BODY WATCH : Music to Their Ears : Antibiotics? Surgery? Or nothing? For parents and doctors wondering how to treat children’s chronic ear infections, new guidelines may offer some answers.
Michael Artinian’s ear infections began within weeks of his birth.
Every few weeks, says his mother, Chris, the baby would fret and fuss with the pain of a new infection.
His pediatrician tried antibiotics for months. The milder ones did nothing and infections even flared up when Michael was taking the strongest antibiotics. (Because Michael was born with a cleft lip and palate--which are being corrected with surgery--he was highly susceptible to infection.)
Finally, when Michael was 8 months old, the doctor suggested a surgical procedure called a tympanostomy--in which ear tubes are inserted to drain fluid from the middle ear and clear up infection. The Artinians agreed.
Parents often wonder if they are doing the right thing by choosing surgery to heal chronic ear infections, which generally occur as a result of a cold, sore throat or other respiratory infection. Their doubts stem from disagreements in the medical community about whether the procedure is overdone.
“It’s never easy to put your child through surgery,” says Artinian, who lives in Glendale with her husband, Robert. “But, as a parent, you have to get hooked up with the right doctor--a doctor you are in sync with.”
But now parents may have more to rely on than just their doctors.
An article in last month’s Journal of the American Medical Assn. suggested a set of guidelines for tympanostomy (while noting that as many as one-fourth of all ear-tube surgeries now performed may be unnecessary).
And, this summer, the federal Agency for Health Care Policy and Research will release guidelines for doctors and parents on the treatment of childhood middle ear infection (otitis media).
Otitis media is the most common reason for doctor visits in children under 6, accounting for about 30 million visits a year. Yet there are no clear-cut guidelines to help doctors and parents know which of several treatment options--antibiotics, surgery to insert ear tubes or doing nothing--work best and with the least risk to the child.
“The reason we suggest certain disorders for the guidelines is that there is substantial variation in care,” says Rose Findley, an agency spokeswoman. “One doctor treats it one way and across town, there is a completely different type of treatment pattern. There isn’t much consensus. And, (the nation) is spending a lot of money on it, but we don’t know what the best or most appropriate treatment might be.”
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The guidelines are highly anticipated, not only because of the magnitude of the problem, but because of the contentiousness that has arisen between doctors on how to treat otitis media.
The experts who contributed to the new federal report, joked one doctor, “will then enter the government’s Witness Protection Program.”
Because of conflicting scientific studies, experts have been loath to recommend one right way to treat chronic ear infections.
Some studies have suggested that antibiotics work well while others say they have failed. Some studies show good results on tympanostomies; others contend that the procedure is dramatically overused.
“I think there is a fair amount of data, but I think it’s confusing and difficult to synthesize,” says Dr. Lawrence C. Kleinman, a Harvard physician and author of the JAMA report. In that study, a panel of doctors reviewed research on tympanostomies to develop criteria on when the surgery should be considered.
There is enough known, Kleinman says, “that the panel of experts were able to definitively say that a fair amount of the surgeries were appropriate or inappropriate.”
Using the panel’s criteria, the study found that of the 670,000 tympanostomies performed each year, 41% were for appropriate reasons, 32% had equivocal indications and 27% were found to be inappropriate.
An appropriate reason to choose surgery, the article states, would be for a child who has fluid trapped in the middle ear behind the eardrum (called otitis media with effusion) that does not clear up despite treatment with antibiotics. The tiny tube inserted in the eardrum during surgery allows the fluid to drain and restores a child’s hearing, which can be muffled when fluid has collected. The tubes remain in the ear for several months to a year and fall out on their own.
Surgery is considered inappropriate, for example, if a child had fewer than four ear infections a year or had not been treated sufficiently with antibiotics.
But, Kleinman acknowledges, it is impossible to predict how any child will fare.
“It’s always impossible to say, on an individual basis, who will benefit or who won’t. This is an attempt to say, ‘Who would you expect to benefit?’ There is no question that there is a good deal of individual variation in response to various treatments.”
But because the guidelines suggested in the JAMA article are among the first on this topic, they should become a helpful tool to doctors and parents.
“Now parents and physicians can have a discussion that includes in it, ‘Well, what did the experts think about this for my child?’ They are able to make a better informed decision. And that, to me, is the key here,” Kleinman says.
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The guidelines might also divert surgeries that take place out of frustration, he adds. Recurrent ear infections can cause misery for families, causing the child a lot of discomfort and parents many sleepless nights. Moreover, doctors and parents worry about the small chance that ear infections will cause hearing loss and speech delay.
“Sometimes the level of frustration with ear infections can lead to hasty actions that are not well considered,” Kleinman says.
The guidelines should be especially useful in cases where, according to the study, the need for ear tube surgery was equivocal. An example of this kind of case is a child with frequent ear infections (more than three in six months or four in a year) who also has an infection while taking antibiotics to prevent a recurrence.
“I would argue that this is where family preference should most strongly be taken into account,” Kleinman says.
No guidelines--whether they are from the federal government or published in JAMA--should revoke the right of doctors and parents to individualize their decisions, says Dr. David Bergman, a Stanford University physician who worked on the federal guidelines.
“The bottom line, to me, is that you have to take each case individually and not use expert consensus as a way of driving your decision one way or another,” he says.
Bergman says he is concerned that any suggested guidelines might be used by insurance companies to deny surgeries that don’t fit tightly within the criteria.
The federal guidelines will try to avoid that problem, he says, by concluding that “there is a variety of treatment options for this, but no one option is overwhelmingly supported by scientific evidence. There are many ways to treat it, but there is no way to know whether one is better than the other.”
As part of the decision on treatment, parents should explore their feelings on having their child take antibiotics for a long period and on surgery--both of which have risks and benefits. Costs should also be considered. A tympanostomy costs about $1,200 as an outpatient.
To help consumers, the federal guidelines will be released in two forms, one for health care professionals and one for parents.
“There are many family preferences here, and families should be involved,” Bergman says.
ECHOING CONCERN
Office visits with a principal diagnosis of otitis media in the United States, 1975-93
IN MILLIONS:
1975: 9.9
1980: 14.1
1985: 18.3
1990: 24.5
1993: 30.1
Source: Centers for Disease Control And Prevention, U.S. Dept. of Health and Human Services
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Middle ear infection (otitis media) usually occur as the result of a cold, sore throat or other respiratory infection. Ear infections decline as the tube matures and a child’s immune system becomes more resistant to germs (both about age 6).
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1. Eustachian Tube
Germs or bacteria travel to the middle ear through the Eustachian Tube, an airway that connects the nose and throat area with the middle ear. (Ear infections are common in chhildren under 2 because the tube is shorter.)
2. Middle Ear
Once the infection reaches the middle ear, fluid often collects in the middle ear space and the eardrum becomes inflamed.
