Ear tubes: who needs ’em?

Remember that funny Sesame Street sketch when Ernie has a banana in his ear and his buddy Bert keeps asking Ernie why he has a banana in his ear?  Ernie answers, “I can’t hear you Bert, I have a banana in my ear!” Ernie’s hearing loss was easily remedied by removing the banana. Temporary hearing loss produced by infection and fluid in the middle ear is remedied by removing the infection and fluid. Ear tubes (myringotomy or tympanostomy tubes) inserted into the eardrum will allow clearing.

Back when we were in training (sixteen years ago, but who’s counting?), Dr. Lai and I were taught any child with persistent fluid in her ears for three months, three ear infections in six months or four ear infections in one year was a candidate for ear tubes by an Otolaryngologist (Ear, Nose Throat Doctor). 

Now the recommendations for ear tubes have been modified. One large study  from 2007 showed toddlers who have ear tubes placed early because of persistent fluid in their middle ears fared the same developmentally as kids who delayed receiving ear tubes, eleven years later. So how do we decide who needs tubes and who doesn’t?

To understand the need for tubes, lets first look at anatomy. Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. This door is the ear drum. Next, open the door. You will find yourself in a room with a set of 3 bones.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a cold, fluid can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. Otolaryngologists give the fluid a different way to escape by placing artificial drainage tubes in the ear drum (the door). The reason young kids get so many ear infections compared to older kids is because the positioning of the eustachian tube in young children does not allow adequate drainage.  Also, young children get many more colds —up to 10 per year.  Tubes buy time until a child’s anatomy changes with age and a child contracts fewer colds.

An operation to insert ear tubes is very brief, yet still has a baseline small risk of anesthesia. Then the ears must be kept dry because the tubes give the “outside” a direct link to the “inside” of the ear. Kids have to prevent pool water from entering their ears by wearing ear plugs. Many kids don’t like to wear the plugs and it’s difficult to get them to fit properly.  

In the past, one way doctors used to stall surgery in kids with reocuring infections was to start daily antibiotics. We gave this antibiotic for several months at a time to lower the ear infection rate. However, with the increased concern about antibiotic resistant “super germs,” this practice is falling out of favor. As for other medications, antihistamines and decongestants have not shown to  help treat or prevent ear infections.

So when is it appropriate to try to hold off on surgery, even in the child who has suffered several bouts of ear infections? If a child has normal hearing despite the history of ear infections, and has been developing language normally, then one option is to continue treating the ear infections with antibiotics as they come and make sure ear pain  is adequately controlled by using oral or topical medication. The same holds true for children with persistent middle ear fluid.

Current recommendations are for health care providers to check on kids with fluid every 3-4 months for signs of hearing loss or changes in ear anatomy until the fluid subsides. But no longer does the presence of persistent fluid without any hearing loss demand immediate surgical consultation.

Because all children are different, they may need different management even with the same ear infection and fluid history. Start asking your pediatrician about tubes not only if your child has suffered  from more than three ear infections within six months, but also if your child shows of hearing difficulty, delayed talking, or any developmental delay (which can be signs of hearing loss). Your child’s health care provider may need the additional input from an audiologist as well as an otolaryngologist.

Julie Kardos, MD with Naline Lai, MD
©2011Two Peds in a Pod®