When a baby, toddler or even an older child comes in for an opinion about whether ear tubes are necessary, here is what I ask and why I ask these questions:
How many ear infections has your child been diagnosed with in the past 6 months? How many in the past 12 months?
For straight forward acute ear infections diagnosed by otoscopy (examining the ear with an otoscope), benefits of tubes should be considered if a child has had at least 3 episodes in 6 months or 4 episodes in 12 months. One can only count them as separate if there is documentation that ears were normal and clear in between episodes.
There are many indications for tubes, which include recurrent acute ear infections, chronic ear infections and complications from acute ear infections. Other indications may include hearing loss, which is entirely separate from infection problems.
Tubes are also indicated if there are severe complications from an acute ear infection, such as “mastoiditis” (a bacterial infection) and even an extension of an infection into the head, like subdural abscess or epidural abscess.
How many courses of antibiotics has your child been prescribed and taken in the past 6 months and 12 months?
If a child has only had “3” ear infections, but has been prescribed and taken over eight courses of antibiotics in the past year (especially documented by a print out from their pharmacy, not just by mom’s memory or recall), then I explain and discuss the benefits of ear tubes.
What led you to take your child to seek medical attention?
Many moms can tell when their infant/toddler behaves differently or when sleep is disturbed. Often moms tell me they know it’s an ear infection if their child pulls on their ears. I ALWAYS inform families that research shows that ear pulling is not sensitive, instead, fever and performing an actual otoscopy is the most sensitive way to diagnose an ear infection.
Where were diagnoses made?
With all due respect to the many walk-in and urgent care clinics in our communities, if most diagnoses are made by individuals that the family never sees again, nor has a relationship with, this scenario is less than optimal than most diagnoses being made by the child’s primary care provider with whom parents have a relationship. Let’s face it, accountability is really not a mandate, nor even relevant, if the person seeing you and your child may never see you again. Yet, it is precisely accountability that must be a key part of medical and surgical treatment decision making.
What did the person say when they looked into your child’s ear?
Often, parents will tell me that the person said the eardrum looks “red” and there was no mention of whether or not fluid was present. I ask families to always respectfully push for specific information about the presence of fluid, since research also shows that the subjective description of “redness” of the eardrum is not an accurate way of diagnosing true acute Otitis Media (Swimmer's Ear). Furthermore, please know that the skin on the ear canal is often pinkish/red, and in fact, is part of the normal anatomy of the eardrum where the feeding blood vessels also appear red. I truly urge you never to believe that your child has an ear infection simply because someone tells you his/her eardrum is “red.”
Does the healthcare provider always prescribe antibiotics?
Once again, it amazes me the differences in how primary care providers practice, but it’s easy to understand that physicians and providers usually practice how they were trained, and it takes a motivated and disciplined individual to read and keep up on the latest research and recommendations, and evolve their practice and treatments in line with the explosive growth of new scientific information all the time. Again, even if the provider has the best intentions and may wholeheartedly believe he/she is doing the best thing for your child, he/she can be wrong if the way they practice medicine does not reflect what’s been recommended as clinical standards based on current research evidence. I never suggest that we providers should act as robots and every human healthcare decision should be as simple or as black and white as some statements or guidelines. However, before we go making exceptions, we have the responsibility of making sure that those exceptions are truly exceptions. You and your child deserve so much more than just someone’s opinion. My opinion must be based on research and evidence, otherwise it’s not good enough for my patients and not good enough for me.
How is his/her hearing and speech?
If a child has poor hearing, speech may be affected. There are so many factors to consider, including the severity of hearing loss and the length of time a child has hearing loss. It’s important to note that if a child has normal hearing, he/she can still be speech delayed.
Just because a child has had 3 infections in the past 6 months, if on the day of the visit the ears look great, hearing is perfect, speech is normal, and especially if it’s spring and warmer months are approaching, I will often ask parents to wait. I will not just recommend ear tubes because I do not run my practice like a “business.” Yes, we all work and ultimately, healthcare is a business, however, each and every patient encounter and decisions made in the office with parents should never be a business transaction. I sleep soundly at night because I never suggest surgery until I truly believe the benefits highly outweigh the risk and we have exhausted all nonsurgical options.
Conversely, if a child has been noted to have fluid in the middle ear, has an abnormal hearing test, and has been diagnosed with or clearly has a speech delay, even if he/she has never had symptoms of acute ear infection, I certainly discuss the benefits and risks of having ear tubes. If your child was born with normal hearing, there is no good reason to live for months with decreased hearing, which can impact speech development. This part is not as simple as looking at “flat” lines on tympanograms, because once again, an ENT should consider the entire picture and I have always prided myself in never making surgical decisions based on a “test” alone.
Any child who has clinical speech delay should have a full hearing test when they come into an ENT’s office, and the physician should fully explain the results of the test. If hearing is considered normal on the test, then I send them for a formal speech evaluation. Thank goodness moms are often stricter on the definition of a speech delay than our speech language pathologists! Meaning that often a child will be considered to have speech within a normal range despite mom’s perception.
Otoscopy is an examination that uses a handheld scope to look into a child’s ear canal to see what is going on in the middle of the ear in order to determine if there is fluid or not, what kind of fluid (infected or not), if there are structural issues with the eardrum, etc. It is the most CRITICAL and important part of your visit to the doctor for ear infections. Research has shown that nothing is more effective nor impacts treatment decisions more than the human eye. While tests like tympanometry can suggest whether there is fluid behind the eardrum, it is not accurate enough to tell us whether your child has an acute or chronic ear infection, since both have “fluid” in the middle ear space.
For infants and young toddlers who may not cooperate in a sound booth by raising their hand in response to sound or repeating words like, “car” or “train,” my practice has used tests that can give me information without their participation. ENT doctors will have audiologists working with them in their offices who are the professionals that perform a variety of hearing tests to help provide information for a complete evaluation of your child. I won’t go into the details of the variety of hearing tests, but know that there are different types depending on the age of the child and what we’re looking for.
Often, I meet preschool or school-aged children who may have “never” had an ear infection, but “fails” a school hearing screen and comes to see me. He/she may have had the fluid for a few weeks or even several months. Clues I ask parents for include whether at home he/she speaks very loudly, has the sound on the TV way up, and always says “huh,” “what” or needs instructions to be repeated. Sometimes these children are bothered by loud noises, which can reflect having middle ear fluid and mild conductive hearing loss. Again, otoscopy by a healthcare professional as well as a hearing test can most accurately help decide on the presence and extent of the problem.