Don't Worry: Delaying Ear Tube Surgery Won't Harm Language Development

From the WebMD Archives

April 18, 2001 -- Until he was 6 months old Matthew Luber had a very rough life -- and so did his mother Mandy Luber. "Sometimes I would come home on a Friday night and Matthew would be crying and pulling his ears and I would think, oh no, we can't go through another weekend like this," Luber recalls. Matthew, she says, suffered from constant, unremitting ear infections that led to a build up of fluid in his ears.

As difficult as it was to find an on-call pediatrician over a weekend, it was even worse when Matthew's infections flared up during the week. "My job was 45 miles away from our home and the pediatrician was 10 miles away in the other direction," she tells WebMD. Luber, who lives in Riverview, Fla., a suburb of Tampa, spent so much time caring for her sick child that "I was written up at work."

Relief came when Matthew's pediatrician referred Luber to an ear, nose, and throat specialist who told her that her son needed surgery to solve the problem. This surgery, popularly known as tube surgery, involves the placement of tiny tubes inside the middle ear. The tubes drain away fluid that builds in some children who have constant ear infections, a problem called middle-ear effusion.

If you have questions about your child and ear tubes, you can get some answers at WebMD's Parenting board with Steven Parker, MD.

Luber says that the tubes did the trick for Matthew and he "was fine until he was 4-and-a-half and then it started all over again." This time when she brought Matthew to another ear, nose, and throat specialist she was told that Matthew needed another tube insertion but he also needed to have his adenoids surgically removed, a procedure called an adenoidectomy.

Matthew is now 7 and Luber says, "he's great."

Debbie Levine says that her son, also named Matthew, had a similar experience but she and her husband found it difficult to convince Matthew's pediatrician that their son needed tube surgery. She says the pediatrician favored a more conservative course "trying antibiotic after antibiotic."

Levine, who is a magazine editor in Mt. Laurel, N.J., says that the breaking point for her was when she realized that her son's hearing was affected. She tells WebMD that "our kitchen was eight or 10 feet from the front door. Every evening Matthew would be sitting in his high chair and I would be feeding him at the time that my husband would come home from work. Matthew would just light up as soon as he heard the key in the door." But then Levine noticed that some nights Matthew wouldn't hear the key and "the next day a fever would spike and the ear infection would be back."

Levine says her son had tubes inserted when he was 11 months old. The family repeated the whole episode five years later when her daughter, Lisa, also needed tubes at 11 months. Both children are fine now, she says.

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Delaying Ear Tube Surgery Doesn't Harm Language Development

Levine and Luber are typical of thousands of parents says Heidi M. Feldman, PhD, MD, who's with the Children's Hospital of Pittsburgh and a professor of pediatrics at the University of Pittsburgh. She tells WebMD that many parents worry that their children will "be robbed of some potential because of these constant ear infections. They worry about developmental problems."

But Feldman says that results of a new study she and her colleagues at the University of Pittsburgh conducted can put some of those fears to rest. They report in Thursday's New England Journal of Medicine that although insertion of tubes in infants with persistent ear infections does reduce the frequency of the infections and eliminate fluid build-up, it has no effect on development of language by the age of 3.

She says that children who waited as long as nine months to have tubes inserted did no worse on a series of language development tests than the children who had earlier insertion of tubes. The findings are exactly the opposite of other studies that suggested that a delay in tube surgery would have an adverse effect on developmental outcomes.

In the new research the scientists studied 402 children who all had a similar history of frequent ear infections during infancy (when they were 2-61 days old). One hundred and sixty-nine children had early placement of tubes and 66 waited up to nine months for the surgery. Feldman and her colleagues then used sophisticated measurements of words, sounds, and conversation to assess developmental differences. "There was no difference," she says.

The children who waited several months before surgery did have more fluid in their ears and longer sustained hearing loss, she says, but that didn't show up in the developmental tests. Feldman says there is an explanation for this: "the hearing loss that occurs with fluid buildup tends to be in the low frequency range. That means that a child might not hear a plane or a machine." The human voice, on the other hand, "tends to fall in higher frequencies." The result is that even with fluid in the ear the children can still hear spoken words, she says.

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This new study means that it is time to rethink current guidelines for tube surgery, says Stephen Berman, MD, president of the American Academy of Pediatrics. Berman, a professor of pediatrics at the University of Colorado Health Sciences Center in Denver, says that current guidelines suggest that tubes should be placed if fluid persists for at least three months. "But this new evidence suggests that it may be better to wait rather than perform an unnecessary procedure," he says.

Glenn Isaacson, MD, professor and chair of otolaryngology/head and neck surgery and chief of pediatric otolaryngology at Temple University School of Medicine in Philadelphia, says the study by the Pittsburgh researchers does call into question the three-month rationale but he says that "children who have tubes placed for persistent fluid represent only one segment of children in whom tubes are inserted."

Isaacson says that he is more likely to insert tubes to treat persistent, painful [ear] infections. And he says that he and other surgeons frequently observe "dramatic improvements in language after tubes are placed." But he says, "whether those dramatic changes will make a difference five years from now is unknown."

James M. Perrin, MD, associate professor of medicine at Harvard Medical School tells WebMD that although the findings from the Feldman study suggest that "[as of] age 3 it is probably better to wait rather than rush to insert tubes, the real question that remains is what the effect will be at ages 4, 5, and 6 [if surgery is delayed up to nine months]." Perrin wrote an editorial that accompanies the study by Feldman and a second study from Canadian researchers.

In the second study Peter C. Coyte, PhD, and fellow researchers from the University of Toronto studied hospital records from more than 37,000 children to determine if combining tube surgery with removal of adenoids, or tonsils and adenoids could improve outcome. Coyte tells WebMD that adding an adenoidectomy to the tube surgery reduced the need for repeat surgeries by 50% and when both adenoids and tonsils were removed the repeat procedures were cut by 60%.

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Isaacson says that most American ear, nose, and throat surgeons consider adenoidectomy a necessary part of tube surgeries done in children age 4 or older. But he says that he doesn't recommend adding a tonsillectomy because the procedure carries a significant risk for complications such as postoperative bleeding.

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