Ear Infections and Ear Tubes
Anatomy of the Ear
The ear is divided into three parts: the external ear, middle ear and inner ear. Each part participates in the mechanism of hearing. The middle ear contains the three middle ear bones which transmit sound from the ear drum to the inner ear. The inner ear contains microscopic hearing nerve endings that transmit sound energy to the brain.
The eustachian tube is a narrow, 1.5 inch long tube in the back of the nose that connects to the middle ear through the nasopharynx and the upper throat, just above the palate. The eustachian tube functions as a pressure equalizing tube for the middle ear, which normally has air in it. During each swallow or yawn, air is allowed to flow into the middle ear space and equalizes the pressure.
Ear Infections (Acute Otitis Media)
Otitis media is an infection that happens when either bacteria or viruses invade the middle ear. The middle ear is located just behind the eardrum, or the tympanic membrane. In acute otitis media, pus accumulates inside this space causing pain, pressure and inflammation. As pus and pressure increase, the eardrum becomes inflamed, red and painful. This also causes temporary hearing loss.
Acute otitis media often accompanies respiratory infections. With upper respiratory infections, the eustachian tube becomes swollen and congested and does not equalize air pressure within the middle ear space as it should. The bacteria find a way into the middle ear and up the eustachian tube. The adenoids can also become infected and obstruct the eustachian tube. The adenoids are located very near the end of the eustachian tube and are clumps of cells that fight infection, similar to tonsils.
In children, the eustachian tubes are smaller and straighter than they are in an adult, which makes children more susceptible to retaining fluid in the ear and prone to more ear infections than an adult. Three out of four children will experience otitis media by the time they are three years of age.
Otitis Media with Effusion (Serous Otitis Media)
Otitis media with effusion means fluid and mucous stay trapped in the middle ear space once the infection is over. Otitis media with effusion makes it harder for the ear to fight new infections. This fluid can also affect the child's hearing. It may begin after an acute infection and the fluid may persist for 6 weeks or longer. When a child's eustachian tube is not functioning properly fluid can accumulate inside the middle ear without being infected. This is called serous otitis media.
Causes of Otitis Media With Effusion or Serous Otitis Media
Serous otitis media may result from any condition that interferes with the periodic opening and closing of the eustachian tube. This may be congenital or due to immaturity, infection, allergy, or blockage of the tube by adenoids.
Infections may cause the lining mucus membrane of either the middle ear, eustachian tube, nose, or sinuses to not function properly and contribute to eustachian tube obstruction.
Allergy reactions of the nose and throat may also result in mucous membrane swelling and may obstruct or affect the function of the eustachian tube. This may be either an acute problem, as in seasonal allergy or more chronic as with chronic sinusitis.
Adenoids are located in the nasopharynx in the area between the eustachian tube and the nose. When enlarged, the adenoids may block the eustachian tube opening, contributing to otitis media with effusion.
Cleft palate can also contribute to serous otitis media due to the fact that the muscles that move the palate also open and close the eustachian tube and may be deficient or abnormal in a child with cleft palate.
What are the symptoms of otitis media?
Younger children with otitis media are usually fussy and irritable and sometimes they have difficulty sleeping and eating. If they are old enough they may note difficulty hearing. Often there is ear pain and a feeling of pressure in the ear. With an acute infection, fever may be present. The child may also have other symptoms associated with an upper respiratory tract infection, including a stuffy or runny nose and cough. Often, with antibiotic treatment, the symptoms of acute otitis media will improve within one or two days. However, fluid may persist in the middle ear space for one to two months. Permanent hearing loss is quite rare with acute otitis media.
Severe infections will occasionally cause the eardrum to rupture, which often relieves pain, decreases fever, and causes ear drainage. Older children or adults may also complain of nausea, dizziness, and loss of balance. A physician should evaluate any person with these symptoms. The physician may confirm the infection and prescribe an antibiotic. Pain medicine or medicine to decrease fever may be necessary.
Occasionally surgical drainage, called tympanostomy, is necessary to drain the fluid from the middle ear and release the pus. Usually this incision will heal within a couple of weeks. Children who suffer from frequent bouts of otitis media and have taken multiple antibiotics may need tympanostomy and tubes placed in the ear. Ear tubes allow fluid to drain down the eustachian tube and air to return to the middle ear space.
As with acute upper respiratory infections, pus in the sinuses and nose drains over the eustachian tube and must be treated with antibiotics, and possibly decongestants or nasal sprays. General health factors, such as a deficient immune system, would also have to be corrected.
Allergy is often a major factor in persistence of serous otitis media and often benefits from treatment with anti-histamine drugs, allergy evaluation and/or injection treatment.
Blowing one's nose may help relieve congestion and re-establish middle ear ventilation ("popping your ears").
Most often treating acute otitis media with antibiotics will help resolve the infection. After the acute infection is treated, the patient will still have uninfected fluid in the middle ear space, which takes time to resolve. During this healing period there are varying degrees of ear pressure, popping, clicking, and fluctuation in hearing with occasional pain within the ear.
