If fluid from the middle ear space is draining out of the ear in a child with an acute ear infection (acute otitis media), there must be an opening in the eardrum – the air-tight membrane that separates the middle ear from the ear canal and helps us to hear. If fluid can get out through this opening, then it makes sense that medicine might get in. Researchers at the Children’s Hospital of Pittsburgh evaluated 80 children who had acute otitis media that was draining through ear tubes that the children already had in place. Half of the children received strong oral antibiotics, twice a day for ten days; the other half received antibiotic drops directly in the ear, twice a day for seven days. Those who got oral antibiotics received about 1000 times more antibiotic than those who got the drops: 90mg of antibiotics for every kg of body weight daily (the average age child in the study would weigh a little more than 12 kg, so over 900 mg daily total); those who received drops received only 0.84 mg total every day, whether they weighed 8 kg or 38 kg.

The results appeared September 2006 in Pediatrics. Even though the drops delivered 1000 times less antibiotics, they went straight to the source of the infection, rather than being spread throughout the body. The drops were more than 25% more likely to clear the infection entirely. The drops worked on average 42% faster. The drops had dramatically fewer side effects (there was an almost 30% side effect rate from the oral antibiotics!). Beyond all of this, I am most concerned that about 10% of the patients who took oral antibiotics had already acquired new bacteria in the ear during treatment; new bacteria did not emerge in any children who received drops. Antibiotic drops worked better, faster, with fewer side effects, and less risk of developing bacterial resistance. I can’t see why for most kids with a draining ear you would choose oral antibiotics as the first line of treatment.

As many as 700,000 children each year in the United States have ear tubes placed surgically to treat chronic and recurrent fluid behind the ear drum (otitis media with effusion, or OME). A study in the December 2005 Archives of Pediatrics and Adolescent Medicine argues that young kids who get tubes are more likely to have some hearing loss 6 to 9 years later than are matched kids who did not get the tubes.

To me, this study underlines the importance of only placing tubes in kids who need them – but it is not a cause for alarm or for change in the May 2004 joint guidelines concerning which children benefit from tubes. This study looked at 125 children who had tubes placed (or not) between 1985 and 1989, when most of the tubes themselves were different (harsher) than today’s bobbin-type tubes, and the recommendations for placing them were less conservative.

The children in the study had already had fluid present in the ear for at least 3 months. Half of the children in the study were randomly assigned to get tubes and the other half were randomly assigned to get 6 months of antibiotics (common in the 1980′s). Those who were assigned to get tubes in the study had a mild average hearing loss (28.7 decibel threshold) before the tubes were placed (today we recommend tubes in otherwise healthy children when fluid has been present for at least 3 months and the hearing loss is moderate — >40 decibel threshold – a level of hearing loss we know can affect speech, language, and academic performance if allowed to persist).

Years afterwards, those in the tube group had hearing that averaged 2 to 8 decibels worse at some frequencies than did their peers in the antibiotic group (although more than half the kids in the antibiotic group were eliminated from consideration, because they ended up getting tubes anyway).

Tubes do carry with them measurable costs and risks. The key is to reserve them for those children where the benefits are likely to far outweigh the costs.

We know that fluid behind the eardrum decreases hearing in children as long as it is present. We also know that the first 3 years of life are a very important time in a child’s development. The question is – does inserting ear tubes to eliminate this fluid help with development?

Researchers led by Jack Paradise MD at the University of Pittsburgh School of Medicine have been at work for years to settle this question. The answers are surprising, according to the August 2003 installment of the study in Pediatrics. The team enlisted 6350 healthy babies from birth to 2 months old and have regularly measured fluid in these children’s ear up until their third birthdays. If children developed significant fluid in the ears that lasted for at least 3 months straight or 4 out of six months, half of the children received ear tube surgery. The other half waited for 6 to 9 months longer and then had surgery only if the fluid remained. What was the outcome?

When the children were 4 years old, they received an extensive battery of intelligence, development, speech, language, and behavioral tests, looking at verbal and nonverbal growth. No difference could be found between the early and late treatment groups. Researchers will continue to follow these children as they grow up.

