despite tube placement
• Patulous eustachian tube: In some cases, symptoms of patulous eustachian tube can mimic those of middle ear effusion 2

3. Bloody Drainage

Post-operative bloody drainage may result from:

• Normal post-surgical inflammation: Some bleeding is expected after the procedure
• Tube-related complications: Tympanostomy tube sequelae are common but generally transient 1
• Middle ear inflammation: Pronounced inflammation of the tympanic membrane and middle ear mucosa may persist after tube placement 1

Diagnostic Approach

For adults with persistent symptoms after myringotomy tube placement:

1. Otoscopic examination: Verify tube patency and position
2. Tympanometry: Assess middle ear pressure and tube function
3. Imaging studies: For pulsatile tinnitus, imaging is strongly indicated
   • CT angiography (CTA) with mixed arterial and venous phase through the head and neck 1
   • MRI may be necessary to evaluate temporal bone/skull base 1

Management Options

For Pulsatile Tinnitus

• Imaging evaluation: The American Academy of Otolaryngology guidelines recommend targeted imaging for unilateral persistent tinnitus 1
• Vascular consultation: May be needed if vascular abnormalities are identified

For Persistent Pressure

• Tube assessment: Ensure the tube is patent and properly positioned
• Consider tube replacement: If the tube is blocked or displaced
• Treat underlying eustachian tube dysfunction: May require additional interventions

For Bloody Drainage

• Short-term observation: Some drainage is expected post-procedure
• Topical antibiotic drops: If infection is suspected
• Avoid water exposure: To prevent contamination through the tube

Important Considerations

• Tube complications: Tympanostomy tube sequelae are common but generally transient (otorrhea) or do not affect function (tympanosclerosis, focal atrophy) 1
• Long-term effects: Tubes may cause visible changes in the appearance of the tympanic membrane but these rarely require intervention 1
• Persistent perforation risk: Seen in approximately 1-2% of cases after tube extrusion 1

When to Consider Additional Intervention

• Persistent symptoms beyond 2-4 weeks: May indicate need for revision or alternative treatment
• Worsening symptoms: Particularly increasing pain or hearing loss
• Signs of complications: Such as tube extrusion, persistent perforation, or infection

For adults with persistent pulsatile tinnitus specifically, imaging studies should be strongly considered as this symptom may indicate underlying vascular pathology that was not addressed by the myringotomy tube placement 1.