Written by Jesse Hackell MD., FAAP.
Ear tubes, or more properly known by their medical name, tympanostomy tubes, represent the most common surgical procedure performed on children in the United States.
Over 600,000 children undergo ear tube placement every year, in a simple procedure under general anesthesia, with the attendant risks of surgery and anesthesia as well as the costs associated with these procedures having a significant impact on these children and their families.
The arguments for and against tube placement have been debated for years, and various guidelines have been proposed in order to develop some degree of a rational approach to the medical issues which lead to ear tube surgery.
The American Academy of Otolaryngology–Head and Neck Surgery has recently convened a panel of experts in several fields of medical care, as well as experts in hearing and audiology and consumer protection, in order to develop a set of clinical practice guidelines on tympanostomy tubes in children.
This panel, of which I was a member, met several times over the course of a year, and was charged with reaching a consensus opinion on how best to apply the scientific evidence in the literature to the decision-making process regarding the placement of ear tubes in children.
The panel’s research and deliberation has resulted in a comprehensive article on this topic, which includes a thorough discussion of the nature of middle ear disease, as well as specific recommendations regarding the decision to place ear tubes in children who fall into a number of distinct categories. The complete article has been published in the journal Otolaryngology–Head and Neck Surgery (Otolaryngol Head Neck Surg July 2013 vol. 149 no. 1 suppl S1-S35) and can be accessed online here: http://oto.sagepub.com/content/149/1_suppl/S1.long .
Some of the recommendations made by the panel relate directly to acute otitis media (ear infections) and otitis media with effusion (ear fluid), which as we all know are very common complaints and findings in children.
For example, one recommendation is that ear tubes NOT be placed when the ear fluid has been present for less than three months.
However, this is complemented by the recommendations that hearing testing should be performed if the fluid lasts three months or longer, and that tubes should be offered if the fluid has persisted for more than three months and hearing loss is found to be present.
The guidelines further recommend that children with fluid but without hearing loss should be re-evaluated on a regular basis, watching either for resolution of the fluid or development of a hearing loss.
Another guideline recommends NOT placing tubes in children with repeated episodes of acute ear infections, unless persistent fluid is seen between episodes of acute infection.
Of particular note in these guidelines is the attention paid to children with special needs, such as cranio-facial abnormalities and chromosome abnormalities such as Down’s Syndrome. In these children, the guidelines recommend a much more liberal use of tubes, since they have a greater incidence of hearing loss and are at greater risk of secondary problems developing as a result of even brief periods of ear fluid and hearing loss.
Two additional recommendations of particular interest to parents whose children have already had tubes placed are, first:
that acute drainage of fluid from an ear with a tube in place should be treated only with antibiotic ear drops, and not with oral antibiotics, unless the child appears systemically ill with a complicated course of the infection, and, second, that water protection, such as ear plugs, is NOT recommended when children go swimming after they have had ear tubes placed.
Because these evidence-based principles are guidelines, of course, they serve as a starting point for dealing with the question of tympanostomy tube placement, and should not be taken as the absolute and final word on the subject.
Children and their illnesses are unique, and each and every case may not fit clearly into one of the guideline categories. For this reason, each of the recommendations emphasizes the role of shared decision making between the clinician and the parents.
As a panel member and an author of the report, I would suggest that if your child’s physician is suggesting that ear tubes be placed in your child, it would make sense to at least make sure that the physician is familiar with these new guidelines, and is willing to discuss how your child fits in with these new recommendations.
Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.