What Water Precautions Should Be Used After Ear Tubes?

Patient Presentation
A 2.5-year-old male came to clinic with purulent drainage from both ears. He had myringotomy tubes placed after a series of acute suppurative otitis media episodes. He had had one previous episode of unilateral ear drainage that had resolved with antibacterial ear drops. The current history was that he had been swimming in a pool during vacation but also had been in a lake. He developed some pain and drainage in both ears within 24 hours of being in the lake. His parents began ear drops but now 36 hours later the drainage was not improving and they felt it was getting worse with more, thicker, and now smelly, yellow-green discharge bilaterally. The review of systems showed no fever, but the skin of the helix was irritated from the drainage.

The pertinent physical exam showed overall well appearing male with normal vital signs and growth parameters in the 10-25%. HEENT revealed normal eyes, nose, and throat. He had some shotty anterior cervical nodes. Bilateral ears showed copious secretions that were as the parents described. Part of the left tympanic membrane showed pus behind the membrane and the tube was draining. The right tympanic membrane could not be visualized because of the discharge.

The diagnosis of presumed bilateral acute otitis media was made. The patient was begun on oral antibiotics and the topical antibacterial/steroid drops were also continued to provide some local pain relief and help to potentially thin out the secretions to keep them draining. “We knew he probably shouldn’t go in the lake but we had forgotten his ear plugs when we left on vacation,” the parents lamented. The pediatrician noted that there are some different interpretations for these precautions and expected that he should do well with the treatment.

Discussion
Myringotomy tubes (MT) placement is one of the most common surgical procedures. In pediatrics they are usually placed for prevention of recurrent, acute suppurative otitis media and prevention of hearing loss and/or speech acquisition. It is a relatively safe procedure but does have complications including bleeding, infection, chronic otorrhea, persistent perforation, retraction pockets, tympanosclerosis, MT blockage, repeated surgery and anesthesia risks. The MT are extruded naturally usually within 6-18 month. Acute otorrhea episodes are recommended to be treated with ear drops only for most cases.

Learning Point
The American Academy of Otolaryngology – Head and Neck Surgery Clinical Practice Guideline from 2022 recommends no routine water precautions for most patients after MT placement. They note that the MT have a small hole (1/20th inch) making it less likely for water to get into the middle ear. Surface swimming and shallow diving probably do not create enough pressure to cause middle ear penetration. They also note that even with deep diving, the pressure in the nasopharyngnx can also prevent eustachian tube opening and thereby prevents fluid from moving into the middle ear. They do note that water precautions may be appropriate for some patients such as those with: