F2.smallInsertion of tympanostomy or ear tubes is the most common outpatient surgical procedure performed on children in the United States.  Done under brief general anesthesia, tiny plastic tubes (1/20 of an inch wide) are placed in the ear drum, allowing air pressure to be equalized between the middle ear space (where fluid can accumulate and ear infections — otitis media — occur) and the outer ear.  “Ventilating” the middle ear in this way prevents ear infections from occurring by either allowing fluid buildup in the middle ear to drain or preventing the buildup of such fluid (usually the result of a simple cold) in the first place.  Young children are especially vulnerable to ear infections during colds because their eustachian tubes, which are natural ventilating tubes that connect the middle ear to the back of the nose, are pretty small and don’t function efficiently.  (As children get bigger, their eustachian tubes also get wider and function better, so ear infections are less common with age.)  Approximately 670,000 ear tube surgeries are performed in the U.S. every year, for an annual estimated cost of $1.8 billion (about $2,700 per surgery is the average).

Last week, the American Academy of Otolaryngology — Head and Neck Surgery (also known as ear, nose, and throat — ENT — docs) published updated guidelines regarding the insertion of these ear tubes in children between the ages of 6 months and 12 years old.

Key recommendations point not to the number of acute ear infections a child has, but rather, to the time it takes for the fluid that accompanies ear infections to go away and resolve:


  • If fluid persists in the middle ear space of both ears (bilateral otitis media with effusion or OME) for longer than three months at a time, ear tube insertion should be considered.  (Note that the newest treatment guidelines for ear infections — covered in a prior PediaBlog post — do not recommend antibiotics for this persistent fluid.)
  • Hearing tests should be performed when fluid is present for more than three months.
  • Ear tubes are recommended if fluid is present in both ears for three months AND hearing is diminished.  If fluid is present and hearing is normal, children can be monitored at 3-6 month intervals.  If, in that time period, hearing loss is documented, or if the ears become acutely infected (pain, fever, bulging red ear drums) and require more antibiotics, then tubes are indicated.
  • Children who have recurrent bouts of acute ear infections (these usually make kids miserable) do not need tubes as long as the fluid in the middle ear clears up between infections.  If the fluid between infections persists longer than three months, tubes are indicated.
  • Children with speech disorders or developmental delays — where chronic middle ear fluid can affect hearing, learning, and overall comfort — are exempted from these rather strict rules.
  • Dry ear precautions — keeping water out of the ears by using earplugs, headbands, avoiding swimming — are no longer advised for children who have tubes.


So the takeaway from this is:  More watchful waiting, fewer antibiotics, more hearing tests and ear rechecks, fewer ear tubes. And no more parental panicking (or physician scolding) when water gets in the ears!

Read guidelines (great illustrations like the one above) here.

Read new AAP ear infection guidelines here.