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BackTable / ENT / Article
In-Office Ear Tube Placement: Benefits & Drawbacks
Megan Saltsgaver • Updated Oct 23, 2024 • 78 hits
Can pediatric ear tubes be placed in the office? Yes! In-office ear tube placement is gaining popularity among parents due to its convenience. Skipping a pre-operative appointment, avoiding fasting and anesthesia, and having both the consultation and procedure done on the same day makes it an efficient option. But how can parents determine if this approach is right for their child? Pediatric otolaryngologist Dr. Shalegh Cofer explains who makes a good candidate for in-office ear tubes, what to expect on the day of the procedure, and the potential benefits and drawbacks of performing it in an office setting.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• In-office ear tubes are becoming increasingly popular due to their convenience, efficiency, and the elimination of operating room and recovery room costs.
• Before the scheduled appointment, it’s important for parents and patients to do some research and consider if this procedure is the right choice. Setting realistic expectations about the process and determining whether the child can tolerate it are essential.
• All ages and patients who are candidates for ear tubes in the operating room are generally suitable for in-office placement as well.
• While the risks are the same as those in a traditional operating room setting, additional challenges may include a child experiencing anxiety or moving during the procedure, potentially causing injury to the ear canal.
• The procedure typically involves the physician and two assistants or nurses to help hold the child’s head steady and manage instruments. Parents are usually welcomed into the room to offer support. Overall, in-office ear tube placement is a great option for those seeking a more streamlined approach to this procedure.
Table of Contents
(1) Who is a Good Candidate for In-Office Ear Tubes?
(2) What to Expect on the Day of Ear Tube Placement
(3) Benefits & Drawbacks of In-Office Ear Tube Placement
Who is a Good Candidate for In-Office Ear Tubes?
When parents consider their child undergoing a procedure, one of the biggest concerns is how cooperative the child will be. In-office ear tube placement is no different, and since children are often sensitive about their ears, this can heighten parental anxiety. A child’s age plays a significant role in determining how well they tolerate the procedure. Children aged 8 and older can usually be coached through it, while very young children can often be swaddled to immobilize them, with a nurse assisting in holding the head still. The challenge tends to arise with children in the in-between ages, where immobilizers and assistance may be needed to keep the child’s shoulders and head steady during the procedure.
As for candidacy, the criteria for in-office ear tubes are similar to those for tubes placed under anesthesia in an operating room setting. However, in-office procedures may not be suitable for children with small ear canals, retracted eardrums, or bleeding disorders.
[Dr. Ashley Agan]
When you are seeing patients in clinic and talking about potentially doing in-office ear tubes, do you think about your patient selection differently depending on the age? Your little kids that are under two versus your two to five range versus the over five? The reason I'm asking, I'm just thinking about smaller kids being easier to swaddle and hold still, and then older kids having enough maturity to potentially talk them through it. Then with the kids in the middle, just potentially being impossible. I don't know. Tell me more about how you think about the age.
[Dr. Shelagh Cofer]
That is a really good point. I, in my mind, also break it down into similar age ranges, the very little littles that we use a gentle swaddle technique to help immobilize them, and a nurse or an assistant will help steady their head. Then the older kids, eight and older, I would say, probably, who you can coach through. Then that in-between range where they're really too big to put them into a swaddle. It just doesn't feel right.
We do have ways that we can work with them and different ways to immobilize, primarily the shoulders, and helping to steady the head. Involving the parent a little bit in this process is really helpful. As far as the patient selection, really, you have to meet the same criteria as you would for any child to recommend ear tubes. If you have a very teeny tiny ear canal, or let's say your eardrum is super retracted, it's stuck in and there just isn't a space behind the eardrum or if you have a tendency to bleed easily, these are the reasons that we would consider you not to be a candidate to do tubes in the office. Otherwise, anybody else, no matter what your age, can easily have it done.
