Tympanostomy tube insertion, which involves placing a tiny drainage pipe, or ear tube, into a child’s eardrum, is the most common ambulatory pediatric surgery. As of 2006, some 667,000 kids were sitting through the procedure each year in the U.S. By age three, roughly one in every 15 children has had tympanostomy tubes, a number that doubles for children in daycare.
The procedure creates a small opening in the eardrum, allowing middle ear fluid to drain and alleviating pain and conductive hearing loss for children with chronic ear infections as well as kids with chronic colds that cause fluid buildup, eliminating the need to handle repeated batteries of potent antibiotics. Given that fluid buildup behind the eardrum can cause hearing problems that delay a child’s natural speech and language development, inserting the tubes is an easy sell for a pediatric otolaryngologist, who can correctly claim that the surgery will help children hit speech milestones.
But research demonstrates that ear fluid-related delays in the development of speech tend to resolve on their own. Otherwise healthy kids with speech delays caused by ear infections — not a small group — catch up without outside influence. Data from a pivotal 2001 study in The New England Journal of Medicine suggests that speech delays due to infection and fluid buildup were resolved in most children by age three without intervention. A 2007 follow-up demonstrated that those same kids, some 6,350, patients, experienced no residual language issues at ages nine and ten. In other words, ear tubes may be a nice-to-have, but they aren’t always a need-to-have. In a sense, they seem to be used to treat parental anxiety.
The NEMJ studies hasn’t made the procedure less common, but it has cast doubt over whether it should be, especially when it can cost thousands of dollars ($10,000 on the extreme side, closer to $2000 on average) with insurance coverage. That said, many pediatric ear doctors stand by the procedure, pointing out that it makes a meaningful difference regardless of whether it’s necessary or not.
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Parents see nearly immediate tympanostomy results in the form of pus and mucus.
But before we interrogate that claim, let’s answer the question on everyone’s mind: What the hell is an ear tube?
Tympanostomy tubes are small, hollow cylinders less than two millimeters in diameter — barely wider than the head of a pin — that serve as ventilation and drainage pipes, allowing pressure to equalize inside and outside the middle ear. This can make an outsized difference for children because their eustachian tubes, which connect the inner ear to the back of the nose so that ear pressure can be automatically regulated, are horizontal and only become vertical as they age. Gravity helps fluid move, which adults get fewer infections and why parents see nearly immediate tympanostomy results in the form of pus and mucus.
Contrary to some parents’ expectations, ear tubes won’t prevent every ear infection down the road, but they do make future infections easier to treat and manage by providing doctors a window to treat future ear infections more effectively with antibiotic ear drops. By allowing more effective and immediate treatments as well as reducing fluid buildup, tubes mitigate the conductive hearing loss that causes speech delays.
The tubes are tiny — you can’t see them without an instrument and you can’t jostle them by sticking a finger in the ear — both common misconceptions that parents tend to have, according to Dr. Allison Dobbie, a pediatric ENT at Children’s Hospital Colorado. Inserting them only takes minutes, but because doctors need to use a microscope to do so, they tend to prefer knocking the child out with general anesthesia, which presents some risks.
The American Academy of Pediatrics last updated its national ear tube guidelines in June 2014, and it’s not clear that formal recommendations were ever put in place before that, though the AAP published research into ear tube procedures in 2003. According to the AAP, a child should be considered eligible for ear tubes if they’ve had three recurring ear infections in six months or six infections in a year, says Dr. David Chi, Chief of the Pediatric Otolaryngology division at UPMC Children’s Hospital of Pittsburgh. And if fluid, whether or not it’s infected, doesn’t clear out from behind the eardrum after three months, the AAP recommends tubes to drain it.
“All of us follow guidelines that we’ve established as a society,” Chi says.
Dr. Kara Meister, a pediatric otolaryngologist who’s also a head and neck surgeon at Stanford Children’s Health shared a chart about risk factors and potential benefits that she shows parents to help them decide whether ear tubes are right for their children — all a way to help better inform parents and involve them in the decision-making process.
“I look at the whole picture before offering ear tubes. For example, if a child has an allergy to certain antibiotics or has a speech delay, I am more likely to offer ear tubes sooner for that child,” Meister wrote in an email. “However, if a 2 year old patient sees me in May and only has infections during the winter months, then I am more likely to recommend watchful waiting with hopes that the child will outgrow the need for ear tubes by the next winter.”
Dobbie and other doctors follow AAP guidelines when asked whether they recommend ear tubes. There is no financial component to those guidelines. And, as such, there are almost certainly many parents paying for procedures that, while helpful, are not medically critical. Doctors are sensitive to this, but operate within medical best practices.
“That helps make sure we’re not recommending them too often,” Dobbie says, “or not enough.”
But that question is not entirely otolaryngological (that’s a mouthful) in nature. There are broader developmental components as well as a financial component to the question — it’s not in a child’s best interest if it wrongfoots a family financially in service of minor benefits. There are risk and personality management elements as well. “Are ear tubes worth it?” turns out to be a complicated question.
