in the management of effusion. One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME. Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective. Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes. More recent ones are coated with antibiotics and phosphorylcholine. Aftercare There is little scientific evidence to guide the care of the ear after tubes have been inserted. A single, randomized trial found statistical benefit to using ear protective devices when swimming although the size of the benefit was quite small. In the absence of strong evidence, general opinion has been against the use of ear protection devices. However, protection such as cotton covered with petroleum jelly, ear plugs, or ear putty is recommended for swimming in dirty water (lakes, rivers, oceans, or non-chlorinated pools) to prevent ear infections. For bathing, shampooing, or surface-water swimming in chlorinated pools, no ear protection is recommended. Complications The placement of tubes is not a cure. If middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection. There may be early drainage through the tube (tube otorrhea) in about 15% of patients in the first two weeks after placement, and developing in 25% more than three months after insertion, although usually not a longterm problem. Otorrhea is considered to be secondary to bacterial colonization. The most commonly isolated organism is Pseudomonas aeruginosa, while the most troublesome is Methicillin-resistant Staphylococcus aureus (MRSA). Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial biofilm. A laboratory study showed that tubes covered in the antibiotic vancomycin prevented in-vitro formation of MRSA biofilm as compared to noncoated ones, although no study has been conducted on humans yet. Comparing phosphorylcholine-coated fluoroplastic tympanostomy tubes to uncoated fluoroplastic tympanostomy tubes showed no statistically significant difference in the incidence of post-operative otorrhea, tube blockage, or extrusion. Efficacy Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have