On Call: Does Your Child Need Ear Tubes?

Middle ear infections are very common in young children. Most of these clear up fairly easily, usually without antibiotics. But a small number of children may develop hearing loss or speech delay related to recurrent middle ear infections and may benefit from ear tube surgery. This article will discuss the indications for this surgery, the procedure itself, its complications and alternative ways to deal with repeated middle ear infections.

Infections of the middle ear are known to doctors as acute otitis media (AOM). These should not be confused with external ear infections, or otitis externa, which is also called “swimmer’s ear” and is treated with antibiotic ear drops. The middle ear is behind the ear drum, or tympanic membrane, and is normally an air-filled cavity. A normal ear drum and middle ear cavity is important for normal hearing. As sound comes into the ear, the eardrum should vibrate and cause tiny bones in the middle ear to vibrate, transmitting sound signals to the inner ear, then to the brain.

Ear Infections
Bacteria or viruses can get into the middle ear through the Eustachian tube — a passage connecting from the back of the nose which is designed to equalize pressures between the middle ear and the outside environment. This often happens when a child has a cold. When the middle ear becomes infected, it may fill with fluid or pus. This can cause pressure and pain on the eardrum. Since it may also interfere with normal vibration, hearing might temporarily be diminished. As the acute infection clears up, hearing is usually restored.

But a small portion of children have persistent fluid buildup in their middle ears, and the prolonged hearing loss may affect their speech development. (The middle ear fluid has nothing to do with getting water in your child’s ear from the outside.)

Persistent middle ear fluid without signs or symptoms of acute ear infection is known as otitis media with effusion (OME). This persistent fluid causes decreased mobility of the ear drum and interferes with sound conduction. OME may occur due to poor function of the Eustachian tube, as a result of prior AOM, or spontaneously. OME is extremely common, and more than 90 percent of children have it at some point before school entry. Mostly, OME clears up without treatment, but 30 to 40 percent of children have recurrent OME.

Who Needs Surgery?
Indications for ear tube surgery include OME lasting four months or longer with persistent hearing loss or other signs and symptoms, recurrent or persistent OME in children at risk (see below) regardless of their hearing ability, and when the OME is accompanied by structural damage to the ear drum or middle ear. In children with OME, some high risk factors often lead to a recommendation for early ear tube surgery. These include permanent hearing loss; speech, language or other developmental delays; autism-spectrum disorders; Down syndrome; and craniofacial conditions that include cognitive, speech and language delays, uncorrectable vision impairment, and cleft palate.

Ear Tube Surgery
When ear tube surgery is performed, small slits (myringotomies) are made in one or both ear drums, and a wheel-shaped tube called a tympanostomy tube is placed. This keeps pressure equalized between the middle ear and the outside, and helps to prevent recurrent infections. The surgery is done under general anesthesia, and usually takes 10 to 15 minutes. The risk of death from anesthesia has been reported to be about one in 50,000 cases. Minor complications of the surgery are not serious, and include scarring or depressed pockets in the ear drum and holes in the ear drum which may require surgical repair.

Living with Ear Tubes
The hole in the eardrum does not affect hearing, and the tubes often result in improvement in hearing and speaking. The tube remains in place for six to 18 months or more and generally falls out on its own. Randomized trials have shown that ear tube surgery reduces OME by 62 percent and improves hearing in most children while the tubes are functioning. Between 20 and 50 percent of children who have had ear tube surgery have a relapse of OME after the tubes fall out, and they may need repeat surgery.

Dr. Daniel Neuspiel is a general pediatrician at CMC-Myers Park Pediatrics. He is Director of Ambulatory Pediatrics at Levine Children’s Hospital.