Treating recurrent ear infections in children

Tympanostomy tubes, or “buttons,” are among the most common pediatric surgeries performed in the United States, accounting for around 20% of same-day surgeries. They are helpful in children who have recurrent ear infections (recurrent acute otitis media) and children who keep non-infected fluid behind their eardrums (chronic otitis media with effusion). Tubes help to decrease the number and severity of ear infections, may improve hearing, allow more accessible treatment of ear infections with drops rather than oral antibiotics and prevent fluid from remaining behind the eardrum. The Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) defines recurrent acute otitis media as three or more episodes in the past three months or four or more episodes in the past year, with at least one infection occurring in the past six months.

A recent clinical practice guideline released by the AAO-HNS recommends placing tubes in children with recurrent infections who have fluid behind the eardrum at the time of their visit with their Ear, Nose, and Throat doctors (ENTs). The AAO-HNS recommends against placing tubes in children whose fluid has resolved by the time of their ENT appointment. However, some kids are more complicated, having immune deficiencies, allergies to oral antibiotics or even seizures following ear infections. For these children, ENTs often have a lower threshold to place tubes.

In children at risk for speech or learning delays, ENTs often place tubes earlier.

These children include those with autism, intellectual disabilities, ADHD, craniofacial disorders like Down Syndrome, visually impaired children, kids with cleft palates or other causes for learning delays. We want to ensure that these children are hearing as well as possible so they have the best chance of acquiring excellent speech and language skills.

Placing tubes is a very quick procedure often done at an outpatient surgery center. In the operating room, team members keep the child comfortable by singing songs, talking to the child or letting them watch videos on a phone while the child goes off to sleep. Anesthetic gas is most commonly used to help the child off to sleep. Often, children do not require breathing tubes but are instead mask-ventilated during the procedure. Once off to sleep, ENTs take a good look at the eardrum with a surgical microscope. We clean out any wax and ensure no other worrisome findings are present after all wax is clear. A small incision, roughly 2mm, is created using a tiny blade. Any fluid present is suctioned free from the middle ear, the space behind the eardrum. The tube is gently put in place, and ear drops are administered. Ear drops may or may not be prescribed postoperatively. Some physicians may recommend water precautions after ear tubes. Pain after tubes is generally controlled with Tylenol and ibuprofen. Within 24 hours, most kids are back to their normal behavior. Some drainage, either mucus or bloody, may occur after tube placement.

Tubes typically stay in place between 6 and 18 months. Regular follow-up with an ENT should take place during that time. At these follow-up appointments, we ensure that the tubes are still in place and functioning. Minor infections can be picked up on regular post-op visits. These can be treated with drops to help prevent blockage of the tubes by reactive tissue. Once tubes fall out, we monitor whether the child needs another set of tubes and whether the hole made in the eardrum closes. If a second set of tubes is needed or in kids aged four or older, ENTs may discuss removing the adenoid pad at the time of tube placement. The adenoid pad is lymphoid tissue that lives at the back of the nose. If large, it can block the drainage pathways of the ears. An audiogram, or hearing test, is often obtained before or after surgery. Roughly 1-2 per 100 children will have a persistent hole in the eardrum after tubes fall out. If this hole does not close on its own, we can repair it with same-day surgery. If tubes do not come out after several years, ENTs may remove them in a clinic or the OR.

Children may still develop ear infections with tubes in place, but the infected fluid can drain through the surgically placed tube. Drainage during conditions may be thick, yellow, green, white, or bloody. When drainage is noticed, prescription drops can treat the infection. It is important to call an ENT if your primary care doctor cannot see the tube in the ear if your pediatrician is concerned the tube may be clogged, if ear drainage lasts more than 10 days even with treatment, or if the drainage does not seem to stop at all.2

Torrey Fourrier, MD, is an assistant professor of otolaryngology-head & neck surgery and Saudamini Lele, MD, is a fifth-year resident of otolaryngology-head & neck surgery at LSU Health Shreveport.