Guide: Not all kids need ear tubes to relieve fluid

• In an otherwise healthy child%2C inserting the tubes for drainage may not be necessary
• For kids whose hearing is affected%2C the tubes may be advised%2C guideline says
• By age 3%2C nearly 1 in 15 children have received such tubes

Not every kid should get ear tubes to relieve excessive fluid buildup in the middle-ear canal, says a first-ever clinical guideline for physicians released today.

An extensive body of research shows that in cases where an otherwise healthy child gets middle-ear fluid, insertion of the tiny tubes (which help ventilate the middle ear and provide drainage) is not always necessary. Kids typically get better on their own, especially when the fluid is present for less than three months, says the recommendation from the American Academy of Otolaryngology — Head and Neck Surgery.

"The other circumstance where it's good to watch and wait, and this is a particularly novel aspect of this guideline, is if you have frequent or recurrent ear infections (known as acute otitis media, or AOM) without persistent fluid buildup," says Richard Rosenfeld, chair of the guideline panel and a pediatric ear, nose and throat specialist: "A lot of those kids are getting ear tubes, and it turns out it really doesn't help them."

Children who develop hearing difficulties and have fluid buildup (known as otitis media with effusion, or OME) in both ears for at least three months should be offered tube insertion because the fluid usually persists. Inserting tubes will improve hearing and quality of life, the recommendation says. It is based on an analysis of 113 randomized trials and 15 systematic reviews of ear tubes.

In addition to mild-to-moderate hearing difficulty, middle-ear fluid can result in pain and discomfort, ear infections and balance problems, says Rosenfeld,

professor and chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn.

Young children are particularly at risk for fluid buildup and ear infections because their immature eustachian tube does not work efficiently to provide the needed ventilation, creating "a vacuum, sucking in fluid, infection and goo" from the nose and throat "and keeping it there," he says.

Ear tubes "bypass the eustachian tube," allowing air to get into the middle ear and preventing fluid and bacteria from entering, he says.

Nearly 670,000 ear tube surgeries (known as a myringotomy) are performed annually on children under age 15, making it the most common outpatient surgery performed on kids in the USA, according to the National Center for Health Statistics. By age 3, nearly one in 15 kids have received the tubes, officially known as tympanostomy tubes.

The tiny, hollow, plastic devices (about 1/20 of an inch wide) are inserted via a small incision in the eardrum, usually in an outpatient surgical procedure under general anesthesia.

Despite being widely used, this is the first evidence-based guideline designed to "identify children who shouldn't get the tubes and those who should," as well as advise on "the best way to take care of the tubes if you do get them," Rosenfeld says.

It's a misperception, for example, that kids with ear tubes shouldn't go swimming because their tubes need to be kept dry.

The recommendation that "watchful waiting" is a better option for otherwise healthy children with a buildup of middle-ear fluid does not apply to kids who are at-risk for pre-existing developmental delays, such as permanent hearing loss, autism-spectrum disorder, Down syndrome and cleft palate.

Because these kids don't tolerate fluid in the middle ear well, they may be offered tubes when fluid buildup is present in one or both ears and is unlikely to resolve quickly, Rosenfeld says, adding that observational studies show the tubes provide significant benefits in these cases.

Although the guideline "brings together in one report much information that will be useful to the practicing clinician," it suffers from important limitations and is still too lax in sanctioning tube use, says Jack Paradise, professor emeritus of pediatrics at the University of Pittsburgh School of Medicine.

He notes that the guideline covers children ages 6 months to 12 years but says middle-ear disease is very different in young children and older children. It also doesn't take into account some newer information arguing against tubes for some children with recurring problems, according to Paradise, a strong advocate against the overuse of tubes in otherwise healthy kids, age 3 and under.

It is correct that older children typically do not get tubes, Rosenfeld says, but the guideline "used this range because it is the same age range used in most randomized, controlled trials of tympanostomy tubes."

And, he says, "if anything our guideline will likely decrease the number of tubes (placed) since we advise not doing tubes in two common circumstances."