How many episodes of acute otitis media (AOM) are required before considering tympanostomy tubes?

Tympanostomy Tubes for Recurrent Acute Otitis Media

Consider tympanostomy tubes when a child has 3 or more well-documented AOM episodes in 6 months OR 4 or more episodes in 12 months with at least 1 in the past 6 months, but ONLY if middle ear effusion is present at the time of assessment. 1, 2

Critical Prerequisite: Middle Ear Effusion Must Be Present

The American Academy of Otolaryngology-Head and Neck Surgery is explicit that clinicians should NOT perform tympanostomy tube insertion in children with recurrent AOM who do not have middle ear effusion in either ear at the time of assessment for tube candidacy. 1, 2 This is a crucial distinction—the frequency threshold alone is insufficient; fluid must be documented at evaluation. 2

• If a child meets the frequency criteria but has no effusion at assessment, observation with episodic treatment is recommended instead of surgery. 2
• The presence of middle ear effusion (unilateral or bilateral) at the time of tube candidacy assessment changes the recommendation to offering bilateral tube insertion. 1, 2

Specific Numeric Thresholds

The definition of recurrent AOM requiring consideration for tubes is precisely defined as:

• 3 or more well-documented and separate AOM episodes in the past 6 months, OR
• 4 or more well-documented and separate AOM episodes in the past 12 months with at least 1 in the past 6 months 1, 2

These episodes must be well-documented and separate, meaning clear resolution between episodes. 1

Pre-Surgical Requirements

Before proceeding with tube placement, the American Academy of Otolaryngology-Head and Neck Surgery recommends:

• Obtain an age-appropriate hearing test prior to surgery when a child becomes a candidate for tympanostomy tube insertion. 1, 2
• Assess developmental risk factors including permanent hearing loss, speech/language delay, autism spectrum disorder, Down syndrome, cleft palate, blindness, or developmental delay—these children may benefit from earlier intervention with less stringent criteria. 1, 2

Expected Benefits

The evidence shows modest but meaningful benefits:

• Grommets reduce AOM recurrences by approximately 1.5 episodes in the 6 months following surgery compared to active monitoring. 3, 4
• At 6 months, 46% of children with tubes had no AOM recurrence versus only 5% with active monitoring (low-quality evidence). 3
• By 12 months, the effect diminishes: 48% with tubes versus 34% with active monitoring had no recurrence. 3
• Tubes allow treatment of breakthrough infections with topical antibiotic drops rather than oral antibiotics. 1, 2

Important Caveats and Pitfalls

The evidence base has significant limitations. All major trials were conducted before pneumococcal vaccination became standard, which has fundamentally changed AOM epidemiology and bacteriology. 3 The true effectiveness in vaccinated populations may differ from these older studies.

Persistent tympanic membrane perforation occurs in approximately 2% of children after short-term tube placement, which may require surgical repair. 1

Do not place tubes based on frequency alone—this is the most common error. The child must have middle ear effusion documented at the time of surgical candidacy assessment. 1, 2

Alternative Considerations

For children ≥4 years old, adenoidectomy may be considered concurrently with tube placement to reduce future recurrence and need for repeat tubes by approximately 10%. 2, 5

Antibiotic prophylaxis is an alternative, though evidence comparing tubes to prophylaxis is very low quality and shows uncertain benefit differences. 3