But for now, this large, carefully designed study has found no developmental benefit from rushing to ear tubes for young children.

Dr. Greene’s Answer:

The average length for most types of PE tubes to stay in is about nine months, but this length varies depending on the kind of tube used. They sometimes stay there a good bit longer.

Generally, the tubes should be allowed to fall out on their own. If they don’t, they may have to be removed. Most ear specialists wait at least 2 years before considering surgical removal of a tube.

About 15 percent of kids who have tubes in for several years will have a small hole left that takes a while to close on its own. About 1 or 2 percent will have a hole that doesn’t close. Some of them need a simple surgery to close it.

The scarring that people talk about is cosmetic and inside the ear. It doesn’t generally affect hearing at all.

The American Academy of Pediatrics established in 2002 five guidelines for the care of children who have tympanostomy tubes.

The first guideline calls for a follow-up visit within the first month after surgery to ensure that the tubes are open and functioning, to answer questions, and to agree on a plan for any new ear infections.

The second guideline calls for hearing tests. A baseline test should be done before tubes are placed, and unless the hearing was perfect, a follow-up hearing test should be performed after the surgery.

The third guideline calls for routine follow-up visits every 6 months, to monitor the functioning of the tubes and the healing of the eardrums. These visits could be done by either a pediatrician or an ENT, but the results should be communicated between both.

The fourth guideline calls for both a pediatrician and an ENT to be involved in the child’s care until the tubes are out, the eardrums have healed, hearing has normalized, and the child’s own Eustachian tubes are working.

The fifth guideline outlines a number of situations when a child needs to see the ENT between routine visits. These include problems such as ongoing drainage from the ear, worsening hearing, language delay, ear pain, or balance problems.

While the needs of individual children will vary, I’m pleased to have a general roadmap for care after tubes, so that important issues are less likely to fall through the cracks.

Dr. Greene’s Answer:

The question of earplugs and ear tubes is an interesting one. For years the standard recommendation has been to use earplugs, but there was a fascinating study a few years ago where children with ear tubes were monitored for ear infections with swimming. Some of the kids with tubes wore their earplugs and spent time in the water, some swam and played in the water without wearing their plugs, Some swam with plugs but received an antibiotic ear drop afterwards, and some avoided water to the ears altogether. The surprising result was that the rate of ear infections was the same in all 4 groups. There is an article here on the site called Swimming with Ear Tubes that tells the full story.

On average, wearing the earplugs doesn’t seem to make a difference. I tell parents in my practice not to worry about using the plugs at all, unless their child continues to get ear infections after the tubes, in which case the plugs are worth a try.

Ear tubes last an average of 9 months; some stay in for years. The peak season for ear infections is November through March in the northern hemisphere.

In your situation, there is no reason to feel guilty. First, you didn’t know the tubes were still there. Second, even if you did, many doctors would no longer recommend the plugs. Not wearing them probably had nothing to do with this infection.

Nevertheless, you might want to use earplugs from hereon just in case they might help. You may also want to discuss your child’s case with his otolaryngologist (ear specialist) since he/she may have a strong opinion about the use of earplugs.

Ear tube surgery is the most common operation performed on children. The most common reason for the surgery is to treat prolonged fluid in the ear (otitis media with effusion, or OME). An article in the August 2001 issue of Laryngoscope evaluated an interesting alternative.

Half of the children in the study received nasal aerosols containing glutathione, a naturally occurring major antioxidant in humans. The other half received placebo nasal aerosols.

Those that got the glutathione were far more likely to be fluid-free at the end of the study (66% of those who used glutathione, 8% of those who used placebo).

Further research is needed, but this looks like a welcome, gentle, yet effective, new option for this very common problem.

Dr. Greene’s Answer:

Dear Dr. Fitzgerald, Thank you for sharing your concern. Although I have at least two readers review every answer before it is posted, I welcome additional input. It is an honor for me to be “reviewed” by other physicians.

