Pediatric Annals

The Use of Tympanostomy Tubes

Herman Felder, MD, FACS, FAAP

Abstract

The use of tympanostomy tubes has been the most important development in the treatment of ear disease since antibiotics. The advent of antibiotics virtually eliminated the incidence of acute mastoiditis, and the use of pressure equalization (PE) tubes has markedly reduced the incidence of chronic mastoiditis and acquired cholesteatomas. In addition, PE tubes have decreased the need for multiple myringotomies and have improved the quality of life for millions of children and their parents. This article will attempt to justify the use of tympanostomy tubes by describing the indications for their use, refuting some of the myths used to disparage the procedure.

The procedure, introduced by Beverly Armstrong in 1954, is relatively new. Since 1954, the number of these procedures has increased annually to an estimated 1 million per year. Even though 34 years may be considered a short time, experience with an entire generation has provided enough supportive anecdotal (albeit not sufficient scientific) evidence.

Numerous articles and books have been written on the etiology of acute suppurative otitis media and chronic nonsuppurative otitis media. The conclusion is that eustachian tube obstruction (anatomic or physiologic) or eustachian tube dysfunction is the culprit. The tympanostomy tube acts as an artificial eustachian tube and, thus, has two main functions:

1. It equalizes the pressure between the middle ear and the atmosphere.

2. It can drain the middle ear when necessary.

The two major indications for inserting tympanostomy tubes are recurrent bouts of otitis media (usually in infants) and persistent fluid (usually in older children). Occasionally, tubes are also inserted because of chronic tympanic membrane retraction.

Otitis media is very common during the first year of life, and it is the most common reason for visits to the pediatrician for illness during that period.2 The symptoms of the disease are well known so I do not need to repeat them. However, I will emphasize that these babies are miserable. Their misery is worse when they lie down so that naps are given up and sleepless nights for the child and the family are the rule. Treatment consists mainly of antibiotic drugs prescribed in ascending order of potency and cost. Compliance is questionable - it is not easy for parents to remember to give the antibiotics three to four times per day for ten days - and regardless of the "pleasant" taste, one can never be certain how much of the dosage the infant retains. When symptoms recur eight to ten times during the first year of life, the infants are candidates for the insertion of tympanostomy tubes. Following the procedure, the infants' sleep and eating patterns become more regular, their balance and verbalization improve, and their need for antibiotics is minimal. Studies in both animals5 and children4 support the benefit of tympanostomy tubes in preventing recurrent acute otitis media.

Antibiotic prophylaxis may be beneficial during the first year of life if the child's ears clear completely between bouts of otitis media. If the fluid persists, however, then antibiotic prophylaxis is useless in clearing up the ears and may even mask serious problems. If therapeutic doses of antibiotics will not clear the fluid, prophylactic doses should not be expected to help. Also, if the child develops an infection (acute otitis media) while taking the antibiotic in a prophylactic dosage (once a day), then he or she is a candidate for tubes.

Persistent fluid affecting hearing in a child over 1 year of age is the other major indication for the insertion of tympanostomy tubes. There is no argument that hearing is necessary for speech development; if hearing is impaired, speech is retarded.5,6 Speech usually…

The use of tympanostomy tubes has been the most important development in the treatment of ear disease since antibiotics. The advent of antibiotics virtually eliminated the incidence of acute mastoiditis, and the use of pressure equalization (PE) tubes has markedly reduced the incidence of chronic mastoiditis and acquired cholesteatomas. In addition, PE tubes have decreased the need for multiple myringotomies and have improved the quality of life for millions of children and their parents. This article will attempt to justify the use of tympanostomy tubes by describing the indications for their use, refuting some of the myths used to disparage the procedure.

The procedure, introduced by Beverly Armstrong in 1954, is relatively new. Since 1954, the number of these procedures has increased annually to an estimated 1 million per year. Even though 34 years may be considered a short time, experience with an entire generation has provided enough supportive anecdotal (albeit not sufficient scientific) evidence.

Numerous articles and books have been written on the etiology of acute suppurative otitis media and chronic nonsuppurative otitis media. The conclusion is that eustachian tube obstruction (anatomic or physiologic) or eustachian tube dysfunction is the culprit. The tympanostomy tube acts as an artificial eustachian tube and, thus, has two main functions:

1. It equalizes the pressure between the middle ear and the atmosphere.

2. It can drain the middle ear when necessary.

The two major indications for inserting tympanostomy tubes are recurrent bouts of otitis media (usually in infants) and persistent fluid (usually in older children). Occasionally, tubes are also inserted because of chronic tympanic membrane retraction.

Otitis media is very common during the first year of life, and it is the most common reason for visits to the pediatrician for illness during that period.2 The symptoms of the disease are well known so I do not need to repeat them. However, I will emphasize that these babies are miserable. Their misery is worse when they lie down so that naps are given up and sleepless nights for the child and the family are the rule. Treatment consists mainly of antibiotic drugs prescribed in ascending order of potency and cost. Compliance is questionable - it is not easy for parents to remember to give the antibiotics three to four times per day for ten days - and regardless of the "pleasant" taste, one can never be certain how much of the dosage the infant retains. When symptoms recur eight to ten times during the first year of life, the infants are candidates for the insertion of tympanostomy tubes. Following the procedure, the infants' sleep and eating patterns become more regular, their balance and verbalization improve, and their need for antibiotics is minimal. Studies in both animals5 and children4 support the benefit of tympanostomy tubes in preventing recurrent acute otitis media.

