Our 9 month son has experienced 3 ear infections in a 6 month timeframe. He was in a daycare during this time. Amoxicillin was prescribed and was effective in clearing the infections. As a preventive measure he was put on 1 Tspn/day of Amox. He has been on this for 8 weeks now and has not had an infection. We took him to an ENT specialist because we are concerned about all the antibiotics he is being exposed to and the ENT suggested tubes and removal of his adenoid. Our concern for the antibiotics are resistance builup, possible link to ADD in teen years, and that fluid build up will still occur cuasing possible hearing loss. We received a second opinion today and from a doctor strongly stating NO to the adenoidectomy and that it would be premature for the tubes to be inserted. This doctor recommended continued antibiotic use. I am the father and as a youg boy had many ear problems. I had tubes several time and had my tonsils and adenoid removed around the age of 5. We are now very confused about the decision for the tubes and the adenoidectomy since the two doctors we have seen have varied opinions. Please help us understand the true concerns of extensive antibiotice use and risk assesment of this use compared to surgical procedures.
Sincerely,
Concerned and Confused
Reply: ------------------------
Let me start by saying that I would agree strongly with the second
otolaryngologist that both adenoidectomy and myringotomy with tube
insertion would be very premature for your child based upon the
information you have provided. I would, however, acknowledge that this
issue of when tubes are indicated for childhood ear infections can be
very confusing. To add to the problem, one not uncommonly will read
accounts in the press concerning the dangers or risks of ear tube
placement in children which are typically greatly exaggerated or
overstated.
You can for the most part divide ear problems in children into 2 basic categories for all practical purposes. The first type is the child who has recurring acute ear infection which would typically be associated with obvious illness including fever and discomfort. The infection is then treated with antibiotics and a follow-up exam reveals that the infection is completely cleared but another ear infection develops within a short time span and the process is repeated. This type of problem is often referred to as "recurrent acute otitis media".
The second general type of ear problem in children is often commonly referred to as "fluid" behind the ear drum. This condition is usually not associated with the same degree of ear pain and the child usually does not have a fever. Non-infected fluid behind the ear drum is a common sequela of acute otitis media but usually clears by itself within several weeks after the infection has cleared. When middle ear fluid fails to clear it is known as "chronic otitis media with effusion".
The most controversial area is the former type of problem, "recurrent acute otitis media". The exact definition is somewhat arbitrary, but most physicians consider roughly 4-6 infections during a 6-8 mo. period recurrent otitis. Anecdotally, most otolaryngologists feel ear tube placement significantly helps young children with this problem. Unfortunately, there is not conclusive scientific evidence available as of yet to confirm this observation. Many otolaryngologists will recommend antibiotic prophylaxis be tried first before tubes are placed, reserving surgery for those children who develop infections while on antibiotic prophylaxis. The 2 antibiotics used in a preventative or maintenance fashion are amoxicillin or gantrisin usually in a single daily dose for 6-8 weeks typically. There is now considerable debate concerning prophylaxis because of concern regarding the emergence of antibiotic resistant organisms in society in general. Presently, I continue to recommend antibiotic prophylaxis in otitis prone infants, reserving ear tube placement for children who experience acute infection while on maintenance antibiotics. Adenoidectomy has been shown in numerous studies to be beneficial in the management of recurrent ear infections in children over 4 years of age. It is not advisable in an infant unless there is obstruction to the nasal breathing passage.
The management of the child with chronic otitis media with effusion is more straightforward. A multi-disciplinary investigative group of otolaryngologists, pediatricians, and family physicians have developed a set of guidelines for the management of this condition which has been widely, but not universally, accepted. In a nutshell, if a child has persistent fluid behind the ear drums, has had a single course of antibiotics within the previous 6-8 weeks, and is relatively without symptoms (ie no severe pain and no fever), observation alone is recommended for a period of approximately 3 months. If the fluid persists beyond a 3 month period and the fluid is present in both ears, then ear tube placement can be reasonably considered balancing the potential risks versus the potential benefits.
As a final note, much has been written in the press regarding the risk of scarring of the ear drum following ear tube placement. One should be aware that such scarring, known as tympanosclerosis or myringosclerosis, is not uncommonly seen in individuals who have never had ear surgery nor ear trauma. Certainly myringosclerosis is likely to be more common in individuals who have had tubes than in those who have not had ear surgery. However, it virtually is never associated with significant hearing dysfunction nor any other significant pathophysiology. It is not in my opinion a highly important concern or consideration in determining whether or not to proceed with ear tube placement in a child.
--
Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
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