My seven-month-old son was diagnosed three weeks ago with an inner ear infection and has been prescribed a total of four different antibiotics. In order, they are amoxicillin, cefzil, sulfatrim, and lorabid. The infection is still not clearing up, and an ENT specialist has now suggested tube surgery. Our regular pediatrician recommends waiting to see if things are better in the spring. What is going on here? We are totally confused! Surgery or no surgery? Or should we throw out all the docs and start from scratch? What do you suggest?
Thanks for your help.
Dr. Greene’s Answer:
To have a specialist suggest surgery for your son must have felt quite mixed: Finally, a light appears at the end of the antibiotic-tunnel! Hope for uninterrupted sleep! But, I don’t want my little one to have surgery!!! And then, when your doctors disagree about what to do, the whole situation becomes very unsettling!
The surgical procedure for placing tubes in the ears has become one of the most commonly performed operations of any kind. The procedure is a simple one. A tiny tube, with a collar on both ends (which looks like this ][ and is called a grommet in England ) is slipped through a tiny incision in the eardrum. “This pressure-equalization (PE) tube provides a temporary, extra Eustachian tube which can help in several ways.” The procedure has been in widespread use since 1954, and is very safe — probably safer than driving to the hospital for the surgery.
Middle ear infections are categorized into two basic types that behave very differently. Otitis media with effusion (OME) is the name given to fluid in the middle ear. Acute otitis media (AOM) refers to fluid in the middle ear plus sudden symptoms of pain, and often fever. There may be redness, and a bulging of the eardrum. Children with OME act well. OME is often discovered at well-child examinations. Children with AOM act sick, especially at night, often with a fever. After an episode of AOM, the child is often left with OME for several weeks.
For AOM (acute otitis media), tubes are often considered for several reasons. One of the most common reasons is if the episodes are recurrent. Children with 3 episodes in 6 months (or 4 episodes in 12 months) are candidates for tubes. This is especially true if prophylactic antibiotics (low dose antibiotics to prevent ear infections) are tried and fail. Children with complicated AOM should get tubes.
Complications are uncommon but include abscesses, facial nerve problems, and an ear infection that stays hot, painful, and bulging despite several antibiotics.
For OME (fluid in the ears), new guidelines were published in 2004 regarding the indication for tubes in this situation. It is recommended that tubes be placed for children with moderate hearing loss (greater than or equal to 40 dB). Children with mild hearing loss (between 21-39 dB) may be considered for tubes. For healthy children with normal hearing (hearing loss less than or equal to 20 dB), a “watch and wait approach” is recommended. For healthy children with normal hearing, it is recommended that their hearing and ear exam be monitored every 3-6 months until the fluid is gone.
There are several other reasons to consider early tube placement.
Early tube placement should be considered for children who have complicated OME. These complications are uncommon and relate to the prolonged retraction of the eardrum causing damage to the eardrum or the little bones of the middle ear. Early tube placement should also be considered for children who have any type of preexisting hearing loss or balance disorder. Children who have any other communication or sensory difficulty (visual, developmental delay, autism, speech delay, etc.) are also candidates for early tubes. There is no reason to delay tubes for children with known craniofacial, structural problems predisposing them to recurrent infections (cleft palate, Down’s syndrome, etc). Ongoing pain also calls for tubes at the earlier end of the spectrum. Finally, seasonal timing affects the advisability of tubes. In the fall or early winter, the child’s ears are likely to get worse over the ensuing months, rather than better, and early tube insertion may be warranted.
Aside from the published guidelines, other factors may be used by physicians to suggest further observation, rather than rushing to tubes. Children for whom prophylactic antibiotics have resulted in a reduction in the frequency and/or severity of bouts of AOM may warrant further observation before PE tube placement. As your pediatrician mentioned, in the spring and summer ear infections clear more easily and recur less readily, suggesting a delay, if possible.
Find out from your pediatrician what has been going on with your son. Has it been three weeks of AOM, with hot, bulging eardrums in a clearly ill child the whole time? If so, surgery, or another antibiotic more effective against resistant bacteria (antibiotics such as Cefuroxime or Rocephin) might be indicated. Has it been three weeks of OME in an otherwise healthy child? If so, tube surgery is not a good idea. More likely, did this begin with AOM, but has not cleared completely? If so, your pediatrician’s suggestion to wait and see if the situation is better in the spring (perhaps on low-dose antibiotics to prevent flare-ups of AOM) sounds like good advice.
In the northern hemisphere, ear infections are most common (and clear least easily) in November through March. For you, Jinny, and for the millions of other parents whose children suffer from ear infections, happy first day of April!