THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Tuesday, August 2, 1994 TAG: 9408020036
SECTION: DAILY BREAK PAGE: E1 EDITION: FINAL
SOURCE: BY DIANE TENNANT, STAFF WRITER
LENGTH: Long : 157 lines
TAYLOR BRYANT, at 14 months, already had quite a medical history.
Three-fourths of her short life have been spent on antibiotics, hearing loss, food allergies and the real problem: ear infections.
From the age of 4 months, Taylor was never without an antibiotic. But the ear infections just kept coming, even breaking through preventive antibiotics.
So Taylor came to Children's Hospital of The King's Daughters for the most common surgery done on children today - ear tubes.
The insertion of tiny plastic tubes in the ear drum to drain the fluid that can harbor bacteria takes only 15 minutes. But the question of whether they are used too frequently will be debated much longer.
Ear tubes were first used in the late 1890s, and reinvented in the 1950s, said Dr. Craig Derkay, assistant professor of pediatric otolaryngology with Eastern Virginia Medial School and the hospital.
They were developed to relieve infection in the middle ear, the part behind the ear drum, which should be filled only with air. When fluid becomes trapped behind the ear drum, an infection can result. Untreated infections can cause hearing loss and can, in rare cases, spread in the skull.
Tubes came into widespread use in the 1970s and early '80s, and today are placed in approximately 670,000 children a year. The cost averages between $1,200 and $2,000.
``The number increased basically because of education of the primary care physicians and the advent of day care,'' Derkay said. It is unclear, he continued, whether doctors just missed ear infections before then, whether they began looking harder for them, or whether the number of infections has actually increased.
Whatever the reason, they are accepted today by many parents and doctors as the common end result of ear infections that just won't go away, despite repeated doses of antibiotic.
``The peak age for ear infection is the first three years of life,'' Derkay said. There are many reasons for that: the structure of the ear in small children inhibits draining, the muscles around the throat opening that leads to the ear are weaker in children than in adults, and teething causes more saliva in infants' mouths. Also, children in day care are more prone to ear infections than those who stay home, because they are exposed to more germs, Derkay said. Cigarette smoke can contribute to ear infections. Breast-feeding can help prevent them.
Most ear tubes last about a year, he said. Children who have tubes put in their ears average one infection per year after the surgery, with a painless drainage through the tube. Only one out of five children needs tubes a second time.
The three professional groups that represent family practitioners, pediatricians and ear, nose and throat doctors have agreed that children should not have ear tubes unless they have four infections in six months, or one infection with fluid in the ears that lasts three months or longer despite antibiotics.
``I have educated my pediatricians not to send children over unless they meet those criteria,'' Derkay said. ``Not every child that has met those criteria needs to have tubes put in. Some have allergies. Some have fluid in only one ear. You can afford to be conservative in that kind of case.''
But for some children, tubes seem to be the only answer. Taylor exhibited some hearing loss, and her infection didn't respond to antibiotics. But she never pulled her ears or woke up at night crying, her parents said.
``I think it was almost at her young age she decided that's the way my ears are supposed to feel,'' said Mike Bryant, her father. ``She didn't know to complain about it.''
After the surgery, there was an immediate change in her speech, said Joy Bryant, her mother. ``She started babbling the next day. There was really a noticeable difference.''
CHILDREN ARE more prone to ear infections because of their head structure, Derkay said. In adults, the eustachian tube that leads from the ear to the throat is slanted, allowing for easy drainage. In small children, the tube is nearly horizontal, allowing fluid to be trapped in the ear, which creates a breeding ground for the bacteria that make infections.
Antibiotics, Derkay said, reduce swelling in the eustachian tube and kill the bacteria. But there is a down side to repeatedly dosing children with such medications: the bacteria are becoming resistant, meaning that antibiotics will not always kill them.
``I think we are kind of shooting ourselves in the foot a little bit with the amount of antibiotics we're prescribing,'' Derkay said. ``The bacteria adapt faster than we can develop new antibiotics.''
A federal panel in July recommended less use of antibiotics to treat uninfected fluid in the ear, saying that the condition often clears up on its own. The condition, which accounted for up to 8.5 million visits to doctor's offices in 1990, should be monitored, the panel said, but antibiotics are usually not needed.
``That's a child that is in no dire need of tubes in their ears,'' Derkay agreed. ``That's not the typical child. The minority will have just fluid without symptoms, without speech or language problems, without hearing loss.''
Fluid by itself - called otitis media with effusion - is not the same as ear infection, which may have fever and sharp pain. Infections, the panel said, should be treated with antibiotics.
T HE ROLE of allergies and sensitivities is often overlooked in ear infections, said Stephanie Story, a Virginia Beach resident who is licensed as a doctor of naturopathic medicine in Oregon, because Virginia does not license naturopaths.
Sensitivities to foods such as dairy products can cause the body to produce mucus, she said. Large amounts of mucus, combined with a small child's horizontal eustachian tubes, can lead to ear infections, Story said.
``It's one of the most common things naturopaths see in children,'' she said. ``It (treatment) can be as simple as stopping dairy products, with the caveat it's not really curing it, it's relieving the symptoms.''
Removing certain foods from a sensitive child's diet may prevent the buildup of fluid in the ears, which can remove infection's breeding ground, she said.
Ear tubes seem to work in the long run because they also prevent the buildup of fluid, she said, ``but really they've just grown out of it.'' The body still produces mucus, but it drains because the angle of the eustachian tubes changes as the child grows, Story said.
A recent article in the Journal of the American Medical Association claimed that more than one-fourth of ear tube operations may be inappropriate. The analysis of 6,611 children who were scheduled for such surgery was conducted by a utilization review concern hired by three large medical insurance companies.
``If these findings are generalizable, each year several hundred thousand children in the United States may be receiving tympanostomy tubes that offer them no demonstrated advantage over less-invasive therapies and may place them at increased risk for undesirable outcomes,'' the article said.
Derkay disagrees. ``I don't think that ear tubes are done more frequently than is necessary,'' he said. ``I don't think that ear, nose and throat doctors are overzealous about putting tubes in children's ears.''
Other doctors have also been quoted as criticizing the JAMA article, saying it was scientifically poor and failed to note that the number of ear tube surgeries has been dropping, from about 1 million in 1980 to 670,000 in 1988.
T AYLOR BRYANT wasn't interested at all in the debate. She cried when she was carried into the operating room, so Derkay held her on his shoulder and showed her pictures of his own children until she calmed down. A nurse cuddled her while she breathed the anesthesia. Fifteen minutes and two tubes later, she was waking up.
``She won't know she has them,'' Mike Bryant said, ``except she'll feel better.'' ILLUSTRATION: Color photo
BETH BERGMAN
Joy Bryant hugs her daughter after ear tube surgery at Children's
Hospital of The King's Daughters. Dad Mike Bryant and nurse Diana
Bowden look on.
Graphic
JOHN EARLE/Staff
SURGERY SHOULD BE CONSIDERED IF:
OTHER POSSIBLE REMEDIES:
[For complete graphic, please see microfilm]
Photo
BETH BERGMAN/Staff
Joy and Mike Bryant listen to instructions at King's Daughters
before taking Taylor in for ear tube surgery.
by CNB