Both of my sons had frequent ear infections when they were infants and had tubes put in their ears. The oldest had them put in twice, because the first ones fell out after a year. The problem? He still has a tube in his ear at the age of 24. This causes a lot of problems for him, including a "smelly" ear. Does the tube need to come out? How big is the operation? Is the physician who originally put the tubes in under an obligation to take them out since he stated, specifically, that they would fall out in a "little while?"

J.S.

Not everyone knows what these tubes are for, so please bear with me while I explain "ear tubes." The space behind the eardrum is air-filled. Air gets into this space via the eustachian tube, which is a tube of muscle and cartilage extending from the middle ear space to the throat. These tubes open periodically, allowing air to reach the middle ear space. Many children and adults suffer from eustachian tube dysfunction, which can lead to infection of the middle ear.

Ventilation tubes are very small plastic tubes that are placed into the eardrum by a surgeon. The tubes allow air into the middle ear space, thus functionally replacing the eustachian tubes. The implanted tubes usually last six to 18 months and are then spontaneously extruded (ejected) by the eardrum. Occasionally, however, the tubes are not extruded and must be removed by a surgeon.

I am certain that if your son's surgeon is still in practice, he will be willing to remove the tube. He cannot be faulted for telling you they were temporary, since in the vast majority of cases, they do not stay in for over 20 years! Nevertheless, when I discuss tubes with parents, I usually tell them, "Very rarely, one or both of the tubes will not fall out on its own. If the tube remains in place for two or three years, and in particular if the tube appears to be causing any problems, I will have to remove it." It's possible that the tube is causing your son's smelly ear (a symptom that suggests your son is suffering from a chronic ear infection), in which case removal of the tube should be curative.

Removal is very simple. In a teenager or adult, the tube can be taken out in the office using only local anesthesia. Your son should be warned that a 20-year-old tube, once removed, may very well leave behind a chronic perforation, that is, a non-healing hole in the eardrum. If I were your son's surgeon, I would recommend performing a "fat patch" or "paper patch"; these are fairly simple procedures (again, office procedures requiring only local anesthetic) that encourage the hole to heal. I would do this immediately after removing the tube.

It's also possible that the tube is not causing your son's ear to be smelly. Chronic ear infection can cause a smelly ear, and it is very possible that the tube is only a distraction -- not the real problem at all. Some chronic ear infections can be exceptionally serious, essentially "ticking time bombs" that if allowed to fester for very long can lead to permanent hearing loss, damage to the balance system, damage to the nerve that controls the muscles of facial expression and even spread of infection to the brain. Consequently, a chronically smelly ear is a potentially serious condition that must be evaluated by an ear, nose and throat surgeon. Unfortunately, a few primary care physicians will treat such infections with ear drops and antibiotics, not realizing the risk inherent to the situation.

Does the tube need to come out? I think so. Twenty years is an awfully long time for a tube to remain in an ear. But much more important is that your son have his smelly ear examined by an ear, nose and throat surgeon.