Watchful Waiting and OME

For the past 20 years I have used the T-tube (originally designed by Richard Goode, MD). I redesigned the tube for Richard in the late 1980s to make it smaller, as the original tube had a problem with causing perforations if left in too long. These tubes-and I have used almost every type of tube on the market-seem not to extrude as easily, and, being smaller, don’t cause as many permanent perforations. The case against the T-tubes causing too many perforations is overplayed-they just need to be followed up more closely.

I have seen some of these small tubes, to which you refer-probably the Reuter bobbin titanium, Teflon, or silicone types-come out within one week, one month, six months, and, in one case, the tube stayed in for 5 years, causing scar tissue to form, injuring the hearing partially. The problem with the small tube is that you can’t predict when they will come out, or if they will come out. This leaves the patient with either incomplete treatment because the congestion in the MEC has not subsided when the tube extrudes, or the problem of having the tubes in too long, causing scar tissue or perforations. I see our patients routinely two weeks postop and 6 to 12 months later, as well as any time they have any problem, and are referred back by their pediatrician, such as for an infection from getting water in the ears. We fit all our patients with either Mack’s plugs or commercial grade swimmer’s plugs to protect their ears. When we feel the disease process is cleared or significantly improved, we remove the tubes and use an alloplastic graft over the TM perforation (which might be as large as 5 to 7 mm) to help guide the squamous epithelium to give a normal closure, instead of growing down into the middle ear, causing a cholesteatoma. We then see them three weeks later, and then 6 to 12 months later, even if they don’t have any problems.

I don’t think that we should give up on PETs, as they have been very beneficial, when used appropriately, and after proper evaluation of the clinical indications for treatment. I don’t think watchful waiting, by itself, is the whole answer, since just looking at a TM, after it has been infected, would frequently show a cloudy, dull-looking TM, which the examiner might think normal if it didn’t show erythrema, although the MEC might even had significant fluid in it-this leaves too much to subjective determination. I feel we have adequate modern testing that can be used-and should be used-to follow these kids who have recurrent OME to give us a better guideline on what therapy is indicated, not just watchful waiting.