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What to Expect on the Day of Ear Tube Placement
Providing patients and parents with educational brochures ahead of time helps manage expectations for in-office ear tube procedures. This ensures that by the time they arrive for their scheduled appointment, they can have any remaining questions or concerns addressed. The doctor should offer more detailed information during the consultation, and shared decision-making should be used to determine if proceeding with the procedure that day is appropriate.
If the procedure is approved, the parent and child are taken to the procedure room. Ideally, the child would have completed an audiogram prior to the appointment, providing a baseline for their hearing. This hearing test is typically done in a sound booth when possible. A follow-up hearing test should then be scheduled six to eight weeks after the procedure.
Before the procedure begins, children are usually given a dose of ibuprofen or Tylenol if they haven't already taken one. After discussing all potential risks, parents sign a consent form. The child is then placed on a flat table, often with the use of a medical immobilization board, and is swaddled to keep them still. Using a large microscope, the doctor starts by cleaning out any earwax.
Numbing medicine is applied to the eardrum, with the application method varying depending on the device used. Dr. Cofer, for instance, uses the Hummingbird device and applies phenol to numb the eardrum. Children may describe a sensation of fullness or slight stinging as the numbing agent is placed.
Once the eardrum is numbed, the doctor uses the medical device to make an incision in the eardrum. The ear tube is pre-loaded into the device, so once the incision is made, the tube is deployed in the same step, and the doctor swiftly withdraws the device. This process is repeated on the other ear, with both sides typically completed in under three minutes.
A medical assistant or nurse is usually present to help hold the child's head, while another person hands the doctor instruments to maintain efficiency. Child life specialists are often consulted beforehand to help develop strategies for getting the child through the procedure. If available, these specialists, or music therapists for younger children, may be present in the procedure room to help create a more comforting environment. While parents are also present for support, they generally do not assist in immobilizing the child but play a key role in keeping them calm.
[Dr. Ashley Agan]
Once a parent has said, "Okay, we want to do this office procedure thing," what happens next in your office? Are most people getting it done the same day as their consult? Do they already know that they're leaning towards that anyway?
[Dr. Shelagh Cofer]
We have a great setup and a great system to be successful at doing this. I think if you want to incorporate this into a practice, for example, it's important to start setting up the expectations even before the clinic appointment. We have a half day where we schedule all of our patients who are interested. They've already been sent an educational brochure, which describes the procedure. When they show up already to my office, they know what to expect. They have already thought about it. They've already decided, "Yes, I'd prefer this approach."
Even so, when I see them in the clinic, I do talk to them about, "You can have this set up as a scheduled procedure in the operating room and with fasting," all of that, or we can do it today here in the clinic. We just use that shared decision-making process, which I think is really important to make sure that the right child, the right parent is getting the right procedure in the right location.
It works really well, but it does help to have that expectation. When I see them for consult, I also describe in more detail what will happen during the procedure. We are in a consult room and we have a procedure room that's just a few doors down from us where we go to do the procedure. As soon as we're done, we just pop up and we go back to the other room. It's a very smooth process. I would say it takes about 30 minutes to do a consult, do the ear tubes, and have the patients do their scheduled follow-up.
[Dr. Ashley Agan]
Are your kids usually coming in with audiograms already or do they do it before they see you that day?
[Dr. Shelagh Cofer]
They do. We have appointments scheduled for their hearing tests to be done the same day. These are linked appointments. That's my office staff and how amazing they are and getting this coordinated and supporting this.
[Dr. Ashley Agan]
As far as your audiograms, is it like the classic audiogram or is it just OAEs or just tymps, tympanograms? What kind of information is necessary for you?
[Dr. Shelagh Cofer]
Yes. My preference is to have them complete a full audiogram and a sound booth, including tympanograms. If they're able to wear headphones or inserts, we might be able to obtain your specific hearing information, but sound-filled hearing test results is adequate as well and can reveal mild hearing losses, which is what we would see from a child with an effusion, is a mild conductive hearing loss.
