What are the next steps for a patient with a recently placed Eustachian (ear) tube who still experiences pressure and muffled hearing in the affected ear?

Persistent Symptoms After Tympanostomy Tube Placement

For a patient with persistent pressure and muffled hearing a few weeks after tympanostomy tube placement, obtain age-appropriate hearing testing and perform pneumatic otoscopy to assess tube patency and middle ear status, as tubes should provide immediate relief by allowing direct air entry into the middle ear. 1

Immediate Diagnostic Evaluation

The presence of ongoing symptoms shortly after tube placement is abnormal and requires prompt assessment:

• Perform pneumatic otoscopy to verify the tube is patent (open), properly positioned, and that the tympanic membrane is not retracted 1
• Obtain tympanometry to assess for persistent type B (flat) pattern, which would indicate continued middle ear dysfunction despite the tube 1
• Conduct age-appropriate hearing testing to quantify any conductive hearing loss, which should improve by 6-12 dB with patent tubes 2, 1

Common Causes of Persistent Symptoms

Several scenarios can explain continued symptoms after tube placement:

• Tube obstruction or malfunction - The tube may be blocked by dried blood, mucus, or debris, preventing adequate middle ear ventilation 1
• Persistent middle ear effusion - Thick fluid may not drain adequately even with a patent tube 1
• Tube malposition - The tube may have migrated or was not optimally placed 1
• Underlying sensorineural hearing loss - This would not improve with tubes and requires separate evaluation 3

Management Algorithm

If Tube is Patent and Functioning:

• Continue observation for 3 months total from the time of tube placement, as the American Academy of Otolaryngology-Head and Neck Surgery recommends reevaluation at 3-month intervals for chronic otitis media with effusion 1
• Optimize the listening environment if mild hearing loss persists (get within 3 feet before speaking, turn off background noise, face the child when speaking) 3
• Consider nasal balloon auto-inflation as an adjunct therapy, which has demonstrated benefit (NNT=9) for clearing middle ear effusion 2, 1

If Tube is Obstructed:

• Apply antibiotic ear drops (ofloxacin or ciprofloxacin-dexamethasone) twice daily for up to 10 days if infection is present 1
• Avoid oral antibiotics unless the patient is systemically ill or ear drops fail 1
• Do not use ear drops for more than 10 days to prevent yeast infections of the ear canal 1

If Tube Has Extruded Prematurely:

• Reassess for persistent effusion at 3-6 month intervals 1
• Consider repeat tube insertion only if effusion persists beyond 3 months with documented hearing loss or structural changes 1
• Add adenoidectomy to repeat tube surgery if the patient is ≥4 years old, as this reduces the need for future operations by 50% 1

Critical Pitfalls to Avoid

• Do not assume tubes are functioning without direct visualization - Always examine the tympanic membrane to confirm tube patency 1
• Do not use intranasal corticosteroids for Eustachian tube dysfunction, as they have shown no improvement in symptoms or middle ear function 2, 1
• Do not use topical nasal decongestants for more than 3 days to prevent rhinitis medicamentosa 2
• Do not skip hearing testing before considering any additional interventions, as this is essential for appropriate decision-making 1
• Do not use prolonged or repetitive courses of oral steroids or antibiotics for persistent effusion, as these are strongly not recommended 1

Expected Outcomes with Functioning Tubes

When tubes are working properly, patients should experience:

• Immediate relief of pressure sensation as the tube allows direct air entry into the middle ear 1
• Hearing improvement of 6-12 dB while tubes remain patent 2, 1
• Resolution of muffled hearing within days to weeks 1

The persistence of symptoms "a few weeks" after placement warrants investigation, as benefits should be apparent much sooner with properly functioning tubes.