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How Do I Know If My Child Needs Ear Tubes?

Written by Jesse Hackell MD., FAAP.

imageEar 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.

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My Child Has Ear Wax In His Ear, Should I Be Worried?

Written by Kristen Stuppy MD. Dr. Stuppy is a practicing pediatrician in Kansas. She feels privileged to be able to help families keep their children healthy and she loves watching entire families grow!  Dr Stuppy is active on Facebook and puts a more personal touch to pediatric topics on her blog.

5085250_f520We make ear wax, also known as cerumen. Many people are annoyed by wax buildup, but it has a purpose! Wax grabs all the dust, dirt, and other debris that gets into our ears.

It also moisturizes the ear canal ~ without it our ears become itchy. It even has special properties that prevent infection. That’s all good stuff, so don’t be too frustrated with a little wax!

Most often the wax moves from the inner part of the ear canal to the outer edge of the canal on its own.

It is amazing to me how our bodies are put together so perfectly: it is designed so the wax is made deep in the canal, then skin cells and wax migrate to the outer edge of the canal, taking with them debris! Some people naturally make dry wax, others make wet wax.

This can be due to genetics and other factors. The important thing to remember with this is how your wax tends to build up and how to best keep it from building up.

If wax builds up it can cause pain, itching, ringing in the ear, dizziness, decreased hearing, and infection. Inappropriate cleaning with hard and/or sharp objects (such as an cotton swabs or paperclips) can increase the risk of infection or even perforation of the ear drum.

Even special cotton swabs made “safe for ears” can push wax deeper and cause a solid collection of wax plugging up the canal.

How can parents help babies and kids keep their ears clean?

  • Routine bathing with clean warm water allowed to run into the ear followed by a gentle wiping with a cloth is all that is needed most of the time.
  • Ear drops made for wax removal with carbamide peroxide can be put in the ear as long as there is no hole in the ear drum or tubes. The oily peroxide acts to grab the wax and bubble it up. Then rinse with clean warm water and a soft cloth (see syringe tips below).
  • If there is excessive buildup, daily use of drops for 3-5 days followed by weekly use of the drops to prevent more buildup is recommended. (For particularly stubborn wax, using drops 2-3 times/day for 3-5 days initially can help.)
  • Make your own solution of 1:1 warm water:vinegar and gently irrigate the ear with a bulb syringe.
  • Mineral oil or glycerin drops can be put in the ear. Let a few drops soak for a few minutes and then rinse with warm water and a soft cloth.
  • Occasional use of a syringe to gently irrigate the ear can help. Using the bulb syringe:
  • First, be sure it is clean! Fungi and bacteria can grow within the bulb ~ you don’t want to irrigate the ear with those! While they can be boiled, they are also relatively inexpensive and easily available, so frequent replacement is not a bad idea.
  • Use only warm water /fluids in the ear (about body temperature or just above body temperature is good). Cold fluids will make the person dizzy and possibly nauseous!
  • If using drops first, put the bottle in warm water or rub it between your hands a few minutes (as if rubbing hands together to warm them, but with the bottle between the hands). Don’t overheat the fluid and risk burning the canal!
  • Have the child stand in the tub or shower.
  • Pull up and back gently on the outer ear to straighten out the canal.
  • Aim the tip slightly up and back so the water will run along the roof of the canal and back along the floor. Do NOT aim straight back or the water will hit the eardrum directly and can impact hearing.
  • Don’t push the water too fast ~ a slow gentle irrigation will be better tolerated. If they complain, recheck the angle and push slower. If complaining continues, bring them to the office to let us do it to be sure there isn’t more to the story.
  • Refill the syringe and repeat as needed until the wax is removed.
  • Use a soft cloth to grab any wax you can see and dry the ear when done. Some people like to use a hair dryer set on low to dry the canal. Just be sure to not burn the skin!
  • If wax continues to be a problem, we can remove it in the office with one of two methods:
  • After inspecting the ear canal carefully with an otoscope (or as I call it with the kids: my magic flashlight), we can use a curette (looks like a spoon or a loop depending on provider’s preference and wax type) to go behind the wax and pull it out.

This is often the fastest method in the office, but is not always possible if the wax is too flaky or impacted into the canal leaving no room for the curette to pass behind the wax. It should only be done by trained professionals… don’t attempt this at home!

  • If the wax is plugging up too much of the canal, the canal is very tender, or if the wax is particularly flaky and breaks on contact with the loop, we will let the ear soak in a peroxide solution then irrigate with warm water.

