Explore This IssueJune 2007
I would like to comment on your article Watchful Waiting May Be the Best Strategy, by Sheri Polley, in the November 2006 issue of ENToday. The author mentioned several ways of treating otitis media with effusion (OME) and the long-term, potentially bad, sequelae possible if one uses PETs and follows the cookbook method of going by the number of infections or lack of response to AB before using PETs. I agree that a cookbook method of treating suppurative otitis media (SOM) and OME is not good, because it leaves the treatment up to the subjective judgment of the individual physician, other health care providers, and the physician’s clinical judgment based on prior experience.
I do feel that there are many ENTs in our country who are too quick to use the PETs instead of trying other means. Many ENTs simply schedule the kids for tubes (without testing) if the pediatrician or family physician refers them for SOM, not responding to AB and decongestants. I am very conservative in my treatment, but feel that PETs are an integral part of the proper treatment of OME. My problem is that I feel that many ENTs and pediatricians are not doing enough evaluations preoperatively, such as doing OAE and tympanographic evaluation on those patients who have had failures in treatment with local and drug means.
I decline to do urgent surgery on about 20% of patients who are referred to me, because the workup does not show significant loss of hearing or significant effusion. I do treat and follow them for several weeks to months; then, if the tests show a resistant OME, we consider PET. Many of these kids are simply teething and get referred pain to the ears, and some of them irritate their ears by either them or their parents using cotton swabs in the ears.
I also feel that the patients who reach the point of having PETs placed in the ears deserve to have proper follow-up. There are too many ENTs who just place the tubes in the TMs, tell the patient that they will fall out in six months, then discharge the patient to be followed by the pediatrician, many of whom don’t have the proper equipment to do the proper testing on follow-up. I’ve placed thousands of tubes in kids’ ears in my 25 years of practice in ENT and always follow them for about two years postop. I want to make sure the fluid doesn’t recur and the hearing is essentially normal before the children start their school years.
For the past 20 years I have used the T-tube (originally designed by Richard Goode, MD). I redesigned the tube for Richard in the late 1980s to make it smaller, as the original tube had a problem with causing perforations if left in too long. These tubes-and I have used almost every type of tube on the market-seem not to extrude as easily, and, being smaller, don’t cause as many permanent perforations. The case against the T-tubes causing too many perforations is overplayed-they just need to be followed up more closely.
I have seen some of these small tubes, to which you refer-probably the Reuter bobbin titanium, Teflon, or silicone types-come out within one week, one month, six months, and, in one case, the tube stayed in for 5 years, causing scar tissue to form, injuring the hearing partially. The problem with the small tube is that you can’t predict when they will come out, or if they will come out. This leaves the patient with either incomplete treatment because the congestion in the MEC has not subsided when the tube extrudes, or the problem of having the tubes in too long, causing scar tissue or perforations. I see our patients routinely two weeks postop and 6 to 12 months later, as well as any time they have any problem, and are referred back by their pediatrician, such as for an infection from getting water in the ears. We fit all our patients with either Mack’s plugs or commercial grade swimmer’s plugs to protect their ears. When we feel the disease process is cleared or significantly improved, we remove the tubes and use an alloplastic graft over the TM perforation (which might be as large as 5 to 7 mm) to help guide the squamous epithelium to give a normal closure, instead of growing down into the middle ear, causing a cholesteatoma. We then see them three weeks later, and then 6 to 12 months later, even if they don’t have any problems.
I don’t think that we should give up on PETs, as they have been very beneficial, when used appropriately, and after proper evaluation of the clinical indications for treatment. I don’t think watchful waiting, by itself, is the whole answer, since just looking at a TM, after it has been infected, would frequently show a cloudy, dull-looking TM, which the examiner might think normal if it didn’t show erythrema, although the MEC might even had significant fluid in it-this leaves too much to subjective determination. I feel we have adequate modern testing that can be used-and should be used-to follow these kids who have recurrent OME to give us a better guideline on what therapy is indicated, not just watchful waiting.
Certainly, being an ENT physician, you might think I am prejudiced to the use of tubes, but I feel they have their place in the treatment of OME and should not be used only as a means of last resort, but after proper testing and review of the past history of denasal breathing or allergies, including sleep apnea, secondary to obstructive adenoid (properly evaluated by X-ray, and nasopharynlaryngoscopic exams), they have a proper place in OME treatment.
In summary, we have two ends of the spectrum: the pediatrician who is now being told that watchful waiting is the best method, and the ENT who might put tubes in all kids who are referred to their clinic for OME. There is some middle ground, and proper evaluation with our new methods of testing should give us the answer to the best method of treating the child.
David M. Doan, MD, FACS
©2007 The Triological Society