JOSEPH R. ANTICAGLIA,
MD Medical Advisory Board
At times, a mother is faced with a worrisome decision, “Should I allow my child to undergo surgery?” Regardless of the type of surgery the child needs or whether he is 13 months old, 23 months old or older, the words “surgery or operation” makes the parent nervous. For the surgeon, to operate on a 13 month old child who weighs 19 pounds makes him think hard and ask, “Why operate?”
WHY OPERATE?
Ear infections (otitis media) are common problems in a Pediatrician’s office especially in children under two years of age. Each year more than 600,000 children under the age of 15 undergo myringotomies (an incision in the eardrum) with the insertion of ear tubes in the United States. (1)
When kids get multiple ear infections or have fluid in the middle ear that persists (otitis media with effusion), the Pediatrician or Family Doctor may refer the child to an ear specialist for consultation and the insertion of ear tubes. (2) In these instances, ventilation tubes may:
- Reduce the risk of future ear infection
- Restore hearing caused by middle ear fluid
- Improve speech problems and balance problems
- Improve behavior and sleep problems caused by chronic middle ear infections. (3)
WHAT ARE EAR TUBES?
Ear tubes are tiny cylinders about 1/20 of an inch wide which are made of different materials. They are placed through the tympanic membrane (eardrum) but remain attached to the eardrum to allow air into the middle ear. Short term tubes are designed to stay in place for six to nine months but they may come out of place in less than two months or remain in place for more than a year. Long term tubes such as “T” tubes are larger and designed to remain in place for a longer period of time.
(A) Size of tympanostomy tube compared to a dime. (B) Tympanostomy tubes are also called “ventilation tubes” because the opening allows air to enter the middle ear directly from the ear canal (arrows), which bypasses the child’s poorly functioning eustachian tube (X). Reproduced with permission. (4)
In figure B, the arrow points to the ear tube that has been placed through the eardrum part of which is in the middle ear. In the middle ear, above are the tiny bones that conduct sound and below is the opening of the middle ear into the eustachian tube (X).
WHAT IS DONE PRE-OPERAIVELY?
- The surgeon obtains a history of the problem and examines the child.
- A tympanogram is done to evaluate the flexibility of the eardrum.
- A hearing test is performed in a young child with play audiometry or routine audiometry in older children.
- Image studies are rarely indicated
- Your surgeon may advise an adenoidectomy (removal of tissue behind the nose) be done along with the insertion of ventilation tubes to reduce the incidence of ear infections and the frequency of ear tube insertion.
WHAT HAPPENS AT THE TIME OF SURGERY?
A general anesthetic is administered to children without the intubation tube being passed into the windpipe. Using an operating microscope and special surgical instruments, a slit is made in the eardrum referred to as a myringotomy, fluid is suctioned from the middle ear space, and either a plastic or metal tube is placed in the opening made by the myringotomy incision. Next, antibiotic ear drops are placed in the ear and finally cotton in the ear canal. The procedure takes 10 to 15 minutes and the drops may be used for two or three days after the procedure.
AFTER SURGERY WHAT HAPPENS?
After surgery, the patient is monitored and wakes up in the recovery room. The child may be irritable and crying from the surgical experience but settles down especially when the parent walks into the room. The pain is minimal. If fluid is suctioned from the middle ear, there is an immediate improvement in the child’s hearing. In two or three hours the child is ready to go home, and post-operative instructions are reviewed with the parents. The parent is advised to keep the follow up appointment.
AT HOME
At home the youngster resumes normal activities. Your doctor may recommend using ear plugs to keep water out of the ear to prevent the possibility of ear infections. However, studies indicate that it may not be necessary to keep the ear dry during bathing and swimming. It seems that surface water swimming is OK but avoid under water swimming, diving and soapy baths. (5) Talk to your physician about whether it is necessary to protect the ear while the tubes are in place.
COMPLICATIONS
There is a risk that after the ventilation tube falls out or removed, the eardrum will have a hole in it. Also, while the tube is in ear, the child may require medical management because of drainage. These complications are infrequent. Discuss the risks of surgery with your doctor.
SUMMARY
Before a parent consents to have her child undergo myringotomies and tubes, the child should be a medical failure. In other words, medical treatment did not reduce multiple episodes of otitis media nor did it eliminate the persistent fluid from the middle ear.
The success of inserting ventilation tubes along with the use of antibiotics has been remarkable in reducing the incidence of perforated eardrums, mastoiditis and chronic ear conditions. When patients are properly selected, ear tubes are good reasons to operate.
- Cullen KA, et al. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009; (11)
- Ear tubes are also called ventilation tubes, tympanostomy (tim pan OS toe me) tubes and P.E. — pressure equalizing tubes
- American Academy of Otolaryngology, Head & Neck Surgery Ear Tubes
- Sage Journals; AAO-HNS Practice Guidline; Tympanostomy Tubes in Children; Rosenfeld, RM et al; April 2, 2013. ROSENFELD, RM;
A Parent’s Guide To Ear Tubes; Hamilton, Ontario BC 2005. - Salata, JA; Derkay, CS; Arch. Oto HNS; 1996, March.