Ear tubes may be unnecessary in some cases, study finds

Guidelines for ear infections in young children may lead to unnecessary tympanostomy tube placement, according to a study published in Pediatrics.

The study found that recurrent cases of acute otitis media occur in a narrow “window of susceptibility” and that many tube placements likely occur after this window has passed. In such cases, “the cessation of [acute otitis media] is attributed to the surgery when, in fact, our data [suggest] the [window of susceptibility] may have ended and the child would have experienced an end to [the infections] with patience and watchful waiting,” the authors wrote.

“Our goal is to improve the diagnosis, prevention and treatment of ear infections in children,” Michael E. Pichichero, MD, a pediatric infectious disease specialist and director of the Rochester General Hospital Research Institute, told Healio. “Within that paradigm, we have the issue of when [a child needs] to have ear tubes placed because of recurrent ear infections.”

National guidelines endorsed by the AAP and American Academy of Otolaryngology suggest that a child becomes a candidate for tubes following three ear infections in 6 months, or four ear infections in 12 months.
ased on that, about a half million kids get tubes every year in the U.S., and it costs over a billion dollars every year,” Pichichero said. “So, we asked the question: What if we get to that threshold, and the child does not get their tubes?”

Pichichero and colleagues conducted a prospective cohort study in which they enrolled 286 children aged 6 months and followed them until age 5 years, examining the frequency of ear infections and confirming diagnoses via tympanocentesis.

More than 80% of ear infections due to acute otitis media occurred when children were aged between 6 and 21 months.

“What we found is that for over 90% of the children, they don't get any more ear infections [after the initial windows], even though they didn't get the tubes,” Pichichero said. “So, their window of susceptibility to ear infections is a lot [narrower] than was realized. [About] 75% of the children who get ear infections get all of their ear infections in about 5 months, and more than 90% of the kids who get multiple ear infections get all the ear infections they're going to get within 10 months.”

In an accompanying commentary, pediatric infectious disease physicians Rana E. El Feghaly, MD, MSCI, and Mary Anne Jackson, MD, from Children’s Mercy Kansas City and the University of Missouri-Kansas City School of Medicine, said the study could help clinicians determine children who may need earlier referral for tube placement. But they also noted some remaining questions.

“Would the data be replicated in a patient population that is not predominantly white, insured, and with very low smoking exposure, a controllable risk factor for [acute otitis media]?” they asked. “With the decrease in vaccination rates that we are currently witnessing, will the epidemiology of [acute otitis media] shift yet again?

They reminded readers that pneumococcal and influenza vaccines decrease the risk for acute otitis media.

“While working to ensure timely adherence with all vaccinations, catchup vaccinations for those children who have fallen behind during the pandemic are essential,” they wrote. “Clinicians should support families to modify risk factors like tobacco exposure, follow strict criteria to diagnose [acute otitis media], discuss the risks of antibiotics when indicated, and offer watchful waiting when appropriate.”

“Ear tube surgery has needs to be reassessed,” Pichichero said. “It's being recommended far too excessively based on current guidelines.”

References:

Bajorski P, et al. Pediatrics. 2023;doi:10.1542/peds.2022-058556.

El Feghaly RE, et al. Pediatrics. 2023;doi:10.1542/peds.2022-060110.