By JANE E. BRODY
Published: August 15, 2006
When my sons were preschoolers in the early 70’s, ear tubes were all the rage for children with recurring ear infections. Parents were bombarded by warnings that if fluid in the middle ear lingered long after treatment of an ear infection it could impair hearing and cause lasting developmental abnormalities, including problems with speech and language, learning and behavior.
Two decades later, ear tubes were still very much in fashion. A newsletter published in November 1993 for parents of young children proclaimed that hearing loss resulting from otitis media with effusion, or O.M.E., as the problem is known medically, “can cause serious retardation of a child’s language skills, teasing and tormenting by playmates and siblings, anger and punishment from parents or teachers who may think the child is deliberately ‘ignoring’ them and even permanent hearing damage.”
What conscientious parent would not want to prevent such disastrous consequences? And so a million or more children each year underwent surgery to have “ventilation” tubes inserted in one or both ears to clear the eustachian tube and allow the eardrum to move properly in response to incoming sounds.
Acting With the Best Intentions
The tubes were intended to remain in the ear for up to 14 months. By then, many children outgrow the problem. After age 3 or 4, Dr. Robert Stenstrom of St. Paul’s Hospital in Vancouver explained, the eustachian tube lengthens and changes position, reducing the risk of middle ear infections and fluid buildup
Still, after the tubes are removed or fall out on their own, many children need to have them replaced at least once. Each operation involves general anesthesia and the risks it entails.
According to a new long-term study by Dr. Stenstrom and colleagues, when young children were randomly assigned to receive ear tubes or to be treated daily with antibiotics, those with ear tubes suffered greater damage to their eardrums and had, on average, poorer hearing 6 to 10 years after the tubes were removed.
Although the tube design has changed and daily antibiotics are no longer recommended, this controlled clinical trial calls into question whether the benefits of ear tubes outweigh the risks.
Ear tubes remain popular — with an estimated 700,000 insertions a year in the United States — despite subsequent well-planned studies that challenged many of the assumptions that long justified their use. Research directed by Dr. Jack L. Paradise, professor of pediatrics at Children’s Hospital of Pittsburgh, and other independent studies found no lasting effects of lingering fluid in the middle ear in otherwise healthy children.
Although these children typically have mild to moderate hearing loss and may experience some developmental lags for as long as fluid lingers, they soon catch up to their peers. This is true among children from low-income families as well as those of middle incomes.
For example, in a four-year study of 83 children primarily from low-income families, Joanne E. Roberts and colleagues from the University of North Carolina found “no evidence of a significant relationship between a history of O.M.E. or hearing loss and children’s later academic skills in reading or word recognition during the early elementary school years.”
In their report, published in Pediatrics in October 2002, the authors concluded, “A child’s home environment was more related to early math and expressive language skills than was O.M.E. or hearing loss, and the home environment continued to be predictive of all of the language and academic outcomes through second grade.”
In May 2004, the American Academy of Pediatrics published new clinical guidelines to help physicians treat children with the lingering middle ear fluid. The guidelines, written to avoid unneeded surgery, emphasize that the problem usually goes away on its own in three or four months, generally precluding the need for ear tubes.
Following the Guidelines
But as has long been accepted medical practice, the guidelines suggest that ear tubes be used without delay for certain children with the fluid disorder who are already “at risk for speech, language or learning problems” because of other conditions, including Down syndrome, permanent hearing loss, uncorrectable visual impairment, autismlike disorders, cleft palate and speech and language or developmental delay.
Otherwise normal, healthy children with lingering middle ear fluid should be re-examined every three to six months to check for the persistence of effusion, worsening hearing loss or structural abnormalities of the eardrum or middle ear, the academy suggested.
According to the guidelines, a child becomes a candidate for ear tubes when a disorder persists for four months or longer and is associated “with persistent hearing loss or other signs and symptoms” or structural damage to the middle ear.
Watching and Waiting
In an editorial accompanying the report from Vancouver, Dr. Stephen Berman, professor of pediatrics at the University of Colorado and the Children’s Hospital in Denver, said that the guidelines were confusing and that children were likely to continue to get ear tubes they didn’t need.
Dr. Berman suggested that otherwise normal children with the middle ear disorder who did not suffer from recurrent ear infections should be considered candidates for ear tube surgery only if the problem persisted for four months or longer and was associated with a hearing loss of 40 or more decibels. That level of hearing loss is considered a risk to speech and learning.
For otherwise normal children with lingering middle ear fluid and less than 40 decibels of hearing loss, Dr. Berman and Dr. Stenstrom recommend a strategy of “watchful waiting” instead of tubal surgery, with assessments made every three to six months. Dr. Berman considers the high rate of ear tube placements comparable to the overuse of tonsillectomies in the 1960’s.
He says it is up to the otolaryngologists who insert ear tubes to prove that the kind of tubes they now use, which tend to fall out on their own in a few months, are less risky than those used in the Vancouver study. At the same time, ear surgeons have to show that the use of these tubes is beneficial in the long run and, if so, to which children.
“We’re very reassured,” Dr. Berman said. “We now need to educate parents that they don’t have to be as worried about this as parents were in the 1990’s.”
When a child has persistent fluid problems, the guidelines suggest strategies that can compensate for a child’s temporary hearing loss: “Speaking in close proximity to the child, facing the child and speaking clearly, repeating phrases when misunderstood and providing preferential classroom seating,” all far safer than surgery.
Dr. Stenstrom says he suspects that the problem and the insertion of ear tubes are declining now that infants are routinely immunized against pneumococcal bacteria, a common cause of ear infections.
It is now known that most ear infections clear up in a few days without treatment. Antibiotics shorten these infections by only a day or so and have their own risks, including cost, diarrhea and the development of resistance to antibiotics.
But for children especially prone to ear infections after colds, Dr. Stenstrom suggests that when cold symptoms develop, treating the child with antibiotics for four or five days may prevent these infections.
Source: Brody, Jane E., The New York Times, “Ear Infection? Think Twice Before Inserting a Tube.” August 15, 2006.