Loose Grommets in the Ear Canal: Complications and Management
A loose grommet (tympanostomy tube) that has migrated into the ear canal is not dangerous but requires removal by a clinician to prevent potential complications including ear canal irritation, infection, and obstruction of the canal. 1
Understanding the Problem
When a tympanostomy tube becomes loose and falls into the ear canal rather than extruding completely out of the ear, it creates a foreign body situation that differs from normal tube extrusion. While the tube itself is no longer functioning to ventilate the middle ear, its presence in the canal can cause issues. 1
Key Complications of Loose Tubes in the Canal
- Ear canal irritation and inflammation from the foreign body rubbing against sensitive canal skin 1
- Risk of secondary infection (otitis externa) if the tube traps debris or moisture in the canal 1
- Potential for granulation tissue formation if the tube remains in contact with the tympanic membrane remnant or canal skin 1
- Obstruction of the ear canal particularly with larger or longer-term tubes 1
- Discomfort or pain from mechanical irritation 1
Immediate Management Approach
Parents should NOT attempt to remove the tube themselves or insert any objects (cotton swabs, tweezers, tissue) into the ear canal, as this risks pushing the tube deeper or causing canal trauma. 2
What Caregivers Should Do
- Keep the ear dry until the tube is removed by a clinician 1
- Avoid inserting anything into the ear canal including cotton swabs or cleaning instruments 2
- Schedule prompt evaluation with the child's otolaryngologist or primary care provider 1
- Monitor for signs of infection including new drainage, pain, or fever 1
Clinical Removal and Follow-Up
The clinician should remove the loose tube under direct visualization, typically using microscopy or otoscopy with appropriate instrumentation. 1 This is usually a simple office procedure that does not require anesthesia in cooperative children.
Post-Removal Assessment
After tube removal, the clinician should:
- Examine the tympanic membrane to assess healing and check for perforation (occurs in approximately 2% of cases with short-term tubes) 1
- Evaluate for middle ear effusion recurrence which may necessitate consideration of repeat tube placement 1
- Clean any debris from the ear canal using gentle suction or tissue spears if needed 1
- Assess hearing if there are concerns about fluid reaccumulation or persistent conductive loss 1
When Infection Develops
If the loose tube has caused secondary infection with visible drainage, prescribe topical antibiotic drops only (ciprofloxacin or ciprofloxacin-dexamethasone) without oral antibiotics. 1 The ear canal should be cleaned of debris before administering drops to ensure adequate drug delivery. 1
Common Pitfalls to Avoid
- Do not irrigate the ear when a loose tube is present, as this may push it deeper or cause discomfort 3
- Avoid using hydrogen peroxide in the ear canal with a loose tube, as this can cause significant irritation 3
- Do not prescribe oral antibiotics for uncomplicated cases; topical therapy is superior and avoids systemic side effects 1
- Do not delay removal thinking the tube will work its way out naturally, as prolonged presence increases complication risk 1
Long-Term Considerations
After tube removal, approximately 20-50% of children may develop recurrent middle ear effusion requiring additional surgery. 1 The clinician should:
- Schedule follow-up evaluation 4-6 weeks after tube removal to assess for effusion recurrence 1
- Consider adenoidectomy with repeat tube insertion if the child is 4 years or older and requires additional surgery 1
- Monitor hearing especially in children at risk for developmental or speech delays 1
The key message is that while a loose tube in the canal is not an emergency, it requires timely professional removal rather than watchful waiting or home intervention attempts.