Watchful waiting not ear tube implants best for ear infections

A new study suggests that children who typically receive an operation to insert ear tubes because of ear infections or fluid in the ear may not need it, according to clinical practice guidelines.

The research, conducted by Salomeh Keyhani, MD, MPH, Assistant Professor in the Department of Health Policy at Mount Sinai School of Medicine and her multidisciplinary team of colleagues, found that most children who had ear tube operations in the New York City area in 2002 had mild disease for which experts recommend either medical treatment or watchful waiting - not ear tube implantation. This study is published in the January 2008 issue of Pediatrics, the official journal of the American Academy of Pediatrics. These findings suggest overuse of ear tubes and update a similar finding made about this practice in the United States in 1990-1991.

Tympanostomy tubes, or ear tubes, are small implants that ventilate the middle ear space to the ear canal through the tympanic membrane. Ear tubes may be inserted to treat recurrent episodes of acute otitis media (inflammation of the middle ear), or the persistence of otitis media with effusion (fluid in the middle ear space, but without the symptoms of an acute infection). Both conditions may be associated with hearing loss, may risk long-term damage to the ear structures, and can often be improved with ear tubes surgery. Tympanostomy tube insertion is the most common procedure that requires general anesthesia for children in the United States, with half a million or more surgeries done each year.

“Ear infection is the most common illness with which children present to the doctor,” said Dr. Keyhani, lead researcher of the study. “We found that many children are getting surgeries for minor disease and the typical child who gets ear tube surgery does not have disease severe enough to warrant the operation. If the study findings could be applied to rest of the country, it would be particularly troubling.”

For the study, Dr. Keyhani and her colleagues at Mount Sinai examined the clinical data for 682 children who received tympanostomy tubes from any of five New York Metropolitan area hospitals in 2002. This data was collected from the pediatrician, otolaryngologist, and hospital chart for each child for the year prior to surgery.

Clinical practice guidelines endorsed by the American Academies of Pediatrics, Family Physicians, and Otolaryngology – Head and Neck Surgery recommend that, in general, children with fluid in their ear should not receive ear tubes unless that fluid has been persistent for at least 3 to 4 months consecutively. Dr. Keyhani said, “One of our key findings is that more than three quarters of the children in our study who got ear tubes had fluid for less than a month and a half.”
This study suggests that many clinicians use variables other than those generally studied, such as duration of effusion or fluid, number of recurrent infections, hearing loss, and speech delay when deciding whether to insert tubes in the ear. Future research needs to explore both the optimal course of treatment and why clinical practice so frequently deviates from the accepted guidelines.