Study: Ear Tubes Not Always Needed

Hundreds of thousands of toddlers and preschoolers in the U.S. get ear tubes each year, but a landmark study shows that a large number may not need them for the purpose of avoiding future developmental problems.

Researchers followed otherwise healthy children treated as toddlers for persistent middle-ear fluid buildup until they reached ages 9 to 11 to determine if treatment choices affected their overall development.

Fluid buildup by itself is usually not painful, but it does affect hearing in the short term.

The thinking has been that these early hearing problems could lead to long-term language and developmental impairment.

Some of the children in the study got tubes soon after they were diagnosed, while others had tubes put in after a six-to-nine month observation period. Some of the children never got tubes at all.

Early treatment with tubes was not shown to improve developmental outcomes, as measured by a battery of tests conducted throughout the children's lives, up to ages 9 to 11. The tests included checks of reading, spelling, writing, behavioral issues, social skills, and intelligence.

The findings are published in the Jan. 18 issue of The New England Journal of Medicine.

"We saw no differences at age 3, 4, 6, and now 9 to 11," researcher Jack L. Paradise, M.D., tells WebMD. "It is not likely that differences between the two groups would emerge later in life, so this is pretty definitive."

The report does not address the usefulness of tubes for the treatment of kids with repeated, painful ear infections. But it does show that tubes may not be an appropriate option for children who simply have persistent middle-ear fluid. Fluid can build up following an ear infection, but it can occur without a history of ear infection as well.

Paradise and colleagues enrolled 6,350 healthy infants in their study between 1991 and 1995. Just over 400 of the children were diagnosed with persistent middle-ear fluid before age 3. About half got tubes immediately and the other half did not.

Of the 196 children in the delayed-treatment group (up to 9 months later) followed until at least age 9, 88 got tubes after close observation and 108 never got them.

"When treatment was delayed, many of these children ended up not getting tubes," Paradise says. "Of those who did get tubes, a fair number got them because they were also experiencing repeated ear infections."

Earlier findings from the study were so convincing that they prompted a change in guidelines regarding the treatment of kids with persistent middle-ear fluid. Doctors are now urged to take a watch-and-wait approach to treatment, which includes frequent hearing assessments. If a hearing loss of 40 decibels or higher is documented or language delays are seen, tubes are recommended.

Pediatric medicine expert Stephen Berman, M.D., says the study by Paradise and colleagues should serve to reassure parents of children with persistent middle-ear fluid buildup.

"Parents often want tubes because they are worried about developmental delays," he says.
Berman, who is a pediatrician at Children's Hospital in Denver, tells WebMD that as many as 70 percent to 80 percent of children who get tubes in the U.S. have persistent fluid buildup without repeated infections.

"About 400,000 tubes are put in a year [in the U.S.] at a cost of between $3,500 and $5,000 each," he says. "I would think that maybe half of these surgeries could be avoided. That money could be redirected to interventions that would actually impact child development."

Such programs would include those designed to promote language and learning skills among low-income children, he says.

"We know that poverty is independently associated with an increased risk for language and learning delays and these kinds of ear problems," he says. "The interpretation has been that the [ear problems] were causing the learning delays. But we now know that this is not true."

SOURCES: Paradise, J.L. The New England Journal of Medicine, Jan. 18, 2007; Vol. 356: pp. 248-261. Jack L. Paradise, M.D., professor emeritus, University of Pittsburgh. Stephen Berman, M.D., pediatrician, Children's Hospital, Denver; professor of pediatrics, University of Colorado School of Medicine.

By Salynn Boyles
Reviewed by Louise Chang, M.D