Tympanostomy tubes improve short-term hearing but lack long-term benefit

Tympanostomy tubes are widely used in pediatric care, taking first place as the most popular ambulatory surgery. However, new research reveals that tube placement provides just short-term hearing improvement and has little impact on quality of life.

Dale W. Steele, MD, associate professor of Emergency Medicine, Pediatrics, and Health Services, Policy and Practice at Brown University, Providence, Rhode Island, and co-author of the report, says there have been very few randomized trials involving tympanostomy tubes for children with recurrent acute otitis, and there is a particular need for further research-particularly for higher risk patient groups. Little is known about the adverse effects of tympanostomy tubes or benefits for different indications.

Overall, Steele says the study revealed that tympanostomy tubes provided better short-term results for hearing improvement, but watchful waiting didn’t have a negative impact on outcomes, either.

“A period of watchful waiting does not seem to affect speech and language development, behavior, or quality of life in otherwise healthy children,” Steele says. “Children with recurrent acute ear infections may have fewer episodes after surgery, but more research is needed. Overall, the benefits of tympanostomy tube placement must be weighed against a variety of adverse events.”

Tympanostomy tube placement currently is the most common ambulatory surgery in the country, with nearly 700,000 children aged younger than 15 years having the procedure done annually. Through this study, Steele and the research team sought to determine how effective the intervention is in treating chronic otitis media with effusion (OME) and recurrent acute otitis media (AOM).

Researchers analyzed previous studies and found that children with chronic OME who were treated with tympanostomy tubes experienced improved hearing at 1 and 3 months postoperatively compared with children treated with watchful waiting. However, by 12 to 24 months postoperatively, there was little difference between the 2 groups.

Whereas children treated with tympanostomy tubes tended to have fewer episodes after placement, adverse events with tube placement are poorly defined and reported, according to the researchers.

The efficacy of tube placement is believed to be influenced by a host of factors, including age, frequency of respiratory track infections, and social factors such as daycare exposure. The American Academy of

Otolaryngology–Head and Neck Surgery currently recommends tympanostomy tube placement for children with bilateral OME if they are aged 3 months and older and have hearing difficulty, the study notes. Tube placement also may be indicated in children with unilateral or bilateral OME if there are other symptoms present, such as ear discomfort, vestibular problems, and reduced quality of life or school performance. Likewise, the American Academy of Pediatrics supports tympanostomy tubes for children who have experienced recurrent AOM, with 3 episodes over 6 months or 4 episodes in a year.

In children with OME, researchers found that mean hearing thresholds increased by 9.1 decibels after tympanostomy placement, and that tympanostomy tubes, tympanostomy tubes with adenoidectomy, and myringotomy with adenoidectomy were the most effective interventions when it came to hearing improvements. There was no difference, however, in hearing thresholds between children treated with tympanostomy versus watchful waiting after 1 to 2 years.                             

For long-term hearing improvements, the research team found that tympanostomy tube insertion with adenoidectomy and myringotomy with adenoidectomy were the 2 most effective interventions, while tympanostomy tubes alone, antibiotic prophylaxis, and watchful waiting were the least effective strategies.

For AOM, researchers compared tympanostomy placement to a placebo group and found that 3 of 20 children in the placebo group had no further episodes of AOM, while 12 in 22 who received tympanostomy tubes were without additional episodes after the intervention. Another study analyzed by the research team found that 40% of children in a placebo group had no further episodes of AOM compared with 35% in the tympanostomy tube group. Researchers noted, however, that children in that study who were treated with tympanostomy tubes had a shorter duration of AOM episodes than the placebo group.

Although evidence does support short-term positive results, researchers note that the lack of long-term hearing benefits between watchful waiting and tube placement supports the hypothesis of the preferred natural, spontaneous resolution of middle-ear effusion that most children experience.

Despite some limited evidence of improved quality of life after tube placement, neither of the 2 studies that actually evaluated parental stress or health-related quality of life found a significant difference between tympanostomy tube placement and watchful waiting, according to the researchers. In addition, they did not find evidence to support improvement in cognition or behavior.

Adverse events were difficult to track as they were not often reported, and many cohorts did not follow up post–tympanostomy tube placement until the extrusion of the tube, the report said.

Researchers note that they were not able to predict which children would be most likely to benefit from tympanostomy tube insertion for chronic middle-ear effusion, although there was evidence that tubes might be particularly effective in young children attending daycare or in older children with persistent hearing impairments lasting more than 3 months.

Steele says his report does not offer recommendations on when or if tubes should be placed, but says the findings of his research team are in line with recommendations already established by the American Academy of Otolaryngology–Head and Neck Surgery. He says he hopes the report will encourage shared decision making between parents and pediatricians.