Ear Tubes Reduce Infections

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Once again, your baby is spiking a fever and tugging at his earlobe, obviously in pain. Your pediatrician confirms what you already knew: another middle ear infection. Only this go-around, instead of taking a "wait and see" approach or prescribing antibiotics, she suggests it might be time to turn to tubes.

Ear ventilation tubes reduce or eliminate ear infections for up to six months after insertion, according to a new review of studies, led by Dr. Stephen McDonald, an ear, nose and throat specialist at St Michael's Hospital in Bristol, England.

In the United States, physicians perform anywhere from 500,000 to 2 million tube insertions each year on children with recurrent acute otitis media and chronic fluid.

McDonald does not make wide use of tubes in his own practice: "I tend to be conservative, as the major indication, otitis media with effusion — OME, or 'glue ear' — tends to be a relapsing, remitting condition, with only a minority of children having a sustained hearing loss."

Some consumer health advocates and parents question whether the tubes are worth the risks of surgery.

"Most tubes in children are done under general anesthesia, although kids older than 8 years may tolerate local anesthesia," said Kenny Chan, M.D., chief of pediatric otolaryngology at the Children's Hospital in Denver. Risks of tube insertion include post-operative pain, ear drainage after infection and a small risk of eardrum perforation when the tube falls out, Chan said.

"Discharge for a day or two post-insertion is common," McDonald said. "More rarely, discharge continues for longer, or occurs after an interval. In some cases this is an indication for topical treatment with antibiotic drops," McDonald said, though oral antibiotics are sometimes used.

"The controversy has been around a long time for recurrent otitis media and putting tubes in," said Stephen Berman, M.D. He is section head for general academic pediatrics at the University of Colorado medical school and the Children's Hospital. "To decrease infections by one to two over a six-month period: is it worth it?" he asked.

A variety of bacteria and viruses can cause middle-ear infections, with pneumococcal pneumonia bacteria and influenza B virus the most common culprits, according to the researchers. Preventive antibiotics are one strategy for treatment, but with growing concerns about antibiotic- resistant germs, most doctors prescribe antibiotics only when infections actually arise, if at all.

Often, all parents have to do is watch and wait for the infection to clear. "In children ages two and older, people are moving away from antibiotics, it's more of a wait-and-see interval," Berman said. "If in 48 to 72 hours the child is still febrile, still in pain, we may use antibiotics."

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Physicians consider ear tubes when ear infections become a pattern. Recurring infections can cause mastoiditis, temporary hearing loss or even permanent hearing damage, according to the reviewers.

An ear tube, or grommet, "bypasses the Eustachian tube by creating a direct path between the middle ear and the outside world," Chan said. The tubes most commonly used in the United States often last between nine and 12 months, he said. Once inserted, the tubes are not visible and are maintenance free.

In their search for randomized controlled trials that compared ear tubes with other treatments, the reviewers found two studies that met all their requirements. One took place in Ohio and the other took place in Riyadh, Saudi Arabia.

The studies comprised 148 children under three years old. In the larger U.S. study of 95 children, tubes reduced otitis media episodes by 1.5 episodes for the first six months of treatment. Also, a significant proportion of children had no episodes whatsoever in that time. Results for the smaller study, which compared tubes to antibiotics, were not statistically significant.

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The Cochrane reviewers concluded that "Ventilation tubes have a significant role in maintaining a disease-free state in the first six months after insertion." However, they cautioned, "Clinicians should consider the possible adverse effects of grommet insertion before surgery is undertaken"

"My approach is, I tend to be more aggressive with tubes the earlier the onset of otitis, and the younger the child," Berman said. "In the first six months, I tend to refer after the third episode.If you have two- or three-year-olds with their first infection, I tend not to refer as much."

Berman took issue with the Cochrane review in that it analyzed few studies and that some could consider those outdated.

McDonald said the while the reviewers had hoped to include more studies, "The whole point of a Cochrane Review is to set strict, explicit criteria about study quality before the review is conducted, to avoid the temptation to include studies of a lower quality that would weaken or bias the conclusions, and then to carry out a thorough review of all the evidence."

Both review studies followed children for six months after tubes insertions. Many parents worry about what happens farther down the road. "Probably in terms of long-term hearing, academic performance and learning ability, there's no difference between children who do and don't have tubes," Berman said.

As for the impact that even short-term hearing loss caused by glue ear might have, "Conservative measures such as parental education — such as making sure to make eye contact when speaking to a child — can ameliorate any potential educational deficits," McDonald said.

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