What is the best course of action for a patient with bilateral ear pain, worse on the right, and a history of multiple ear infections as a child, who had tympanostomy tubes (ear tubes) placed bilaterally, but incorrectly, and has not had an ear infection since?

Management of Bilateral Ear Pain in Adult with History of Tympanostomy Tubes

Immediate Course of Action

This patient requires urgent otolaryngology referral for direct visualization with otomicroscopy to assess for structural complications from the prior tube placement, including persistent tympanic membrane perforation, retraction pockets, cholesteatoma, or adhesive atelectasis. 1

The history of "incorrectly placed" tubes with subsequent malpractice litigation raises serious concern for iatrogenic structural damage that could be causing the current bilateral ear pain.

Diagnostic Approach

Essential Examination Components

• Pneumatic otoscopy should be performed immediately to assess tympanic membrane mobility, identify retraction pockets, and detect middle ear effusion 1
• If pneumatic otoscopy shows any uncertainty about structural integrity, otomicroscopic examination is mandatory to search for retraction pockets, ossicular erosion, and areas of atelectasis and atrophy 1
• Audiometric evaluation is indicated given the history of chronic ear disease and prior tube placement to assess for conductive or sensorineural hearing loss 1
• Tympanometry can identify type B (flat) patterns suggesting persistent middle ear dysfunction or effusion 1

Key Structural Complications to Rule Out

• Persistent tympanic membrane perforation - a known complication after tube extrusion that can cause recurrent pain and infection 1
• Retraction pockets or adhesive atelectasis - particularly posterosuperior retraction pockets that may benefit from intervention 1
• Cholesteatoma formation - can develop from chronic negative middle ear pressure and retraction 1
• Ossicular erosion - structural damage that requires specialist evaluation 1

Symptomatic Management Before Specialist Evaluation

Pain Control

• Acetaminophen or ibuprofen for analgesia while awaiting specialist evaluation 1
• Avoid inserting anything into the ear canal, including cotton swabs or tissue 2

What NOT to Do

• Do not prescribe oral antibiotics empirically without evidence of acute infection (fever, purulent drainage) 1
• Do not prescribe topical antibiotic ear drops unless there is visible drainage or confirmed infection 1, 3
• Do not attempt any instrumentation of the ear canal in primary care given the complicated surgical history 2

Monitoring for Infection

• If visible ear drainage develops, this indicates infection requiring topical antibiotic drops (ciprofloxacin or ciprofloxacin-dexamethasone) twice daily for 7-10 days 1, 2
• Oral antibiotics are unnecessary for most ear infections unless the patient is systemically ill 1

Critical Pitfalls to Avoid

The most important pitfall is assuming this is simple otitis media or otitis externa and treating empirically without specialist evaluation. The history of incorrectly placed tubes with malpractice litigation strongly suggests structural damage that requires direct visualization and potentially surgical correction. 1

• Do not delay ENT referral - structural complications like cholesteatoma or significant retraction pockets can worsen with time 1
• Do not assume bilateral pain means bilateral infection - structural problems can cause pain without active infection 1
• Do not prescribe water precautions or swimming restrictions without confirmed active infection or perforation 1, 3

Timeframe for Specialist Evaluation

• Referral should be made within days to weeks, not months, given bilateral symptoms and concerning surgical history 1
• If any signs of acute complications develop (severe pain, facial weakness, vertigo, hearing loss), immediate emergency department evaluation is warranted 4, 5