Pediatric Ear Infections: Watchful Waiting May Be the Best Strategy

Kenneth Grundfast, MD, Professor and Chairman of the Department of Otolaryngology–Head and Neck Surgery at Boston University School of Medicine, whole-heartedly agrees with this approach to antibiotic usage for AOM. He thinks that too many children may have received too much antibiotic for ear infections for too long. He even cites recent studies that call into question the long-held notion that persistent fluid in the ears of young children causes delays in speech development or impairs cognitive ability in children. He states, “Watchful waiting is a major step back toward a rational process—doing what’s best for the patient.”

It is important to note that advocates of the wait-and-see approach for prescribing antibiotics emphasize that the child should be treated symptomatically for the pain associated with AOM, typically with ibuprofen and otic analgesic drops.

Ventilating Tubes

Steven Berman, MD

The insertion of ventilation tubes for treatment of chronic and recurrent OME is surrounded by controversy regarding effectiveness and long-term sequelae. For decades, placement of ventilation tubes has been recommended by physicians and accepted by parents as necessary to avoid having children suffer lasting developmental abnormalities as a result of lingering fluid in the middle ear. Several studies, including the Pediatrics study by Roberts et al., mentioned earlier, have shown evidence that any developmental lags experienced by children who suffer from chronic or recurrent OME is temporary, and they soon catch up to their peers.

The American Academy of Family Physicians; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media with Effusion Clinical Practice Guidelines, published in Pediatrics in 2004, advocate a more conservative approach to insertion of ventilation tubes (Pediatrics 2004;113:1412–1429). These guidelines recommend watchful waiting without surgical procedures, with 3- to 6- month reassessments of symptoms, hearing, and the development of tympanic membrane pathologic abnormalities for normal, asymptomatic children with hearing thresholds of less than 40 dB.

Additionally, in a study published in Archives of Pediatric and Adolescent Medicine in December 2005, Robert Stenstrom, MD, et al. concluded that placement of ventilation tubes may actually cause harm to children in the long-term. The study, entitled, “Hearing Thresholds and Tympanic Membrane Sequelae in Children Managed Medically or Surgically for Otitis Media With Effusion” (Arch Pediatr Adolesc Med 2005;159:1151–1156), showed that insertion of ventilation tubes was associated with a 4.5-fold increase in risk of myringosclerosis and a 9.9-fold risk of tympanic membrane abnormalities at 6- to 10-year follow-up. Hearing thresholds were significantly poorer (5–11 dB HL) in patients exposed to ventilation tubes when compared with those who were not.