What is the latest on what is best for recurrent acute ear infections (otitis media): frequent antibiotics or ear tubes?

This has been a controversial topic in pediatrics for many decades. In my forty year experience one of the most common determining factors in whether or not a child gets tympanostomy tubes (ear tubes) is whether or not they’ve been seen by an ENT physician (ear, nose, and throat surgeon). In fairness to my ENT colleagues, of whom I have many excellent ones, I find this not surprising. Any specialist physician is naturally inclined to do what they are trained to do. I suppose it’s also a version of the ancient saying I learned during my surgery rotations: “A chance to cut is a chance to cure.” So generally if your child’s physician refers you to an ENT specialist for recurrent acute ear infections, the recommendation will be for ear tubes. On the other hand, if the referral goes to a pediatric infectious disease specialist, the recommendation may well be for recurrent antibiotics as needed. So what’s the latest on which of these approaches is best? Before we get to that, I should provide some quick background on the cause of acute middle ear infections. If you want a deep dive into that question, you can find more information here.

Ear infections are extremely common in children, particularly toddlers. Estimates are that a quarter of children will have at least one by their first birthday and half will by the age of three. The cause is pretty well known. You can think of an ear infection as a complication of a viral cold, and toddlers get a lot of colds. Inflammation in the back of the nasopharynx blocks drainage from the Eustachian tube that connects the middle ear to the back of the nose. Bacteria normally living in the nose take advantage of this disruption to crawl into the middle ear and multiply, leading to infection. Toddlers are more susceptible because in them this tube is short and straight; as children age it lengthens and develops a kink, making it more inaccessible to bacterial invasion. This process is illustrated in the image below.

Antibiotics are used to kill the bacteria, which generally, but not always, works. But recurrences are common, often leading to multiple rounds of antibiotic treatment. The idea of tympanostomy tubes is to put a plastic ventilation device across the eardrum so that the middle ear has another way to get ventilated if the Eustachian tube gets blocked. After a year or two the tubes usually fall out, but by then the child is often at lower risk owing to age. There are pros and cons to both approaches: antibiotics are cheaper, but recurrent bouts of otitis can add up, and frequent courses of antibiotics carry problems; ear tubes are more expensive up front and they carry the risk of any surgical procedure. So which way is best? We have some useful new information to help parents choose.

The group at the University of Pittsburgh have been doing research on otitis media for a long time — Dr. Jack Paradise has been leading this effort for decades. That group recently published a randomized study in the prestigious New England Journal of Medicine: “Tympanostomy tubes or medical management for recurrent acute otitis media.” Although the study was randomized, meaning assignment of the children to the antibiotic group or the ear tube group was random, of course it couldn’t be blinded, since it’s obvious which group the child is in. Still, it is an excellently designed study. The article is accompanied by a useful editorial on what it all means. If you don’t read the article, I at least recommend the short editorial, even though the editorialist’s final conclusion reads a bit mealy-mouthed to me. So what did they find? The answer is both satisfying and not satisfying, depending upon your perspective, I suppose.

Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management.

To me, that’s kind of an odd way to put it, although I suppose the question they were getting at is if ear tubes are better, which their study shows they aren’t; the two approaches gave equivalent outcomes. Although the two approaches gave the same benefits, there are some differences between them in risks, and that’s where parental choice plays an important role. Recurrent courses of antibiotics carry with them risks of developing allergic reactions to them. There is also the issue of the relatively unclear risks of causing derangements in the normal bacteria living in our gut, since oral antibiotics indiscriminately slaughter masses of “friendly” bacteria. Certainly diarrhea is a common side effect. We are also always concerned about how excessive antibiotic use can lead to development of resistant strains of bacteria. On the other hand, any surgical procedure, even a relatively minor one like ear tubes, carries a slight anesthetic risk. I have also seen complications of ear tubes, such as persistent holes in the eardrum that won’t heal. Tubes can also fall out too soon and need replacement, meaning another surgical procedure.

An important point to understand is that this study is about recurrent bouts of ACUTE ear infections, not CHRONIC, persistent ear problems. Using ear tubes in chronic ear problems is an entirely different issue. If you’re interested in that debate, or if your child has that problem, you can read more about it here. But with recurrent acute ear infections, the editorialist correctly points out:

Thus, management decisions can be made jointly with a high degree of parental satisfaction.


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