Antibiotic prophylaxis may be beneficial during the first year of life if the child's ears clear completely between bouts of otitis media. If the fluid persists, however, then antibiotic prophylaxis is useless in clearing up the ears and may even mask serious problems. If therapeutic doses of antibiotics will not clear the fluid, prophylactic doses should not be expected to help. Also, if the child develops an infection (acute otitis media) while taking the antibiotic in a prophylactic dosage (once a day), then he or she is a candidate for tubes.

Persistent fluid affecting hearing in a child over 1 year of age is the other major indication for the insertion of tympanostomy tubes. There is no argument that hearing is necessary for speech development; if hearing is impaired, speech is retarded.5,6 Speech usually starts to develop at 18 months of age and if a child has fluid in the ears that has not cleared on antibiotic therapy, tubes should be inserted.

Kindergarten and first grade are difficult periods in a child's development when hearing is normal. They can be devastating when the child's hearing is impaired. These children do poorly in vocabulary and spelling; they fidget a lot and become introverted. They are accused of not paying attention and not following directions. Most of these children have hearing levels of 25 to 40 dB due to the fluid and should have tympanostomy tubes inserted. A marked difference in the children can be observed after the procedure. True, there are no scientific studies to show that these children suffer from the delay in speech or learning, but no one can argue that they benefit from the delay. If a child has a problem that can be easily corrected, why not do it as early as possible?

There are many myths associated with insertion of tubes. As with any procedure, one must weigh the risks of the procedure versus the benefits derived versus the risks of not performing the procedure. Not performing the procedure in infants requires continuing the administration of antibiotics. There are risks inherent in antibiotic therapy - from simple diaper rash to overgrowth of nonsusceptible organisms and fungi to allergic reactions and erythema multiformae. Inserting the tubes does require a general anesthetic and some are concerned about using general anesthesia in infants. In my opinion, modern general anesthesia performed or supervised by an anesthesiologist is just as safe, if not safer, than the administration of some antibiotics. In performing over 15,000 operations of tympanostomy tubes, I have never had a problem with anesthesia. The safety of general anesthesia in children has been verified in other, larger series.7,8

Another myth about tubes is that the scar tissue that forms on the eardrum is bad. Just as many children who have had recurrent infections, hut not had tubes inserted, have scar tissue on the eardrum. This scar tissue or myringosclerosis rarely affects hearing. The tubes can prevent conditions that do affect hearing such as fibrosis, tympanosclerosis, and severe tympanic membrane retraction that leads to cholesteatoma. Scar tissue on the tympanic membrane should not be a reason not to recommend tubes.

Some are against the use of tubes because of the expense of hospitalization and surgery. The cost of repeated physicians office visits, drugs, missed work by the parents, and the need for babysitters has not been added to their calculations.

The final myth I would like to refute is that of middle ear infection caused by contaminated water entering the tube while swimming. All the children I treat swim with or without ear plugs. There are just as many swimming related problems in children with or without the tubes. Several studies have made the same conclusion.9,10

In summary, the insertion of tympanostomy tubes is an excellent operation for curing recurrent bouts of otitis media in infancy and for eliminating persistent fluid affecting hearing in older children. Once myths about general anesthesia, scar tissue, swimming, and expense have been refuted, there is no reason to withhold this procedure from children who would benefit from it.

REFERENCES

1. Armstrong BW: A new treatment for chro;retory otitis media. Arch Otorhmularyngol 1954; 69:655-654.

2. Bluestone CD; Otitis media in children: To treat or not to treat. N Engl J Med W82: 306:1599-1404.

3. Sodeserg 0. 1 lellstrom S, Stentors LE: Tvmpanostomy tubes for prevention ot purulent otitis media. Otularmgol Head Neck Sun; 1985; 95:601-606.

4. Coniale: C: Prevention of tecunent acute otitis media: Chemoprophylaxis versus tympanostomv tubes. Laryngosecope 1986; 96:1350-1554.

5. Watanabe H, Shin T, Fukaura J. et al: Total actual speaking time in infants and children with otitis media with effusion, int J Pediatr Otorholaryngol 1985. 10:171-180.

6. Kaplan GJ, Fleshman JK. Bender TR. et al: Long temi effects of otitis media. A tenyear cohort studv of Alaskan Eskimo children. Peduurtcs 1975; 52:577-585.

7. Smith RM: The pediatric anesthetist. 1950-1975. Anestfiesiologv 1975; 45:144-155.

8. Warner LO. Beach TR Garvin JR. et al: Halothane and children: The first quarter century. AnesuV-su Anruiis 1984; 65:858-840.

9. Jaffe BF: Are water and tvmpanostomy tubes compatible? Laryngoscope 1981; 91:565-565.

10. Becker GD: Swimming and tympanostomy tubes: A ptospective studv. Ltrrvngoscupe 1987; 97:740-741.

10.3928/0090-4481-19881001-06

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