I am often asked by concerned parents if I “believe in ear tubes,” and, if so, might they be appropriate for their child. Ear tubes are not one of the world’s great religions and questions about appropriateness are unfortunately more complex than matters of belief or disbelief. A seven-second sound-bite answer may suit the lay press but a meaningful answer requires more thought. So, put on your thinking cap and let’s ponder the question of who needs tubes.
Why all this fuss about ear tubes?
Ear tubes are inserted in more than 10,000 children every week in the United States and anything this common is bound to attract attention. The only surgery more common than tube insertion is routine circumcision.
Tubes are placed typically for middle ear infections, also called acute otitis media (AOM), and for middle ear fluid, also called otitis media with effusion (OME). In this article I will refer to these conditions simply as “ear infections” and “ear fluid,” respectively.
Ear infections are the most common bacterial infection for which children see doctors and also the number one reason for receiving an antibiotic prescription. Most ear infections cause significant pain and fever and are triggered by the common cold. About 15 to 30 percent of children become their pediatrician’s “repeat customers” in the first few years of life because of frequent infections.
Not to be outdone by ear infections, ear fluid affects 90 percent of children before school age, with 30 to 40 percent having repeated bouts and five to 10 percent having ear fluid that lasts one year or longer. Most ear fluid is triggered by a cold, ear infection or both, and does not cause obvious symptoms (your child can have it without you even knowing). In some children, persistent ear fluid can affect hearing, speech, language, learning and school performance.
How to Cut
There’s an old adage about surgery that every medical student at some point hears: “It is easiest to learn how to cut, harder to learn when to cut and hardest to learn when not to cut.” Applying this philosophy to ear tubes helps shed light on current controversies and lays a foundation for answering the question at hand of who needs ear tubes. Let’s start with “how to cut.”
In 1801, British surgeon Sir Astley Cooper relieved hearing loss by making a small cut in the eardrum. Unfortunately, the cut healed within a few days and when it did, the hearing loss returned, much to the dismay of the patient. Doctors spent the next 80 years trying to find a way to keep the tiny eardrum cut open longer. Adam Politzer, a brilliant Hungarian ear specialist, created the first ear tube out of hard rubber in the 1860s. The tube sometimes lasted for weeks but infections and complications were common.
After Politzer’s failed attempt with ear tubes in the late 1800s, there was little interest in treating ear fluid directly. The most popular procedure to treat ear fluid for the next 75 years was adenoidectomy, whereby a walnut-sized clump of tissue (the adenoids) was removed from the back of the nose where it joins the throat. This is still done today but tubes are often preferred because they are simpler and safer.
In 1954, B. W. Armstrong “reinvented” Politzer’s procedure when he successfully treated five patients with ear fluid by incising the eardrum (myringotomy) and inserting a tiny plastic tube to keep the hole open a few weeks. Later, Armstrong and others modified this initial design to achieve safer and longer-lasting tubes that stay in place for about one to two years.
Ear tubes were shown to be effective in randomized and controlled research studies from Pittsburgh, San Antonio and Minneapolis published in the 1980s and 1990s. When considered together, these studies and others show that while in place, ear tubes reduce by 70 percent both the time the ear spends with fluid in it and the frequency of ear infections. Ear tubes are safe, usually only needed once and they also improve hearing while in place.
When to Cut
In deciding who needs tubes, the starting point is to do a damage assessment. For ear tubes, this means parents need to determine precisely how ear infections and ear fluid affect their child. This is not as simple as it sounds but the information in Tables 1 and 2 will clue you in to the obvious, and not so obvious, manifestations.
In addition to deciding how ear infections, ear fluid or both may be affecting your child, other factors should be considered in the tube decision. Here are the questions you need to answer based on your individual situation:
What symptoms, issues or limitations does my child have because of ear problems?
If some of the problems you’ve identified using Tables 1 and 2 are minor or trivial then tubes are not needed. You should also have a hearing test (audiogram) done by a licensed professional because the impact of ear fluid on hearing varies greatly.
How likely is it that my child will improve on his own, given a reasonable time frame?
