What is the treatment for a 6-year-old with a retracted eardrum?

Treatment of Retracted Eardrum in a 6-Year-Old

For a 6-year-old with a retracted eardrum, the initial approach is watchful waiting with monitoring every 3-6 months, unless there is documented hearing loss, symptoms affecting quality of life, or the child is at risk for developmental problems—in which case tympanostomy tubes should be offered. 1, 2

Initial Assessment and Monitoring

The first step is to determine whether this represents otitis media with effusion (OME) causing the retraction, as eustachian tube dysfunction and middle ear fluid are the primary mechanisms behind tympanic membrane retraction. 3, 4

Key factors to document at each visit:

• Laterality (one or both ears affected) 1, 2
• Duration of the retraction/effusion 1, 2
• Presence and severity of associated symptoms (hearing difficulties, ear discomfort, balance problems, behavioral issues, school performance problems) 1, 2
• Degree of retraction (mild vs. severe, pars tensa vs. pars flaccida involvement) 3

Confirm the diagnosis using:

• Pneumatic otoscopy as the primary diagnostic method 1, 2
• Tympanometry if the diagnosis is uncertain 2

Watchful Waiting Strategy

For children without risk factors or significant symptoms, watchful waiting for 3 months from diagnosis is the recommended first-line approach. 1, 2

During this period:

• Reexamine every 3-6 months until the effusion resolves or complications develop 1, 2
• Educate the family about the natural history of OME and the need for follow-up 2
• Monitor for structural changes to the tympanic membrane 2

Important caveat: Persistent retraction can lead to atelectasis, ossicular erosion, and cholesteatoma formation, particularly with severe attic (pars flaccida) retractions. 3, 5 The duration of disease correlates with development of both atelectasis and attic retraction. 6

When to Obtain Hearing Testing

Hearing assessment is mandatory if:

• OME/retraction persists for ≥3 months 1, 2
• Language delay or learning problems are suspected 1, 2
• The caregiver reports hearing difficulties or the child complains of hearing problems 1
• School performance is affected 1

Indications for Tympanostomy Tubes

Tympanostomy tubes should be offered when:

• Bilateral OME persists ≥3 months with documented hearing loss 1, 2
• Chronic ear fluid contributes to balance problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life 1
• The child has risk factors for developmental difficulties (see below) 1, 2

For a 6-year-old specifically (age <4 years old does not apply):

• Tympanostomy tubes are the preferred surgical intervention 1
• The operation takes 10-20 minutes under general anesthesia with recovery in a few hours 1
• Short-term tubes (lasting 8-18 months) should be used unless there's a specific reason for long-term tubes, as they have lower risk of persistent perforation 1

High-Risk Children Requiring Earlier Intervention

Children at increased risk who may benefit from earlier tube placement include those with:

• Permanent hearing loss independent of OME 2
• Speech/language delay or disorder 2
• Autism spectrum disorders 2
• Syndromes or craniofacial disorders affecting eustachian tube function 2
• Blindness or uncorrectable visual impairment 2

For these children, tubes are an option even if OME has been present for less than 3 months, particularly if tympanometry shows a flat-line reading indicating poor eardrum mobility. 1

What NOT to Do

Avoid these ineffective treatments:

• Antibiotics for routine management of OME/retraction (no long-term efficacy) 1, 2
• Antihistamines and decongestants (proven ineffective) 1, 2
• Intranasal or systemic steroids 2

These medications show only short-term benefits at best, have potential adverse effects, and contribute to antimicrobial resistance. 2

Follow-Up After Tube Placement

If tubes are placed, the family should be educated that:

• Most tubes fall out in 12-18 months 1
• About 25% of children may need tube replacement 1
• Routine water precautions (ear plugs) are unnecessary for normal swimming 7
• Ear plugs are only needed for diving >6 feet underwater, swimming in lakes/dirty water, or if the child experiences pain with water exposure 7
• Antibiotic ear drops should be used if drainage occurs 7

Special Consideration: Adenoidectomy

For this 6-year-old, adenoidectomy can be considered in addition to tubes if there are separate indications such as nasal obstruction or chronic adenoiditis, as it may reduce future need for repeat tube placement by approximately 50%. 1 However, adenoidectomy alone should not be performed solely for OME. 1