This process takes longer but is better tolerated by many kids and they think it is fun to “shower their ear”. We often must follow this with the curette to get the softened wax completely out.

My biggest tips:

  • Never use cotton tipped swabs, pipe cleaners, pencils, fingernails, or anything else that is solid to clean the ear! (Note: I still don’t recommend them if the package says “safe” ~ they aren’t!)
  • Don’t put liquid in the ear canal if there is a hole in the ear drum (tubes are included in this). Pus draining from the ear is a sign that there might be a hole.
  • Ear candles are not a safe solution. Burns are too big of a risk!
  • The ear canal is very sensitive, especially if wax buildup has been there a while and has caused an infection of the skin in the canal. Anything put into the ear can increase any pre-existing pain.
  • If the skin is friable from prolonged wax and/or infection there is often bleeding with cleaning. If you notice this at home, your child should have the ears evaluated in our office.
  • We will look for holes in the ear drum, scratches on the skin in the canal, and signs of infection needing antibiotic.
  • Some people who suffer from itchy ears can help themselves by NOT cleaning their ears so much!
  • Earwax usually can be left alone. Only try to clean it out if there are signs of problems with it (ear pain, ringing in the ears, decreased hearing, etc).
  • If kids don’t tolerate removal with the methods above, bring them in for us to take a good look. There might be more to the story that needs to be addressed.
  • If there is significant ear pain, pus or bleeding from the ear, or an object in the ear, bring your child in to the office to have us assess and treat.
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Why wasn’t my son treated with antibiotics for his red ear?

By Herschel Lessin, M.D.

Before entering the room, I looked at the chief complaint of my new 15 month old patient: pulling at his ear. I was also  seeing her 6 year old with an earache. Mom was concerned with her children’s frequent ear infections. They were always on antibiotics.

After my exam, I tell her that while her infant’s ear was a little red, it was not infected. Her 6 year old had an ear infection. Neither needed antibiotics.

Mom was most definitely not happy. The antibiotic seems to always help. Why weren’t they being treated this time?

The answer was that I was one of the good pediatricians who only used antibiotics when they were appropriate.

For decades, US physicians have been treating every red ear as an ear infection. There is now compelling evidence that not only is this practice wrong, but it is dangerous as well.

First of all, a mild red ear is absolutely NOT a sign of an ear infection. In order for the infection to be present, the entire structure of the eardrum must be distorted and bulging. In addition, there must be fluid behind the eardrum that restricts its movement with air pressure. The mild red ear does not meet any of these criteria and is not a sign of an infection that requires antibiotics. Most red ears are due to infants’ crying while being examined.

The indiscriminant use of antibiotics has resulted in many bacteria that are resistant to many antibiotics and can cause severe, difficult to treat illnesses that may be life threatening

Current American Academy of Pediatrics Policy is to not treat ear infections at any age unless examination reveals the bulging distorted ear drum that I mentioned earlier. Definite ear infections should be treated in children less than 2 years of age.

The recommendation that has caused the most resistance from both parents and pediatricians alike, is the “Observation Option”. Older kids can be observed with aggressive pain relief. If pain cannot be controlled or symptoms last more than 2-3 days, then antibiotics can be used. This idea has met with significant resistance from both parents and pediatricians alike.

Trying to teach old dogs new tricks has always been difficult. Add to this the fact that parents want us to DO SOMETHING! It is a brave pediatrician who does not give parents what they want. Finally, it takes a lot less time to write an antibiotic prescription than to explain to an angry parent exactly why it is not needed. Not to mention the fact that many adults with simple colds get antibiotics from their own physicians.

The indiscriminant use of antibiotics for viral infections and earaches must cease since it is causing enormous problems with bacterial resistance to our strongest antibiotics.

I explained to the parent that while there is a small chance that her son will go on to develop a real ear infection requiring a second trip to the doctor, that is a small price to pay to avoid exposing our children to unnecessary antibiotics that can cause real harm.

Many of us have used a compromise called the SNAP (safety net antibiotic prescription). A time limited prescription for antibiotics is provided to the parent to only fill if they really need it. We trust our parents to do this. Studies are ongoing to see how many actually do not fill the prescription.

Dr. Lessin has been a practicing pediatrician for 30 years. He is a founding partner and served as both Medical Director and Director of Clinical Research at the Children’s Medical Group.