Typically, I have in the past, if there's been a report of parental concern about hearing and there's been a lot of ear infections, they, of course, have to have an effusion on the day that you evaluate them. Just went ahead and done the ear tubes with just tympanograms only and the knowledge that they passed a newborn hearing screen, and then scheduling a follow-up hearing test in six to eight weeks, which is the usual amount of time before we see a patient back. That's just because audiology access can sometimes be a challenge.
[Dr. Ashley Agan]
The child may not be cooperative on the day that they happen to be getting their hearing tests. Little kids are finicky sometimes and aren't always in the mood.
[Dr. Shelagh Cofer]
Yes, sometimes you got to just be flexible.
[Dr. Ashley Agan]
Okay. Moving through the appointment. The patients, they watched their video or they read through their brochure, so they're prepared for it. They know they want it. They get their hearing test. They see you in consultation and you agree, tubes are a good idea, and they want to move forward. Then what happens next?
[Dr. Shelagh Cofer]
What happens next is, sometimes they've already taken a dose of maybe some ibuprofen, some Tylenol at home. If they haven't, we go ahead and administer that in the clinic. They sign their consent form. We reviewed all the risks of the procedure, same risks as with any ear tube placement. You can put a tube in. Typically, we say it stays from 6 to 18 months which is a regular-acting tube durability or duration. All the same potential complications, early extrusion, prolonged retention. After the tube falls out, you can have a perforation or hole.
We review all of that. We have them sign the permission slip, and then we just go down to the end of our hallway where we have a flat table. We've got a medical immobilization board plus a sheet or something soft on the inside of that. We swaddle them up. Our microscope happens to be connected to the ceiling. We're able to just pull it right down. I always do it the same way every time just to make things easy. I start on the left ear. We use speculum, we use a microscope, clean out earwax.
Then what we're going to do is use numbing medicine directly on the eardrum. The Hummingbird device is approved for use with any type of topical anesthetic. I think you were mentioning the Tula device, which has its own proprietary way to numb up the eardrum. We use phenol and we just dab it right onto the eardrum. It's a chemical neurolytic. It works very quickly. Some patients describe that their ear feels full or it stings a little bit or it sounds funny when it hits their eardrum. Then we go right in with the device, makes the incision in the eardrum. It's already got the tube loaded in it, and we deploy the tube and come back out.
It's like, picture earlobe piercing gun, in a way. It's that simple. Then we do-si-do around, switch sides, and I'll do the second ear.
[Dr. Ashley Agan]
Thinking about your team that's in the room, so you have a medical assistant or nurse or someone that's helping hold the head. I assume they're sitting at the head of the bed.
[Dr. Shelagh Cofer]
They sit opposite me. Once the shoulders are immobilized with the sheet, the blanket, the Velcro cross, then they sit opposite me to steady the head. It's a waxing, waning sort of response you're getting from a child. Some kids cry as soon as you lay them down. Some kids cry as soon as you wrap them. Some don't cry until you're done cleaning the ears out, but they start to react and cry when you're putting on the numbing medicine.
What our research has shown is that the response from earwax cleaning is rated exactly the same as the application of the numbing medicine and the tube placement. That tells me that it can be difficult to know why a child is reacting at that age. Some of it is anxiety of something different. It can be pain. It can be, I don't want to be held still. There's a lot of different reasons for that. As soon as we're done, and we are typically done with both ears in three minutes or less, we're releasing the patient and we do what I call R&R, which is we're going to release and retreat.
We leave that area of the procedure room. We go back down to the other room. Most kids, I would say 90%, are no longer crying as soon as we release them and hand them right back to their parent's arm. Then the final 10% might continue to cry, but 100% are done crying by the time we're done with wrapping. up.
[Dr. Ashley Agan]
As far as the personnel that you have helping, so the nurse or medical assistant is helping hold the head, do you have someone that's handing you instruments so that you can put the phenol on really quickly and then go right in with the device right after that so that that moves smoothly?
