Subannular (subcutaneous) ear tubes

What Is a Subannular Tube?

A subannular tube is a type of ear ventilation tube placed under the eardrum, rather than through it. The tube sits just beneath the lower part of the eardrum (called the annulus) in the soft tissues that connect to the middle ear.

It creates a small opening that allows air to flow into the middle ear space, helping to prevent fluid buildup and pressure changes—just like traditional ear tubes, but without piercing the eardrum.

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How Is It Different from a Regular Ear Tube?

The most common ear tubes—called transtympanic tubes—are placed directly through the eardrum (tympanic membrane). While effective, this approach involves making a small hole in the eardrum, which eventually leads to scarring of the eardrum, or worse, can lead to a hole in the eardrum (perforation) once the tube falls out. For patients that have repeated or chronic ear infections or serous otitis, having multiple sets of regular transtympanic eventually leads to thinning of the eardrum, which can cause it to collapse or become more susceptible to infections. For patients that require a long term solution, transtympanic ear tubes are not well-suited. 

In the image below, you can clearly see how these two tubes differ in their placement relative to the eardrum.

Here is a summary of the differences between transtympanic and sub annular tubes.

Key differences:

• Placement: Subannular tubes are placed under the eardrum, not through it.

• Lifespan: Because subannular tubes are placed under a skin tunnel and under the eardrum, the eardrum will not reject them. Therefore, subannular tubes are considered "permanent" (long-term) solutions. If needed, an ENT doctor can safely and easily remove the tube (simply by pulling on it), so this remains a reversible procedure.
  
  

• Healing: Since the eardrum is left intact in subannular tubes, it will not scar or thin over time.

• Indications: Subannular tubes are used when the eardrum is too fragile, scarred, or when repeated tube insertions have failed.

• Infections: Subannular tubes are less susceptible to infections with water exposure, because they are longer and it's harder to water to get through them. This allows patients with subannular tubes to enjoy water activities (in treated water such as pools).

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When Is a Subannular Tube Recommended (Indications)?

Subannular tubes are not the first choice for most patients, but they are a great option in specific situations. Your may benefit from this type of tube if:

• You have a history of repeated transtympanic ear tube insertions and require a long-term solution to ventilate your ears.

• You have chronic eustachian tube dysfunction and you require a long-term solution to ventilate your ears. You can learn more about Eustachian tube dysfonction here.
  
  

• Your eardrum has scarring or thinning (from past infections or surgeries).

• You’ve had a tympanoplasty (eardrum repair) and need a tube without disturbing the graft. Learn more about tympanoplasties in this article.

• You are at higher risk of a permanent hole (perforation) from a traditional tube.

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How Is the Procedure Done?

1. Anesthesia: I perform all my subannular tube placements under local anesthesia, but some ENT doctors may prefer to do them under general anesthesia. The ear will be "frozen" with an injection of a local anesthetic with a needle. Once this step is completed, you will feel no pain during the procedure. In children, a general anesthesia will be required.  

2. Small incision: A tiny cut is made in the ear canal near the lower edge of the eardrum, a few millimeters away from the eardrum.

3. Tunnel creation: The surgeon gently raises the skin of the ear canal to create a small tunnel that will eventually lead to under the eardrum to reach the middle ear. Once the eardrum is elevated, any fluid is aspirated.

4. Tube insertion: The subannular tube is placed into this tunnel and just beneath the lower part of the eardrum (called the annulus, this is where the tube gets its name).

5. Closure: The skin is repositioned over the tube, so that the tube will be covered by the skin tunnel created in the step above. That way, the tube remains securely under the eardrum and will not be rejected. One open extremity of the tube faces the middle ear, and the other extremity faces the ear canal : this allows the middle ear to ventilate towards the outer ear. 

6. Packing: The ear canal is then filled with antibiotic ointment that helps the healing process and ensures the tube does not move. Sometimes, dissolvable gelatinous packing (called gefloam) can be used to stabilize the skin tunnel. A cotton ball is then placed over the ear.

The surgery usually takes about 15 to 30 minutes and is done as an outpatient procedure.

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Risks and Benefits

1. Benefits:

• Offers a long-term ("permanent") solution for patients who need to chronically ventilate their middle ears.
  
  
• Preserve the eardrum's structure because they do not go through the eardrum itself.
  
  
• Reduced risk of infections with water exposure, allowing water activities.
  
  

• Less risk of long-term eardrum perforation (a hole that doesn’t heal).

2. Risks:

• Infection, although rare, can occur and may need treatment with antibiotic drops.

• The tube may become blocked and stop working.

• Rarely, the tube may fall out sooner than expected or shift position.

• A small scar may form in the ear canal where the tube was placed.

Most complications are mild and can be managed easily with follow-up care.

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What to Expect After the Procedure

After surgery, you will feel some mild discomfort, which usually resolves within a day or two. No pain medications are required other than Tylenol or Advil. Your ear will feel blocked at first because it is filled with ointment after the procedure. This sense of fullness will gradually improve over the first 3–4 weeks as your ear heals and the ointment and any blood clots dissolve. As a result, you should not expect your ear to feel completely unblocked or your hearing to return to normal immediately after the procedure.

Here’s what the aftercare typically involves:

• Keep the ear dry: Avoid getting water into the ear canal for 1-2 weeks. Use a cotton ball with vaseline (or ointment) to repel water when bathing.

• Ear drops: Your doctor may prescribe antibiotic ear drops to prevent infection.

• Follow-up appointments: You’ll return to the ENT clinic for a check-up within a few months to ensure the ear is healing well, that the tube is working properly and to clean any residual ointment, blood clots and skin debris.

• Monitoring: Regular exams should be done once a year to monitor the status of the tube and to clean it if blocked. Audiometry (hearing tests) can be done as needed.

• Duration: Subannular tubes should stay in place for many years depending on the case, but they can also be removed if needed.

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Conclusion

Subannular tubes offer a valuable alternative for individuals who can’t, shouldn't  or prefer not to receive traditional ear tubes. While more specialized, they serve the same goal: relieving ear pressure, preventing fluid buildup, and protecting hearing.