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Many parents who have reached the Waiting Room of this office have been referred because their child has been experiencing significant problems with ear infections. Ear infections continue to be an extremely common problem, which we all realize is a source of discomfort, frustration, expense and time-loss for your child and you.
Ear infections often occur in association with an upper respiratory tract infection, occurring most commonly from the autumn through late spring. A lingering after-effect is the presence of fluid in the middle ear space, which tends to diminish hearing capability and, in some cases, language development. Some parents also notice balance problems. In a few patients, problems with the eardrum and middle ear structures can develop.
The information below is available in many textbooks, but also was reinforced by the U.S. Agency for Health Care Policy and Research Guidelines for the Treatment of Otitis Media with Effusion; Dr. Eavey was a panel member.
Fortunately, the most well utilized treatment option is "watchful waiting." Almost all children will have at least one ear infection. After treatment with antibiotics, the child usually recovers completely. The best treatment at that point is basically no treatment at all until a future infection again may require medicine.
For children who are experiencing more frequent ear infections, and in some children who have prolonged middle ear fluid, preventative (maintenance, prophylactic) antibiotics can be prescribed. Many children will respond favorably to antibiotic treatment in this manner. Unfortunately, the Center for Disease Control in Atlanta now discourages this treatment because bacterial resistance to antibiotics has gotten worse.
The "new" pneumococcal vaccine was FDA approved in February 2000 and can help to decrease the frequency of some types of ear infections. In fact, our office helped to perform clinical trials for this vaccine. Your pediatrician actually provides the vaccine.
For children who are not responding to antibiotic management, another treatment option is surgical. The technique involves placement of a set of tiny tubes into the eardrums done in conjunction with evacuation of pus and/or middle ear fluid. In certain circumstances an adenoidectomy might also be performed.
Many parents ask about other types of conditions and/or therapies, which are not traditionally associated with ear infections. Most commonly the issue is one of possible allergies. But also questions come up about alternative management such as with homeopathy, osteopathy, acupuncture, dietary management and other techniques. As part of the U.S. Agency for Health Care Policy and Research Guidelines investigation, many different proponents of these therapies were invited to speak at Bethesda, Maryland. Unfortunately, although many of the individuals who spoke were enthusiastic about their methodology, no one was able to provide scientific data that could offer convincing and unbiased evidence that there were new treatment regiments that could be offered to parents and their children at this time.
Most parents who have been referred to this office have already been made aware that surgery might be a consideration. Therefore, here is a brief description to help you become more informed.
The biggest, and a logical issue for most parents, usually unstated, is the anesthesia rather than the actual surgical procedure. We encourage one parent to accompany their child into the operating room during anesthesia induction. That way, we hope the child is more comfortable hearing a parent talking and feeling a parent holding their hand. From experience, we have learned that it is also more comforting for the parent! A tube operation lasts a few minutes. However, with anesthesia induction and recovery time, a longer period will be spent in the operating room. The child then fully awakens in the recovery room. Overall, from the time a family enters the hospital to the time they leave is roughly 2-3 hours. However, this time can vary. Anesthesia was invented about 150 years ago just a block away from where you are reading this in the waiting room. There's been a lot of experience with anesthesia. Anesthesia provides for painless surgery and is actually a friend. Unfortunately, about the only time people become aware of anesthesia is when very rarely something unfortunate happens, rather like with automobiles and airplanes. The news media does not report when people commute home safely or land at the airport uneventfully; the media does not report that millions of people have experienced safe anesthesia.
The tube itself is very small and hollow, about the diameter of a refill of a ballpoint pen. (The eardrum is about the size of a barrel of a ballpoint pen.) The tube is placed through the ear canal using a microscope. No incisions are made around the ear. A small incision is made in the eardrum and fluid is aspirated. The principle behind tube insertion is that fluid evacuation and ear ventilation usually diminishes the number of ear infections and also increases the hearing.
Patients will often have some discomfort for a few minutes upon awakening. After that, they do not seem to be able to feel that there is a tube in the ear and cannot dig it out with their fingers. The tube stays in on average for 6 to 18 months. The tubes extrude slowly from the eardrums and then along the ear canal. If they are found on a pillow or we retrieve there here in the office, you have the opportunity to save them for the Tube Fairy! Usually only one set of tubes is necessary. Approximately 75% of children who receive a set of tubes will "outgrow" their ear condition so that when the tubes extrude there will be no need for more ear treatment. Approximately another 20% of children will need a second set of tubes while they are still waiting for Mother Nature to make their ears better. An elite 5% of children will go on to need 3 or more sets of tubes. Probably 1% of children will grow up to be adults who will have ear problems.
An estimated 80% of parents will be satisfied that tube placement has provided a positive impact on their life and their child's health by diminishing noticeably the number of ear infections and/or increased hearing ability. This means, unfortunately, that about 20% of children will still continue to have many ear infections. In fact, about 15% of patients will have an ear infection within the first month after tube placement. But fortunately, many of those children in the long run will still be a treatment success. One silver lining to that gray cloud is the fact that children who have a tube (or a perforation) with an ear infection have a port for pus to drain out and so often have less discomfort and also can be treated with topical antibiotics in the form of drops.
Parents are aware of the need for water precautions. Some children with tubes can swim without mechanical blockage of water from the ear canal and will not develop an infection. Unfortunately, many children do develop an ear infection about a day after a significant amount of water enters the ear canal. Along the lines of the philosophy, "an ounce of prevention or a pound of cure," older children are encouraged to wear ear molds (various types are available) and even a headband or tight racing swim cap if they lie to dive underwater. Although a nuisance, it seems to be a minor issue.
On the short run, after tubes are placed, about 1% of the time a tube can become blocked by a clot after some oozing. In the patients in whom it does block, sometimes ear drops are effective in removing the clot. Another issue occurs at the time of tube extrusion. About 1% of patients will have a hole left in the eardrum. Although on the face of it, a perforation does not sound like a desirable situation, the hole actually ventilates the ear in the same fashion that the plastic tube does. (In fact, the tube does nothing more special than prevent the incision from closing which would tend to happen merely a day or two after surgery so that the plastic is helpful to maintain the ventilation for a few months.) Should a perforation occur, it is usually preferable to leave it to continue to ventilate the ear. If the perforation does not heal over the long term, a surgical patching procedure can be performed. Very rarely the tube migrates into the ear instead of out into the canal, necessitating later removal.
This information sheet answers the most frequently asked questions posed by parents. Please let us know any other issues that you wish to discuss since we should all feel comfortable with whatever management strategy we decide upon in the office.
Thank you for the privilege in assisting you and your pediatrician with the care of your child.
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