We know a lot about the natural history of ear fluid and infections so be sure to ask your doctor or do your own research. Frequent ear infections often improve within six months but ear fluid can last months or even years. If you do not consider it in your child’s best interest to wait that long then tubes are a better choice.
Is my child at risk for developmental delays?
If your child has one or more of the conditions in Table 3, the scales should tip in favor of tubes. Reducing ear problems will not magically eliminate delays but it will help your child achieve her potential faster and derive maximum benefit from any ongoing therapies she receives.
What benefits will my child have from tubes and do they exceed the risks?
In general, tubes do not cause significant scarring or hearing loss and are extremely safe and well-tolerated. However, the answer to this final question also depends on your personal values and your doctor’s experience.
To help sharpen the focus, let’s look at some of the more common reasonable indications for ear tubes that I see in my clinical practice. The list that follows is illustrative, not exhaustive. Some typical indications for ear tubes are:
• Infant or child with repeated ear infections and seizures from fever
• Infant or child with very frequent ear infections requiring excessive antibiotics
• Child with frequent infections and antibiotic allergies to one or more drug classes that make treating the infections very difficult
• Infant with chronic fluid in both ears causing problems that include irritability, sleep disturbance and hearing loss, especially if associated with frequent ear infections
• Young child with persistent fluid and speech delay, especially if hearing loss is present
• Young child with persistent fluid and gross motor delays, including clumsiness and poor balance
• Child with persistent fluid and learning problems or school performance issues
• Child with persistent fluid causing eardrum damage, such as a collapsed or worn out eardrum that is sticking to the underlying bone.
When Not to Cut
As the popularity of tubes has soared in the past few decades, concerns have arisen that not all children who receive them derive benefit or really need the procedure in the first place. Articles about the appropriateness of ear tube surgery began to flourish in the 1980s and early 1990s and have again in recent years garnered media attention.
A government-funded study from Pittsburgh has received particular attention because developmental and academic tests at ages three, four, five, six and nine through 11 years showed no difference if tubes were inserted promptly upon diagnosis or after a six- to nine-month delay in infants and very young children. The researchers, however, recruited children through a process of intense monthly screening for ear fluid and selected children who were healthy, mostly symptom-free, had normal development and very few had persistent fluid in both ears. Most children of this description would never have received tubes if they had not been enrolled in a research study.
Why did the Pittsburgh researchers select only healthy children for their study? Because research regulations consider it unethical to study suffering or delayed children, even though they are most likely to show benefits from intervention. Another study from the Netherlands showed that placing tubes in healthy, young children with persistent ear fluid, identified by screening programs, did not improve development or quality of life. The bottom line: it is exceedingly difficult to make children without symptoms or problems feel better – even with ear tubes!
Here are some typical examples of children for whom I would advise watchful waiting instead of ear tube insertion:
• Infant with fluid in both ears detected during a routine office visit two months ago
• Infant or young child who just had a terrible season with frequent ear infections but now has healthy ears without fluid entering the summer
• Young child with persistent fluid in one or both ears for six months, with a slight hearing loss, who is otherwise healthy, has excellent speech and language and no delays in development
• Child with persistent fluid in both ears for one year with normal eardrums, no discomfort, excellent school performance and no hearing difficulties at home or in school
• Child who is otherwise healthy but has relapsing ear fluid and a few infections each year, but spends most of the time fluid- and symptom-free.
Where do we go from here?
Parents, doctors and healthcare professionals continue to grapple with the question of “who needs tubes,” and research is ongoing to shed additional light on this complex question. As the above discussion hopefully makes clear, the answer is unrelated to “belief” or “disbelief” but shrouded in subtleties related to the individual needs of you and your child. Table 4 summarizes some of the key issues to consider. By learning about ear tubes you encourage shared decision-making with your doctor and are more likely to make the best decisions for your family.
For further reading: A Parent’s Guide to Ear Tubes by R.M. Rosenfeld, 2005, available at www.amazon.com.
Donate Now!
DRF funds research that changes lives.