[Dr. Shelagh Cofer]
I do have the luxury of having somebody who is working in a clinic who can come down for each case that we do and hand me the instruments. They've been trained on how to do that properly. We did a lot of education of the office staff so that it wasn't so dependent on just one person or maybe a couple people who know how to do this, but all the office staff is comfortable with it so they can all jump in and help. I like to be able to just be focused on what I'm doing and try not to have my eyes leave the oculars of the microscope. We were always taught to do that. You should be able to put your hand out, have an instrument put into your hand.
That just helps the flow and it helps us to be quick and efficient.
[Dr. Ashley Agan]
I think that makes sense. Is there anybody else in the room, like is there a child life specialist playing a guitar or dancing, helping distract?
[Dr. Shelagh Cofer]
Yes, it's such a great question. Child life therapists are amazing, and I'm so lucky to be able to have access to them in the outpatient world. I think that that's probably less common than say in a hospital setting. They are so great because if you do have one of those older kids that can be coached through, they spend a lot of time meeting that child. During the consultation, they're in there getting to know that child and talking to them and coming up with a strategy that's going to help them get through the procedure.
When available, I do have that child life therapist in the room with us. If it's a small child, we might have a music therapist on any given day. The music therapist is in there playing the music, which we all love because that makes us all feel comfortable.
[Dr. Ashley Agan]
Yes, anything to help bring down the tension of having a screaming child. Then the parents are there too, right? I'm sure that took some getting used to, to having those extra eyes watching you during your procedure. Whereas in the operating room, you don't have that extra, I don't know, pressure of all the eyes watching the procedure.
[Dr. Shelagh Cofer]
Right. It is so important, I think, personally, to have a parent there. It doesn't have to be both. Sometimes, it might be a mom, it might be a dad, somebody might be extremely squeamish. I feel that it's really important. I think it sends a message to the child, "You may not like what's happening, but we as your parents and caregivers, we condone what's happening. We support it. We're here for you." I think that's the primary reason.
The secondary reason, I think, is if anything ever did happen or go wrong, which it really never has, and I don't anticipate something happening, but I think it helps in the event that it would for a parent to say, "Well, I saw that. I know what happened. I know what the response was." You don't have to come out of a room and say, "Oh, this tube got a little bit over-inserted." They're going to be wondering in their mind, "What really happened? Was this safe? Am I questioning my decision now?" I think it helps protect them a little bit and protect us, frankly.
[Dr. Ashley Agan]
As far as where the parents are, are they helping hold? Or do you say, "Okay, I want you guys to stay there because we've got our system here and we don't want you bumping or getting in the way?" How do you manage having that extra people in the room who are not your staff and who are not your patient?
[Dr. Shelagh Cofer]
I think there's probably a lot of different ways to set it up, but the way that we set it up is the parent is always opposite side from where I am. They're sitting, picture adjacent to where the nurse is sitting on a stool opposite me. They're sitting on just a little bit more towards the feet of the patient. We encourage them to lean in if they want to. We don't rely on them to do the setting of the head and things because I feel like I just need immobilization and I want to get the job done and do it right and be safe.
I don't rely on the parents to actually immobilize, but I think their presence there, it's just really supportive. When we switch ears, we just switch sides just like the nurse does.
Benefits & Drawbacks of In-Office Ear Tube Placement
As with any procedure, there are pros and cons. The benefits of in-office ear tube placement are numerous, starting with convenience—patients can skip fasting, avoid anesthesia-related risks such as emergence delirium, and eliminate the need for operating room and recovery room costs. Additionally, there’s no extended recovery time.
Another key advantage is that there are no increased risks when comparing in-office procedures to those performed in an operating room. The ear tubes typically last between 6 to 18 months. However, potential drawbacks include early extrusion, prolonged retention, or the possibility of a non-healing hole in the eardrum after the tubes fall out.
Some challenges can arise depending on the patient’s insurance provider or geographic location, which may affect approval for the in-office procedure. Other possible risks include the child moving during the procedure, which could result in injury to the ear canal, or accidental application of phenol to the skin, causing a burn. There’s also a slight risk of over-insertion of the ear tube, though improvements in medical device design have largely addressed this issue. More commonly, the tube may not fully insert into the eardrum or sit correctly. In most cases, this can be corrected by using an instrument to push the tube into place. In rare instances, the tube may need to be removed entirely, requiring the deployment of a new device.
