After their child has had several episodes of otitis media (ear infections) parents frequently ask me whether their child needs tubes in their ears or to have their tonsils removed.

Myringotomy tubes and tonsillectomies are the most common procedures in general otolaryngology (ENT). The patients most commonly requiring surgery for “tubes” or “tonsils” are children. So much in medicine has changed over the last 100 years with advances in anesthesia, open heart surgery, and the role of DNA in medicine. Yet nearly half of the discussion at the annual conference for pediatric ENT physicians still revolves around tubes and tonsils.

Dr. Adele Evans, a pediatric ENT specialist at Duke, tells us about these frequently performed procedures.

-- Dennis Clements MD, PhD, MPH

Tubes

Frequent ear infections are a common problem in early childhood, affecting nearly one in five children. Frequent is defined by three to four instances in a six-month period, but sometimes it means back-to-back infections with no reprieve for patient or parent.

Adele K. Evans, MDEar infections are often painful, associated with fevers, and may require treatment with oral antibiotics, whose use can be followed by rashes, diarrhea, diaper-rash, or yeast infections.

“Fluid” or an “effusion” is an accumulation of secreted fluid in the middle ear space, which is just behind the eardrum and lined by tissue very similar to that of the nasal and sinus passages.

Fluid may result from a viral infection like the common cold, a bacterial infection of the nose and sinuses, or as a result of anatomy. It can take anywhere from six weeks to three months to go away on its own. When it doesn’t go away and hearing loss persists, then treatment with ear tubes is in order.

Both problems can happen at any age but occur most commonly in children from the ages of 12 months to two-and-a-half years due to their slowly developing immune systems, exposure to bacteria and viruses in daycare settings, tendency to put everything they find in their mouths, and their anatomy. These problems can cause a decrease in hearing that feels like having your head under water or your fingers in your ears.

Tubes are used as a surgical treatment for these problems. Tiny tubes, about two millimeters in size, are inserted in the eardrum using a microscope. This is done under general anesthesia.

Tubes allow for the ventilation of the middle ear space, helping to prevent ear infections. They also provide a means of direct treatment of any ear drainage by using eardrops allowing the use of stronger medications directly to the affected part of the ear. Children can go home the same day as the surgery and usually feel better the same afternoon, particularly with respect to hearing.

Tonsils

Tonsils are lymph node material located in the sides of the back of the throat. The “adenoids” are the same type of tissue but located at the very back of the nose, in the space called the nasopharynx.

These tissue collections are thought to be useful evolutionarily because they form a ring of lymph node tissue surrounding the throat and allow the developing immune system to “meet the world” as infants put everything into their mouths.

As children grow older, these tissues become less important and start to wither away beginning around the age of five years.

In some children, tonsils and adenoids are too large and they get in the way of breathing. When awake these children breathe heavily and chew with their mouths open. When asleep these children snore heavily. They sputter, choke and get very poor sleep.

In these cases, large tonsils and/or adenoids can be removed, offering tremendous benefit to the child by enabling better sleep and providing long-term benefits to the child’s overall health, including the heart’s health.

In some children, the tonsils and adenoids become repeatedly infected with Streptococcus pyogenes, the germ that causes “strep throat,” scarlet fever, rheumatic fever and rheumatic heart disease.

Although antibiotics like penicillin have helped us tremendously over the years to treat the infections and have allowed untold number of children to keep their tonsils, there are still children today who fall victim to repeated infections and miss significant numbers of school days.

These children, and their families, can frequently benefit from tonsillectomy and adenoidectomy. Removal of tonsils is a painful procedure, but it is done under general anesthesia (with the patient totally asleep). In small children, there is often an overnight hospital stay required, but many older children can go home the same day.

After two weeks of healing, sleep patterns, are usually dramatically improved for patient and parent alike. Added benefits in some children include improvements in bed-wetting, attention spans and eating patterns because they are getting more restful sleep.

-- Adele K. Evans, MD, is a pediatric otolaryngology (ENT) specialist at Duke.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.