The goals of surgical treatment for chronic serous otitis media or recurring acute otitis media is to establish ventilation of the middle ear, keep the hearing at a normal level, and prevent recurring infections that might damage the eardrum or the middle ear bones. This involves myringotomy with insertion of a ventilation tube in the ear drum and at times adenoidectomy.
Myringotomy is an incision in the eardrum performed to remove middle ear fluid. A hollow tube (ventilation tube) is inserted to prevent the incision from healing and closing and to insure middle ear ventilation. The ventilation tube temporarily allows air in the middle ear space, helping the eustachian tube to function better at equalizing middle ear pressure. The tube usually falls out on its own between 8 to 24 months, at which time the eustachian tube needs to be re-assessed. As the tube falls out the eardrum usually heals and the eustachian tube should resume its normal pressure equalizing function.
In adults, myringotomy and tube insertion can be performed in the office under local anesthesia. In children, general anesthesia is usually required. If, after the tube falls out, recurring infections or serous otitis media recur, a new tube placement may be necessary.
Clinical Indications for Myringotomy and Tubes as Recommended by the American Academy of Otolaryngology
a. severe acute otitis media
b. significant hearing loss in a patient with otitis media with effusion
c. poor response to antibiotics for otitis media
d. spread of infection outside of the ear due to otitis media
e. otitis media with effusion greater than 3 months
f. recurrent episode of acute otitis media - more than 3 episodes in 6 months and
more than 4 episodes in 12 months
g. weakening of the tympanic membrane, forming a chronic pouch
h. cranial facial abnormalities that pre-dispose to middle ear dysfunction, such as
i. middle ear dysfunction due to head and neck radiation or skull base surgery
EAR, NOSE AND THROAT CENTER SURGERY INSTRUCTIONS
On the day of surgery, the child should have nothing to eat after midnight but may take CLEAR liquids up to 6 hours before surgery. NOTHING AT ALL should be taken by mouth, not even water, for 6 hours prior to surgery. An exception to this would be any medications the doctor has instructed you to take that morning. Failure to follow these guidelines will likely result in the cancellation of surgery that day. If you have any questions about this please call the office.
You will need to arrive at the surgical facility well before the scheduled time of surgery. A day or two before surgery you will be called by the doctor's nurse, or someone from the facility and be told specifically what time to arrive. The surgery takes about 15 minutes. During surgery your child will be kept asleep by breathing gas given by a facemask under the supervision of an anesthesiologist. Occasionally, usually with older children, an IV will be started. The doctor will talk to you after the surgery is done. Please stay in the waiting room the whole time your child is in surgery. After surgery your child will be in the recovery room for about 30 minutes. You will probably be able to sit with your child for part of this recovery time. You will usually be allowed to leave about 30 minutes after surgery.
ONCE YOU ARE HOME
Once you are home allow your child to slowly drink some clear liquids. If in a half hour he or she is doing well then slowly allow a more normal diet to be eaten if desired. If the child vomits, wait 30 minutes and try the clear liquids again. Your child may be clumsy due to the anesthesia so watch them closely and avoid situations that could lead to a fall. The following day he or she may resume normal activity. Your child may be fussy or have some mild pain, if so you may give some Tylenol. Be sure to follow the label directions. You may see some bloody, clear or cloudy drainage from the ear for 3 or 4 days, but please do not let this worry you.
You may be given some ear drops at the time of surgery, if so use the drops as the doctor directs, usually 3 drops in each ear 3 times a day for 3 to 5 days. If not you will probably be given a prescription for drops at your follow up visit. Don't be alarmed if the drops seem to cause some pain or discomfort as they do tend to sting for a brief time when first put in the ear.
FOLLOW UP CARE
As discussed above, there may be some drainage, (other than wax), from the ears on occasion. If so use the eardrops you have been given or prescribed by the doctor; usually 3 drops in the draining ear 3 times a day for about 7 days or until the drainage stops. If this problem is persistent or recurrent please call the office. You can help minimize the chance for drainage by keeping your child on a decongestant when he or she gets a cold and by keeping water out of the ears. Fitted earplugs and swimming head bands can be purchased at the office if you desire.
Please make an appointment now to have your child's ear checked about 3 to 4 weeks after surgery. This visit is to be sure that the tubes are in the proper position and that they are not plugged with mucous or blood. There is no charge for this first postoperative examination. Your child may have a hearing test done at that visit, (especially if they are over 2 or have speech or hearing problems); there is a charge for this test as well as any ear plugs or head bands you purchase. If all is going well, the doctor will usually check the ears every 8 to 10 months after this first check until the tubes are out and the ears are healthy. Some situations will require more frequent checking. If you are covered by an HMO or Medicaid please be sure to call for approval for any office visits. Should your child develop persistent or recurrent ear problems prior to your regular check up, or should questions arise, please call the office at (616) 575-1212.