[Dr. Ashley Agan]
When thinking about just benefits and drawbacks, we talked a lot about benefits, with just the convenience of being able to get it done that day. No fasting, no recovery time, really. What else? Cost-effectiveness, I guess, would be one thing to think about when you're doing tubes in the office versus the OR.
[Dr. Shelagh Cofer]
Yes. I think it's very cost-effective because you're not having all those other associated fees. Like a facility fee to have it done in an ambulatory care center or in an operating room. You don't have the recovery room fees, the anesthesiologist fee, all of that, I think. It can be a lot more economical and yet still be viable to offer it to patients in the office. You can't really expect ENTs to be doing this if they're losing money on every single case.
There are a lot of nuances to the economics of it. It depends a little bit on the region of country you're in. It depends on the patient's insurance status, what kind of population you see. It's hard, but it does make sense that overall, it has to be less expensive. That's number one. In really listening to parents, I think if you really listened to them, you hear how concerned they are about having their child undergo general anesthesia. I think because there really wasn't an option in the past, they just toughed it out and went ahead and did it because they thought their child really needed ear tubes and they wanted them to be better.
In talking to parents and now that we have this option, it's just so exciting, so great because that is probably the number one thing that we hear from the parents who choose to have this done is, "Wow." Yes, we were able to get it done in one single visit, their child's feeling better sooner, and they got to be with their child. They want to be there and support them. Then I think they really do appreciate the fact that they avoided that risk of general anesthesia and things that can happen with it.
General anesthesia is very safe and it's not something-- some procedures can't be done without it. In those circumstances, when you don't have an option, you just go forward and you do what has to be done. I think now that there's an option, a lot of parents really would like to choose that so that they can follow what they feel is best for their child and certainly not having exposure to medications that they've never had before, potentially any other complication from general anesthesia. I think they appreciate it, a lot.
[Dr. Ashley Agan]
Yes. I think I significantly underestimated how parents feel about general anesthesia and how many people are more concerned about that than the actual ear tube procedure. Then the other thing, emergence delirium, like I've had some families where the older child had ear tubes in the operating room setting, but had horrible emergence delirium that was traumatic for the whole family. I think as an ENT, when we're in the operating room, we're going, right? We're in pre-op or in the OR, we're in PACU, we're back to pre-op and we're just circling. I don't think I appreciated the prevalence of emergence delirium and what that was and how common it was. I think I read that in younger kids, it can be as common as 40%. I don't know. What can you comment on that aspect of it?
[Dr. Shelagh Cofer]
Yes. That's one of the things that I prepare. I make sure I go through what the experience of going to the OR to have ear tubes in your child is like. Your child might cry because they're starving and they're a little bit later in the morning, and you can't predict the OR time. It goes on its own time. They could be hungry or they might cry when they separate from the parent. They might cry as the mask is going on. Now the parent won't be there for that part typically. Although in some situations, they are.
Emergence delirium, so they can certainly cry in the PACU. To me, in my mind, if you have a child that has emergence delirium, and I think there was one study that talked about complications in ear tubes and under general anesthesia and had a 2% major complication rate, which was emergence delirium. It can be seen in 50% or more of patients, and it can last for up to 30 minutes, and things like laryngospasm. If you want to see people move fast, have a child in the OR who's having laryngospasm from ear tubes with just a mask and no IV. People will run into that room so fast now.
It can be treated. It's okay. It doesn't usually result in any kind of sequelae from that, but it's a scary event. I can imagine being a parent, especially if you're not in the medical field, of really being nervous about your child going under anesthesia.
[Dr. Ashley Agan]
Yes. Emergence delirium, what does it look like? It's basically just like the child is crying and delirious and not consolable for more than a certain amount of time. More than a matter of minutes, I guess, or having to be restrained to keep them from hurting themselves.
