Ear infections
Description
An in-depth report on the causes, diagnosis, treatment, and prevention of ear infections.
Alternative Names
Otitis media
Surgery
Children may be considered candidates for surgery if they have:
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OME lasting longer than 4 months that is accompanied by hearing loss
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OME that is persistent or recurrent (even if there is no hearing loss) and may put child at risk for developmental delays or structural damage to the ear
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OME and structural damage to the eardrum or middle ear
Surgical Guidelines
. The decision to pursue surgery needs to be determined on an individual basis. In 2004, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology-Head and Neck Surgery released the following general guidelines for surgical procedures:
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Tympanostomy tube insertion is the first choice for surgical intervention. However, approximately 20 - 50% of children who undergo this procedure may have OME relapse and require additional surgery.
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Adenoidectomy (removal of adenoids) plus myringotomy (removal of fluid), with or without tube insertion, is recommended as a repeat surgical procedure. Tube insertion may be advised for children younger than 4 years of age.
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Adenoidectomy is not recommended as an initial procedure unless some other condition (chronic sinusitis, nasal obstruction, adenoiditis) is present.
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Neither myringotomy alone or tonsillectomy (removal of tonsils) is recommended for OME treatment.
Tympanostomy (with Myringotomy)
A tympanostomy involves the insertion of tubes to allow fluid to drain from the middle ear. The procedure involves:
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A general anesthetic (asleep, no pain). Children typically recover completely within a few hours.
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Myringotomy is performed first.
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After myringotomy, the doctor inserts a tube to allow continuous drainage of the fluid from the middle ear.
Postoperative Effects.
Tympanostomy is a simple procedure, and the child almost never has to spend the night in the hospital. Acetaminophen (Tylenol) or ibuprofen (Advil) is sufficient for any postoperative pain in most children. Some children, however, may require codeine or other powerful pain relievers. One study found that lidocaine eardrops were effective in relieving pain and stress after the procedure.
Complications.
Otorrhea, drainage of secretion from the ear, is the most common complication after surgery and can be persistent in some children. It is usually treated with antibiotic eardrops. One study suggests that wearing earplugs may help the problem.
More serious complications from the operation are very uncommon, but may include:
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General anesthetic risks. Rarely, allergic reactions or other complications, such as throat spasm or obstruction, may occur. According to one 2002 study, such complications occur in less than 2% of the patients. The risk is highest in children who have other medical conditions, most commonly upper respiratory infections, lung disease, or GERD. Anesthetic-related risks are nearly always easily treated.
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Tube blockage. Sometimes the tubes become blocked from sticky secretions or clotted blood after the operation.
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Persistent eardrum perforation. This is the most common serious complication, but it too is rare.
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Scarring can also occur, particularly in children who require more than one procedure, but it almost never affects hearing.
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Small keratin (skin cell) containing cysts called cholesteatomas develop around the tube site in around 1% of patients.
Success Rates.
Hearing is almost always restored following tympanostomy. Failure to achieve normal or near-normal hearing is usually due to complicated conditions, such as preexisting ear problems or persistent OME in children who have had previous multiple tympanostomies. In one 10-year study, hearing loss was still present in 12.5% of people who had had surgery, although in half of these individuals, hearing loss was very mild (loss was below 20 decibels). Persistent fluid was the main reason for continued impaired hearing. Only 1.9% of hearing loss cases could be attributed to complications of the operation itself.
A 2004 study randomized 429 children younger than age 3 to receive either immediate or delayed myringotomy with tympanostomy tube insertion (M&T). The children were subsequently evaluated at age 5 for signs of tympanic membrane damage, and also had their hearing evaluated when they were 6 years old. Among the findings:
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There were no significant differences in hearing levels between the two groups, although the children’s hearing was slightly worse than children who did not have OME.
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However, 71% of the children who received immediate M&T had tympanic membrane abnormalities compared to 43% of the children whose M&T procedure was delayed.
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Based on these results, the researchers recommended watchful waiting for young children with uncomplicated middle ear effusion (MEE).
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The data also suggest that many children with persistent, early-life MEE may later have some ear damage regardless of whether they undergo the M&T procedure.
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A 2007 follow-up study of these same children when they reached the ages of 9 – 11, found no evidence that early insertion of tubes improves developmental outcomes. When the researchers compared the children who had delayed tube insertion with those who had prompt insertion, they found no differences in speech, attention, behavior, social skills, and academic achievement.
A 2005 study found similar results. The researchers also advised against prompt insertion of tympanostomy tubes in otherwise healthy children with MEE who are younger than age 3. The researchers recommended tubes for young children who have:
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Repeated occurrences of ear infection that are not controlled well by antibiotics or that keep recurring
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Middle-ear fluid and any degree of hearing loss
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Persistent middle-ear fluid accompanied by ear pain, ringing in the ear, or eardrum structural problems
Earplugs as a Precaution.
Many doctors feel that children should use earplugs when swimming while the tubes are in place in order to prevent infection. Others feel that as long as the child does not dive or swim underwater, earplugs may not be necessary. Parents should consult their own child's doctor on this subject. Cotton balls coated with petroleum jelly are effective alternatives to ear plugs. Children do not need to wear earplugs while showering.
Follow-Up.
Eventually, the tubes fall out as the hole in the eardrum closes. This may happen after several months or more than a year later. It is painless. In fact, the patient and parents may not even be aware that the tubes are out.
Twenty to 50% of children may have OME relapse and require additional surgery that involves adenoidectomy and myringotomy. Tube reinsertion may be recommended for children younger than 4 years of age.
Myringotomy
Myringotomy is used to drain the fluid and may be used (with or without ear tube insertion) in combination with adenoidectomy as a repeat surgical procedure if initial tympanostomy is not successful. It is not effective as a sole surgical procedure. Myringotomy involves the following steps:
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The surgeon makes a very small incision in the eardrum
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Fluid is sucked out using a vacuum-like device
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The fluid is usually examined for identifying specific bacteria
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The eardrum heals in about a week
Adenoid Removal
Adenoids are collections of spongy lymph tissue in the back of the throat, similiar to the tonsils. Removal of the adenoids, called adenoidectomy, is usually only considered for OME if a pre-existing condition exists such as chronic sinusitis, nasal obstruction, or chronic adenoiditis (inflammation of the adenoids). Unless these conditions exist, adenoidectomy is not recommended for treatment of OME.
Adenoidectomy plus myringotomy (removal of fluid) may be performed if an initial tympanostomy (tube insertion) procedure is unsuccessful in resolving OME. This combination procedure works best in children ages 4 years or older. Tube insertion is recommended for children under 4 years of age. It is not necessary to perform an adenoidectomy along with tube insertion for children under 4 years of age.
Laser-Assisted Myringotomy
Laser-assisted myringotomy is a technique that is being investigated as an alternative to conventional tympanostomy and myringotomy. At present, there is not enough evidence to determine how well it works in comparison to standard surgical procedures. Some clinical trials have suggested that the success rate for laser-assisted myringotomy is half that of standard tympanostomy/myringotomy. Many insurance companies consider laser-assisted myringotomy to be an investigational procedure and will not pay for it.
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Review Date: 3/6/2007
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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