Revised ear tube guidelines help parents, doctors make decisionsFERGUS FALLS, Minn. – Jenny Pesek knows more than she’d like about the country’s most common outpatient surgery in kids.
By: Ryan Johnson, INFORUM
FERGUS FALLS, Minn. – Jenny Pesek knows more than she’d like about the country’s most common outpatient surgery in kids.
Her three children have all had ear tubes implanted to deal with chronic ear infections. The baby of the family, 3-year-old Taylor, got a second set in July to finish addressing the problem.
But Pesek’s knowledge doesn’t come with any discounts.
“We did ask if since this was our fourth set of tubes if it would be free, and they said no,” she said, laughing.
Myringotomy, creating a small incision in the eardrum to relieve pressure, dates back to 1649 when a doctor accidentally pierced a patient’s eardrum and their hearing got better.
The surgery was improved in the 1800s, when doctors began to put a small tympanostomy tube made of gold foil into the incision to prevent it from healing and make the benefits last longer. The modern ear tube was introduced in 1954, and about 100 variations of that vinyl tube varying in size and type are still used today.
But Dr. Clark Elliott, a pediatric ear, nose and throat specialist at Sanford Health in Fargo, said the debate over when patients might need ear tubes – and how the small devices should be cared for – hasn’t ended nearly 60 years later.
“It’s gone back and forth in terms of what the indications are, whether water needs to be kept out and that sort of thing,” he said.
Ear tubes are one of the most common surgeries in the country, an option for dealing with recurrent ear infections, excessive fluid behind the eardrum and hearing loss.
But the devices have been the subject of several investigations fueled by fears that they were being used too much, and a Congressional subcommittee looked into their use in the early 1990s.
Elliott said it’s now a multibillion-dollar industry – at least 90 percent of kids will have an ear infection by age 3, and about 5 to 10 percent will have ear tubes at some point.
The American Academy of Otolaryngology-Head and Neck Surgery attempted to tackle the lingering questions about ear tubes, releasing new guidelines July 1 that aim to give parents and doctors help.
The academy said its guidelines for those 6 months to 12 years are the first evidence-based suggestions in the country for the procedure.
A panel of specialists, physicians, speech and language pathologists, consumer advocates and others sifted through the data, coming up with recommendations – but not clear-cut thresholds – to help guide the conversation in the doctor’s office before it gets to the operating room.
The guidelines take a wait-and-see approach, saying the fluid that can build up behind the eardrum after an infection often goes away on its own and shouldn’t be treated with tubes if it’s been there less than three months.
Recurrent ear infections also aren’t necessarily a sure sign that tubes are required and often can clear up without surgery.
The guidelines suggest a lower bar for ear tubes in some children, especially those with symptoms of autism because hearing problems can complicate other issues.
But Elliott said each case is unique, and parents can consult with their family doctor or get referred to an ear, nose and throat specialist to talk it over and see if ear tubes might be a good fit.
“I think it’s best to look at these things as guidelines rather than hard-and-fast rules,” he said.
The guidelines also cite a 2005 clinical trial that found ear plugs to keep water out of the ears while swimming and bathing might not be necessary for most children with ear tubes.
Elliott said he tells parents that the minimal hassle of putting in ear plugs is better than having their kid go back for another surgery if the tube is blocked or water gets through the small hole, possibly leading to drainage and more infections.
But he said the advice given to parents about ear plugs varies widely, and said the study found a “small but statistically significant” rate of drainage in those who swam and bathed without plugs.
“The bottom line is I don’t think that one study has been enough to change the minds of all of the otolaryngologists,” he said.
MAKING A DECISION
Dr. Elliott said ear tubes aren’t drainage tubes, though that misconception is still prevalent today.
The lining of the middle ear produces mucous behind the eardrum that drains naturally, expelled by small finger-like projections called cilia. But a cold or ear infection can impair how well the cilia work.
Elliott said that can affect the overall immune system, and if new colds or ear infections keep coming on, the fluid can build up and start to thicken, potentially causing hearing loss.
Kids in day care often have more infections, he said, because they tend to go through cold after cold rather than getting a break between illnesses, and that can keep the fluid from draining.
Ear tubes can fall out or be surgically removed, depending on the type used, and they work by equalizing pressure and preventing the vacuum effect that can happen because of the fluid.
“When you’re trying to get airflow in your home, you open a window on the one side and a window on the other side and get flow-through ventilation,” he said. “That’s kind of what the tube is doing.”
Getting rid of that vacuum allows the fluid to drain and keeps the middle ear oxygenated, an important way of helping white blood cells work more effectively in fighting off infections.
Elliott said there’s genetic variability in how well a person’s cilia work, and problematic ear infections tend to run in families.
That’s the case for the Pesek family. Her oldest son, 8-year-old Riley, had tubes when he was 1, and 6-year-old Madison got them at 9 months.
“I would say it’s been worth it,” she said. “It was better than always having to deal with ear infections and having pain.”
Pesek’s sister and father still get ear infections from time to time, and her husband, Matt, suffered from them when he was younger.
The tubes have helped her kids lead healthier lives and address the hearing problems that can delay a child’s speech development by as much as three months early in life, she said.
But the family might be facing its fifth set of tubes because Riley is starting to get ear infections again.
“He had a bad cold with it, so I’m kind of hoping that’s what caused it and that we’re not starting up a cycle again,” she said.
Elliott said there’s some “wiggle room” in when ear tubes should be considered, and said there are few times when the decision needs to be made immediately.
While it’s a relatively low-risk outpatient surgery, he said the procedure – and the possible hassles of dealing with the tubes until they fall out or are removed – means parents and doctors should weigh their options carefully.
“The balance is different for every single parent that comes through,” he said.
Readers can reach Forum reporter Ryan Johnson at (701) 241-5587