After receiving your email, I re-read the answer you are referring to. It is to a reader who was concerned about when ear tubes should be used. That answer used to say, “This pressure-equalization (PE) tube provides a temporary, extra Eustachian tube to allow bacteria and fluid to drain from the middle ear.” This statement was a shorthand summary of a more complicated process. I agree with you that it could lead parents to be concerned about fluid continually draining out of the ear. I have changed that entry to read, “This pressure-equalization (PE) tube provides a temporary, extra Eustachian tube which can help in several ways.” That statement is linked to this page for a more complete explanation of how ear tubes facilitate the drainage of bacteria and fluid from the middle ear.

Here is an excerpt from my book, The Parent’s Complete Guide to Ear Infections:

In the first half of the twentieth century, it was noticed that spontaneous holes in the eardrum often cured ear infections. These spontaneous holes, however, appeared and closed unpredictably. Several innovators tried various ways of keeping the holes open, including inserting fish bones, lead wires, and gold rings. Since 1954, the practice of intentionally making a small hole in the eardrum and inserting a small tube to keep the hole open has become very common. Today, more than 2 million ear tubes are implanted every year in the United States (Pediatric Clinics of North America, December 1996).

Ear tubes are made from a variety of materials, including ceramic, gold, plastic, Silastic, stainless steel, Teflon, and titanium. There is no proven advantage of one material over another.

A tube in the eardrum improves drainage of the middle ear space. Years ago, when a can of soda was opened with a can opener, a hole was made on both sides of the lid. While fluid poured out one hole, air was able to enter the can through the other, thus improving outflow. Ear tubes function in much the same way. When the middle ear space is closed, a suction effect prevents easy clearance of the contents down the eustachian tube. A blocked eustachian tube makes this even more difficult. When a tiny hole is made in the eardrum, the contents of the middle ear space flow far more easily either down the eustachian tube or out the inserted ear tube.

Unfortunately, this can also make it easier for bacteria to enter the middle ear space. It is easier for the contents of the nose and throat to travel up the eustachian tube if there is an opening at the other end. Also, bacteria can enter through the outer ear. Studies have shown, however, that for most children, improved drainage far outweighs the increased vulnerability.

It is my editorial goal to make every entry on Dr. Greene’s HouseCalls the best piece of its length, for parents, that is available on the Internet or in print. Thank you, Dr. Fitzgerald, for helping me achieve my goal.

Dr. Greene’s Answer:

The decision to have ear tubes placed in a child’s ears is many-faceted, but with that decision behind you, the decision to fly or not becomes quite easy.

In children without ear tubes, pain results from stretching of the eardrum caused by pressure. As the airplane takes off, the air inside the airplane gets thinner. Most airlines pressurize their cabins to blunt this effect, but still the pressurized cabin is equivalent to air at an altitude of about 7,000 feet. The air in the middle ear space expands along with the air in the rest of the cabin. As it expands, the air is easily forced through the eustachian tube; the eustachian tube automatically opens from the pressure. As long as there is no active, complete obstruction of the eustachian tube, the excess air exits the middle ear with a popping sensation, but little or no pain. Again, during ascent this process is spontaneous.

During descent, as the air pressure rises, the middle ear space needs extra air to re-equilibrate the pressure. However, during descent, the eustachian tube does NOT open spontaneously. A tiny muscle opens the eustachian tube only during swallowing, yawning, or crying. In children, this mechanism is less efficient than in adults. The rising pressure stretches the eardrum inward and can cause pain until air rushes into the middle air space and the ears pop.

The next time you hear a child crying during an airplane’s descent, remember, this is one instance where crying itself helps to solve the problem.

Ear tubes, or PE tubes (for pressure equalization), provide a temporary, extra eustachian tube to allow bacteria and fluid to drain more easily from the middle ear — thus, in most cases, providing relief from ear infections. PE tubes also provide an opening for air in the middle ear space to move freely. In children with PE tubes, the air in the middle ear space flows far more easily both through the eustachian tube and through the inserted PE tube.