We don’t have as many studies as we would like
“Kids definitely have an amazing ability to catch up and overcome something, but sometimes in the short term it helps,” says Dr. Charles Elmaraghy, Chief of Otolaryngology at Nationwide Children’s Hospital in Columbus, Ohio. Still, there’s a catch. “There’s no such thing as a minor surgery on a child,” he adds.
This is why some doctors sometimes opt to hold off on surgery and monitor kids instead — even when parents come in asking for tubes. It’s also why doctors push back a bit on the findings of the 2007 study and what those findings mean.
Not everyone catches up on their own.
“The landmark study that made people question ear tubes — it excluded children that had developmental issues,” says Elmaraghy, referring to that 2007 New England Journal of Medicine study.
A closer look at the research reveals that the doctors focused their efforts on kids who were developing normally outside of the effects of their ear fluid problems. Those kids were fine, but those findings can’t be applied to children with developmental issues.
“If you had otherwise healthy kids, if those kids weren’t delayed before, fluid won’t cause them to be delayed,” acknowledges Elmaraghy. “I don’t think their study was invalid, I just don’t think it applies to every kid. People tend to oversimplify things. Some kids have more complex reasons for speech delays.”
“We don’t have as many studies as we would like,” agrees Dobbie. “That is a discussion we have with the family. Sometimes kids can catch up and not have the language delays even if we don’t do the ear tubes, and for some families, that’s the right choice.”
That said, Elmaraghy believes that there is “absolutely” an overdiagnosis problem, where doctors may take a “better safe than sorry” approach to inserting ear tubes. And even a skeptical ENT could be given inaccurate information from a parent or pediatrician who may have confused a cold for an ear infection or made other errors along the way.
So if speech delays are a parent’s primary concern, inserting ear tubes may not be worth it. The problem — perhaps better phrased as the reason they’re so common — is that there are plenty of other reasons that doctors recommend inserting them.
Added to that is the fact that chronic ear infections or stubborn fluids that resist treatment can cause more serious medical problems on rare occasion. Dobbie says they can cause retracted, stretched-out ear drums and permanent hearing loss. Elmaraghy mentions meningitis — as does Chi, who also brings up potential facial paralysis.
In other words, there are serious concerns — though these outcomes are rare. The fact that draining out ear fluid prevents these rare conditions while also restoring a kid’s hearing tips the balance toward action — even for doctors who freely acknowledge that the procedure is not, in most cases, critical. Part of the math here has to do with complications. They are rare and ear tubes almost always fall out on their own. Which means that the medical case for avoiding the procedure mostly comes down to the fact that it requires (in most cases) anesthesia.
Animal studies and some preliminary human studies —multiple studies with significant sample sizes showed increased likelihood of negative deviation from average test scores, but do not suggest a clear mechanism — indicate that two to three hours of general anesthesia may be harmful for young children, potentially causing long-term cognitive impairments, says Chi.
“We have to balance that with some potential — maybe some are theoretical — risks and benefits, whether the benefits outweigh the risks both of surgery and of anesthesia,” Chi says. “Ear tube surgery is quick. It’s on the order of minutes. The duration of anesthesia is not long. We always are aware, whether it’s theoretical or true, that we want to minimize anesthesia from any child, but we want the child to benefit from the surgery when it’s indicated.”
Meanwhile, Dr. Meister says that doctors at Stanford never perform the procedure without anesthesia. Her staff also monitors children afterward to make sure that the ear tubes haven’t done the child any harm.
Elmaraghy points to an ongoing scientific effort by the International Anesthesia Research Society and the FDA called “SmartTots,” which has published research over the years that suggests brief exposure — again, the procedure takes five to 15 minutes — to general anesthesia doesn’t seem to cause any of the damage that so many parents seem to suspect it can.
“The concern does not seem to apply to ear tubes, at least at this time,” he explains.
That said, some kids may have medical conditions that necessitate skipping anesthesia, but by and large the ENTs contacted for this story prefered to use it whenever possible — citing both the difficulty of inserting a tiny tube into an infant’s eardrum as well as research that suggests skipping anesthesia can cause physical and psychological trauma for small children undergoing surgery.
“We’re not oblivious to the fact that any surgery, even if we consider it a minor surgery, is anxiety-provoking for parents,” says Elmaraghy.
“The main thing is we have to share that decision-making with the parent so they are fully aware what is involved in the decision of moving forward with surgery or not,” says Chi.
This is why these doctors go out of the way to walk parents through what the procedure means and to set realistic expectations, certainly an important part of the process that many doctors tend to gloss over. If parents are determined to put an end to chronic ear infections, ear tubes can help, but they won’t prevent future illnesses and they will require some anesthesia and incur a real cost. Will they work? Probably. Are they the perfect panacea? Absolutely not. They can make a difference.
“The parents who regret doing it are the ones who had an unrealistic expectation,” says Elmaraghy. “There’s no magic to make someone’s brain kick in and have a child start speaking immediately.”