How should an occluded myringotomy tube be managed in a patient (child or adult) with an intact tympanic membrane and no active middle‑ear infection?

Management of Occluded Myringotomy Tubes

For an occluded tympanostomy tube in a patient with no active infection, the tube should be removed and replaced if continued middle ear ventilation is still clinically indicated, or simply removed if the original indication has resolved. 1

Understanding Tube Occlusion

An occluded tube loses its primary function of middle ear ventilation and drainage. 2 When a tube becomes blocked, it essentially creates the same closed middle ear space that existed before tube placement, negating the benefits of the procedure. 1

Key clinical implications of tube occlusion include:

• Loss of pain relief mechanism: Ear pain returns if acute otitis media develops with an occluded tube, whereas functioning tubes typically prevent pain even during infection 1
• Inability to use topical therapy: Occluded tubes prevent antibiotic eardrops from reaching the middle ear space, eliminating the 77-96% cure rates achieved with topical therapy and forcing reliance on less effective oral antibiotics 2
• Risk of tympanic membrane rupture: With an occluded tube, the eardrum can rupture during acute infection, similar to ears without tubes 1

Assessment Before Intervention

Before deciding on tube management, confirm:

• Duration of original indication: Document whether the child still has recurrent acute otitis media (≥3 episodes in 6 months or ≥4 episodes in 12 months) or persistent middle ear effusion 1
• Current middle ear status: Use pneumatic otoscopy and/or tympanometry to determine if middle ear effusion is present 3
• Hearing assessment: Obtain audiometry if effusion has persisted ≥3 months or if language/learning concerns exist 1
• At-risk status: Determine if the child has baseline sensory, physical, cognitive, or behavioral factors that increase risk for speech, language, or learning problems 1

Management Algorithm

If the Original Indication Persists:

Replace the occluded tube with a new tympanostomy tube. 1 This is appropriate when:

• Recurrent acute otitis media continues (≥3 episodes in past 6 months) with middle ear effusion present at assessment 1
• Chronic otitis media with effusion persists for ≥3 months with symptoms 3
• The child is at-risk for developmental sequelae and middle ear effusion is documented 1

If the Original Indication Has Resolved:

Remove the occluded tube without replacement. 1 Consider this when:

• No recurrent infections have occurred recently and no middle ear effusion is present 1
• The child has outgrown the condition (many cases resolve with natural history, especially after age 4-6 years) 1
• Hearing is normal and no effusion is present on examination 1

Watchful Waiting Option:

For children without at-risk features and uncertain tube candidacy, implement surveillance with reassessment at 3- to 6-month intervals rather than immediate tube replacement. 1 This approach is reasonable because:

• Improvements may occur from natural history, especially when chronic otitis media with effusion is not present 1
• The modest benefits of tubes must be weighed against procedural and anesthetic risks (estimated at 1:50,000 for ambulatory surgery) 3
• Tube-related complications include persistent perforation (2% with short-term tubes, 17% with long-term tubes) and tympanosclerosis (31-39% of ears with tubes) 3, 4

Special Considerations for At-Risk Children

Children with baseline sensory, physical, cognitive, or behavioral factors warrant more aggressive management with prompt tube replacement. 1 These children derive greater benefit from continuous middle ear ventilation because even temporary hearing loss can significantly impact their already compromised developmental trajectory. 1

Common Pitfalls to Avoid

• Attempting to "unclog" the tube: Do not instruct patients to use eardrops or other methods to clear an occluded tube, as this is ineffective 2
• Delaying assessment in at-risk children: These patients require prompt evaluation and intervention rather than prolonged observation 1
• Replacing tubes reflexively without reassessing indication: Many children outgrow the need for tubes, and unnecessary replacement exposes them to surgical and anesthetic risks without benefit 1, 3
• Ignoring hearing status: Failure to obtain audiometry when clinically indicated can miss significant hearing loss requiring intervention 1