Children with ear tubes in place may fly freely, without fear of pain upon descent or increased risk of ear infections. Flying is safer and more pleasant for children with PE tubes than for other children.

Whenever I hear of one parent using any excuse to keep the other parent from spending time with their child, I am deeply grieved. Even if there were pain upon descent or greater risk of infection due to a cross-country flight, I would still recommend that a child be allowed to fly in order to spend time with a non-custodial parent. That is how important it is for children to get to be with both parents!

I’m sure that when your daughter was born, both you and her mother had dreams of what life as a family would be like. No matter what the circumstances surrounding the breakup of that family, both of you have experienced a great deal of loss. Your daughter’s mother must feel wrenching pain at the prospect of being without her little girl, even if it is for a short time. I’m sure she must love your daughter a great deal. Now, in spite of her loss, it is time to do what is best for your daughter and comply with the court-ordered visitation schedule.

Your little girl needs quality time with her mother and her father in order to grow up to be a healthy, secure adult. Having ear tubes in place makes it easier, not harder, for that to happen.

If it would help in any way, please feel free to print this answer and share it with both your daughter’s mother and with the judge. As an advocate for your daughter, I’m sure the judge will appreciate your concern for her well being and her need to spend time in her father’s home.

Dr. Greene’s Answer:

From the 1930′s through the 1960′s, tonsillectomies and adenoidectomies were considered routine surgeries. At that time, the tonsils and adenoids were thought to be useless organs, because their function was not understood, and because they often melt away after childhood. In the late ’60′s we discovered that the tonsils and adenoids play an important role in the immune system. Once this was understood, the practice of routine tonsillectomy and adenoidectomy declined.

In 1990, a very well-designed study by Jack Paradise, M.D. (and colleagues), published in the Journal of the American Medical Association, did show a clear but modest reduction of ear infections following adenoidectomies. In 1999, the same author published another study which showed a “limited and short term” effect. Now we are faced with a decision — is the short-term benefit of removing the adenoids worth the cost?

The adenoids (also called the nasopharyngeal tonsils) are positioned at the back of the throat as defenders against bacteria and toxic substances that come into the body through the nose and mouth. When they are active — fighting infections and producing antibodies — they can become quite enlarged. In this state they can block the eustachian tube and clog the drain from the middle ear. Typically this obstruction is not complete and will still allow some of the normal secretions from the middle ear to drain.

Because the risk of adenoid surgery is greater than that of tube placement, the American Academy of Pediatrics recommends tube placement before adenoid surgery for the initial surgical treatment of most children with persistent middle ear fluid (Pediatrics 2004). However in children over 4 years old who mouth breathe chronically, snore heavily, and/or have chronic nasal congestion, the likelihood of benefit from adenoid surgery is increased. Thus, some doctors may consider adenoid surgery with tube placement or with myringotomy (hole made in the eardrum) for children over 4 years old who have the above symptoms of problematic adenoids.

Tonsillectomies are another story.

In 1983, the British Medical Journal reported a controlled study performed by A.R. Maw. The authors compared those who had their adenoids taken out with those who had their adenoids and tonsils removed. They found that adenoidectomy did result in improvement in middle ear disease. However, there was no additional benefit from having the tonsils removed. At present, there is no evidence that tonsillectomy alone is of any benefit in the treatment or prevention of otitis media. If a child were suffering from some other concurrent condition, such as obstruction of the airway or sleep apnea, however, I would consider tonsillectomy in addition to adenoidectomy as a possible solution.

For your son, Pauline, it’s not really a question of antibiotics versus surgery (the long courses of antibiotics may not be necessary — they may not be speeding up the disappearance of the fluid). The question is fluid in the ear versus surgery. Surgery may well be the better option for your son. His 2 or 3 infections per year — each with 1 or 2 months of fluid — mean that his hearing may be decreased for up to 6 months each year. A formal hearing test and thoughtful assessment of his school performance may help you to reach a decision. The information here can be used as a starting point for discussion with your doctors about the best course of treatment for your son.