[Dr. Shelagh Cofer]
Yes. Not being an anesthesiologist, I don't diagnose it, but when you see a patient and you're told that that's what they're having, you see them being just crying, and it's not pain. It's not hunger. It's not they want their parent, they might be sitting in their parent's lap, but nothing that the parent can do or offer can treat this because it is the effect of anesthesia on the brain and this dysphoric state that happens. It's very difficult. You just have to sit and wait it out.
Whereas, in the clinic, as soon as we're done, that parent is consoling. We know that their pain is already subsided because we use the numbing medicine. We've released them from their swaddle. They're handed right back. There are things that the parent can do to try to console. They can give a snack, they can breastfeed, they can try to distract the child. They can do other things, all the things that parents do to try to console their children and they feel more involved. I think they feel more effective.
[Dr. Ashley Agan]
Have parents ever asked for a little bit of sedation or some "silly juice" to take the edge off a little bit? The idea is that it's no sedation. It's just topical, but I've had families ask about just giving a little something. I don't know if you've thought about that or if that's come up.
[Dr. Shelagh Cofer]
I haven't had a lot of requests. I think I've had zero, actually, requests for actual sedation. It would be tricky to do it in our clinic. Not that it could be impossible, but I think there's a lot of policies regarding what medications can be given in the outpatient setting and what kind of monitoring is then required. The beauty of this is that in truth, you really don't need any sedation. Just supporting them in other ways is preferred and works really well.
[Dr. Ashley Agan]
Yes. It can be hard to know how different patients respond to medications. It's not always as predictable. Thinking about complications, separate from what we know in the OR, because you have an awake child that's potentially moving or because it's a different type of device and placement, what are other things that you think about that can happen that we don't really think about in the OR?
[Dr. Shelagh Cofer]
I think some people are concerned that maybe the child's moving, we could injure the ear canal, the canal skin. We might have a drip of phenol that gets on the canal skin and causes a burn or something like that. These things could happen, for sure. They haven't. I have had zero cases of any injury to ear canals doing this in the clinic, but I think it's a fair question.
As far as the tube, we have had 98% success rate of inserting ear tubes in the clinic. Once we get going, we really have a very high rate of coming out of that room with an ear tube in each ear. One situation that I would say could happen is slight over-insertion of an ear tube. Now, there's been some changes made to the actual tube and to try to reduce any risk of that.
To be honest, it's only happened once for me, during the trial. I did have to take that patient to the OR, but I think in working through with the parents and talking about the possibility of a malposition or something, they were okay with it. They felt that they were informed, they knew it could happen. Again, it's a very rare event, and it's just not-- I didn't feel it was safe to try to grasp the tube and pull it back out of the incision safely. I think that can happen, but I think in doing this more and more, it becomes really second nature, and practice and having a great team can set you up for success.
[Dr. Ashley Agan]
Yes. Over-Insertion would be the scenario where the tube is dunked and in the middle part of the ear. What about the opposite when you have a short shot or a tube that's deployed and then it's sitting on the eardrum instead of in the eardrum? What's your process for addressing that in the moment?
[Dr. Shelagh Cofer]
That's a great question. In doing this over the years, I would say I've done a short shot more than I've done a dunk, which was only once. In my experience, what I want to do is, usually, I've made the incision, I've deployed, and if the flange just isn't all the way in, it's not sitting properly.
Maybe one instance I've been able to take a pusher instrument and just gently tap it in. If it's really, there's not even one part of the flange, which is seated well in the incision, I just take an alligator, I take that tube out and I just open a new device and we go right in with a new one. That's how we have decided to handle that situation. I think just, overall, I feel more comfortable doing that than taking extra time. I'm not worried about opening another device and the expense associated with that because I think, over time, it just didn't make sense to me to do that. It happens so rarely we just absorb that cost.
Podcast Contributors
Dr. Shelagh Cofer
Dr. Shelagh Coffer is a pediatric otolaryngologist at the Mayo Clinic in Rochester, Minnesota.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, July 30). Ep. 183 – Office-Based Ear Tubes in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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