Ear Infections (Otitis Media) in Children

Description

Alternative Names

Surgery

Children may be considered candidates for surgery if they have:

• OME lasting longer than 4 months that is accompanied by hearing loss.
• OME that is persistent or recurrent (even if there is no hearing loss) and may put child at risk for developmental delays or structural damage to the ear.
• OME and structural damage to the eardrum or middle ear.

The decision to pursue surgery needs to be determined on an individual basis. In 2004, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology-Head and Neck Surgery released the following general guidelines for surgical procedures:

• Tympanostomy tube insertion is the first choice for surgical intervention. However, approximately 20 to 50 percent of children who undergo this procedure may have OME relapse and require additional surgery.
• Adenoidectomy (removal of adenoids) plus myringotomy (removal of fluid), with or without tube insertion, is recommended as a repeat surgical procedure. Tube insertion may be advised for children younger than 4 years of age.
• Adenoidectomy is not recommended as an initial procedure unless some other condition (chronic sinusitis, nasal obstruction, adenoiditis) is present.
• Neither myringotomy alone or tonsillectomy (removal of tonsils) is recommended for OME treatment.

Tympanostomy (with Myringotomy)

A tympanostomy involves the insertion of tubes to allow fluid to drain from the middle ear. The procedure involves the following:

• A general anesthetic is required, but children typically recover completely within a few hours.
• Myringotomy is first performed.
• After myringotomy, the physician inserts a tube to allow continuous drainage of the fluid from the middle ear.

Click the icon to see an illustrated series detailing ear tube insertion.

Postoperative Effects. It is a simple procedure, and the child almost never has to spend the night in the hospital. Acetaminophen (Tylenol) or ibuprofen (Advil) is sufficient for any postoperative pain in most children. Some, however, may require codeine or other powerful pain relievers. One study found that lidocaine eardrops were effective in relieving pain and stress after the procedure.

Complications. Otorrhea, which is drainage of secretion from the ear, is the most common complication after surgery and can be persistent in some children. It is usually treated with antibiotic eardrops. One study suggests that wearing earplugs may alleviate the problem.

More serious complications from the operation are very uncommon:

• General anesthetic poses risks, although rare, for allergic reactions or other complications, such as throat spasm or obstruction, which are nearly always easily treated. According to one 2002 study, such complications occur in less than 2% of the patients. The risk is highest in children who have other medical conditions, most commonly upper respiratory infections, lung disease, or GERD.
• Sometimes the tubes become blocked from sticky secretions or clotted blood after the operation.
• Persistent eardrum perforation is the most common serious complication, but it too is rare.
• Scarring can also occur, particularly in children who require more than one procedure, but it almost never affects hearing.
• Small keratin (skin cell) containing cysts called cholesteatomas develop around the tube site in over 1% of patients. This raises some concern about the long-term safety of the procedure, although other studies have indicated that this complication is rare. More studies are needed.

Success Rates. Hearing is almost always restored following tympanostomy. Failure to achieve normal or near-normal hearing is usually due to complicated conditions, such as preexisting ear problems or persistent OME in children who have had previous multiple tympanostomies. In one 10 year study, hearing loss was still present in 12.5% of people who had had surgery, although in half of these individuals, hearing loss was very mild (loss was below 20 decibels). Persistent fluid was the main reason for continued impaired hearing. Only 1.9% of hearing loss cases could be attributed to complications of the operation itself.

Precautions. While the tubes are in place, children may take the following precautions:

• Many doctors feel that children should use earplugs when swimming as long as the tubes are in place in order to prevent infection. (Cotton balls coated with petroleum jelly are effective alternatives to ear plugs.)
• Children may shower without earplugs.

Some physicians feel that as long as the child does not dive or swim underwater, earplugs may not be necessary, but parents should consult their own child's doctor on this subject.

Follow-Up. After surgery, the children may experience the following course.

• Eventually, the tubes fall out as the hole in the eardrum closes. This may happen between several months to over a year. This is painless and the patient and parents may not even be aware that the tubes are out.
• Some children (20 to 50 percent) may have OME relapse and require additional surgery that involves adenoidectomy and myringotomy. Tube reinsertion may be recommended for children younger than 4 years of age.

Myringotomy

Myringotomy is used to drain the fluid and may be used (with or without ear tube insertion) in combination with adenoidectomy as a repeat surgical procedure if initial tympanostomy is not successful. It is not effective as a sole surgical procedure. Myringotomy involves the following steps.

• The surgeon makes a very small incision in the eardrum.
• Fluid is sucked out using a vacuum-like device.
• The fluid is usually examined for identifying specific bacteria.
• The eardrum heals in about a week.

Adenoid Removal

Adenoids are collections of spongy lymph tissue in the back of the throat. Removal of the adenoids, called adenoidectomy, is usually only considered for OME if a pre-existing condition exists such as chronic sinusitis, nasal obstruction, or chronic adenoiditis (inflammation of the adenoids). Unless these conditions exist, adenoidectomy is not recommended for treatment of OME. Adenoidectomy plus myringotomy may be performed if an initial tympanostomy procedure is unsuccessful in resolving OME. this combination procedure works best in children aged 4 years or older. Tube insertion is recommended for children under 4 years of age.

Click the icon to see an image of the adenoids.

Laser-Assisted Myringotomy

Laser-assisted myringotomy is a technique that is being investigated as an alternative to conventional tympanostomy and myringotomy. At present, there is not enough evidence to determine its efficacy in comparison to standard surgical procedures. Some clinical trials have suggested that the success rate for laser-assisted myringotomy is half that of standard tympanostomy/myringotomy. Many insurance companies consider laser-assisted myringotomy to be an investigational procedure and will not pay for it.