Indications for Tympanostomy (Ear) Tubes in Children
Clinicians should offer bilateral tympanostomy tube insertion to children with bilateral otitis media with effusion (OME) persisting for 3 months or longer AND documented hearing difficulties, or to children with recurrent acute otitis media (AOM) who have middle ear effusion present at the time of assessment. 1
Primary Indications
Chronic Otitis Media with Effusion (OME)
Bilateral OME ≥3 months with hearing loss:
- Tubes are recommended when fluid persists in both ears for 3 months or longer AND the child has documented hearing difficulties 1
- An age-appropriate hearing test must be obtained before surgery when a child becomes a candidate for tube insertion 1
Chronic OME with other symptoms:
- Tubes are an option (not mandatory) for unilateral or bilateral OME lasting ≥3 months when symptoms are attributable to the effusion, including: 1
- Balance (vestibular) problems
- Poor school performance
- Behavioral problems
- Ear discomfort
- Reduced quality of life
Important caveat: Clinicians should NOT perform tube insertion for a single episode of OME lasting less than 3 months 1
Recurrent Acute Otitis Media (AOM)
Definition of recurrent AOM: 1, 2
- 3 or more well-documented episodes in 6 months, OR
- 4 or more episodes in 12 months with at least 1 in the past 6 months
Critical requirement: Middle ear effusion (MEE) must be present at assessment
- Tubes are recommended for children with recurrent AOM who have unilateral or bilateral MEE at the time of tube candidacy assessment 1
- Tubes should NOT be placed in children with recurrent AOM who do not have MEE in either ear at assessment 1
- This is a common pitfall: the presence of fluid at the time of evaluation is mandatory, not just a history of recurrent infections 2
Special Populations: At-Risk Children
Clinicians should identify children at increased risk for speech, language, or learning problems due to baseline factors including: 1
- Permanent hearing loss (not related to OME)
- Speech/language delay
- Autism spectrum disorder
- Down syndrome or other craniofacial disorders
- Cleft palate
- Blindness or uncorrectable visual impairment
- Developmental delay
- Intellectual disability
- Learning disorders
- ADHD
For at-risk children: Tubes may be inserted with unilateral or bilateral OME that is likely to persist (reflected by type B flat tympanogram) or documented effusion for 3 months or longer, even with less stringent criteria 1, 2
Surveillance and Monitoring
For children with chronic OME who do NOT receive tubes:
- Reevaluate at 3- to 6-month intervals until: 1
- Effusion is no longer present, OR
- Significant hearing loss is detected, OR
- Structural abnormalities of the tympanic membrane or middle ear are suspected
Surgical Considerations
Type of Tube
- Short-term tubes (lasting 8-18 months) should be used for initial surgery 2
- Long-term tubes should NOT be placed as initial surgery unless there is a specific anticipated need for prolonged middle ear ventilation beyond that of a short-term tube 1
- Long-term tubes carry a 17% risk of persistent tympanic membrane perforation versus 2% with short-term tubes 3
Adjuvant Adenoidectomy
- May be performed as an adjunct for children with symptoms directly related to adenoids (adenoid infection or nasal obstruction) 1
- May be considered in children aged 4 years or older to potentially reduce future recurrence of otitis media or need for repeat tube insertion 1, 2
Evidence Quality and Clinical Context
The guideline recommendations are based on the 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation update 1. However, all supporting RCTs were conducted prior to pneumococcal vaccination introduction, which has changed the epidemiology and bacteriology of AOM 4.
Recent high-quality evidence from a 2021 RCT showed that among children 6-35 months with recurrent AOM, the rate of AOM episodes over 2 years was not significantly different between tympanostomy tubes (1.48 episodes/child-year) versus medical management (1.56 episodes/child-year) 5. This suggests the benefit may be more modest than previously thought, though tubes did show advantages in time to first episode and treatment failure rates 5.
Perioperative Management
Follow-up requirements:
- The surgeon or designee must examine the ears within 3 months of tube insertion 1
- Educate families regarding need for routine, periodic follow-up until tubes extrude 1
- Do NOT routinely prescribe postoperative antibiotic ear drops after placement 1
For acute tube otorrhea:
- Prescribe topical antibiotic ear drops ONLY, without oral antibiotics, for uncomplicated acute tympanostomy tube otorrhea 1
Water precautions:
- Do NOT encourage routine prophylactic water precautions (earplugs, headbands, avoidance of swimming) 1