From: mhn@cs.brown.edu (Marian H. Nodine)
Subject: FAQL on ear infections and ear tubes
Organization: Brown University Department of Computer Science
Date: Thu, 9 Apr 1992 14:56:45 GMT

I have volunteered to keep the FAQL on ear infections and ear
tubes.  I have created a draft version of the file, which I am
including below.  I am hoping that interested persons will read
it, comment on it, and fill in blanks/send new information as
needed.

As a basis, I used information I have collected over the last
few months, including my saved record of all who posted in response
to my questions about ear tube operations for my daughter (she
ended up not getting them, but thanks to all who responded!).
I have excerpted some of these, from the people listed below
(I hope I get them all!)

   liz@austin.itx.isc.com (Liz Copeland)
   MBS4@PSUVM.PSU.EDU (Michelle Scott)
   dougm@eugene.convex.com (Doug Meinjohans)
   sg@tredysvr.Tredydev.Unisys.COM (Suzanne Gilliam)
   news@usenet.ins.cwru.edu (Douglas Fowler)
   doug@doug.ksc.nasa.gov (Doug Hammond)
   scott@Apple.COM (Maggie Douglass)
   lhafner@vaxa.weeg.uiowa.edu (Laurie Hafner)
   karenw@tekig1.pen.tek.com (Karen A Walker)
   eli@spdcc.com (Steve Elias)
   sgl@spatial.com (Steve Lanaghen)
   ssa@usl.com (Steve Albert)
   mary@cupid.Berkeley.EDU (Mary Case Williams)
   vivier@sol.crd.ge.com (Barbara)
   meisner@maine.maine.edu (Eddie Meisner)

Anyhow, here is the text.

********* This is very long ***********



                    Misc.kids Frequently Asked Questions
                         Ear Infections and Ear Tubes

=====================================================================
Collection maintained by: Misty Nodine (mhn@cs.brown.edu).
Last updated: April 8, 1992.

To contribute to this collection, please send e-mail to the address
given above, and ask me to add your comments to the FAQ file on ear
infections and ear tubes.  Please try to be as concise as possible, as
these FAQ files tend to be quite long as it is.  And, unless otherwise
requested, your name and e-mail address will remain in the file, so
that interested readers may follow-up directly for more
information/discussion.

For a list of other FAQ topics and how to get the archived discussions,
  write to: Diane Lin, dlin@weber.ucsd.edu or tune in to misc.kids.
=====================================================================

0.  WHAT CAUSES EAR INFECTIONS?
  
Ear infections occur because a young child's eustacian tubes are
relatively straight, and it is easy for fluid to drain into the ears
and build up behind the ear drum, making a nice place for bacteria to
grow in.  As a child matures, the eustacian tubes start to point down,
away from the ears, and the child "grows out of" the ear infections.
This usually occurs by the time he/she reaches age 4 or 5.

1.  WHAT ARE THE SIGNS THAT MY CHILD HAS AN EAR INFECTION?

Different kids respond differently to ear infections.  Some get high
fevers.  Some just ache.  In some children, the onset of an ear
infection can be very rapid and may require immediate medical
attention.  In others, the pain just increases very slowly.

Signs that your child may have an ear infection include:

    Doesn't like to nurse on one side or suck the bottle (the sucking
         motion can really hurt).

    Crying in the night

    Tugging at the ear (This is problematic, though.  Some kids just
         like playing with their ears.)

    The child has a cold or a runny nose.

2.  HOW ARE EAR INFECTIONS USUALLY TREATED?

Ear infections are bacterial, and are thus treated with antibiotics.
Also, in the first 24 hours before the antibiotic really starts working,
the child can have Tylenol to help with the pain.  Also, keep the
child more upright to allow for the eustacian tubes to drain.

2A. WHAT DIFFERENT ANTIBIOTICS ARE USED?
 
Amoxicillin a penicillin-type antibiotic, and is usually the first
antibiotic tried.  It is cheap, and usually effective for most
non-acute infections.  It is, nowever, not very effective against
chronic, asymptomatic ear infections.  This is because many of the
bacteria that cause ear infections secrete a substance (beta
lactamase) that destroys the amoxicillin.

Augmentin is the same as amoxicillin except that it has some
additional substances to disable the effects of the beta lactamase.
It is more expensive.

Septra is a non-penicillin based antibiotic that is often used.  One
boy had a treatment using Septra and Prednizone together for ten days
when he had a really acute infection after several, less acute
infections.  This cleared up the acute infection very rapidly (within
the 10 days, after the previous infections had taken about six weeks
to clear).

Other antibiotics include Ceclor and Suprax.  Suprax is very new and
very expensive -- if your pediatrician prescribes it, try to get a
lot of free samples.

2B. WHAT OTHER TREATMENTS MIGHT HELP?

Milk products increase mucous production, so decreasing the child's 
intake of them may help.

2C. WHAT ARE MAINTENANCE ANTIBIOTICS AND WHEN ARE THEY USED?

Maintenance antibiotics are usually tried after several closely-spaced
ear infections have been diagnosed.  They are usually given once a day
in the evening.  Sometimes higher maintenance doses are prescribed in
severe cases, though.

Septra is sometimes prescribed for maintenance use.  However, there
have been some undesirable side-effects reported.  If your pediatrician
prescribes Septra, be sure he is familiar with these, and monitors your
child at least once a month for them.  (note:  there is a medical
journal article on this, but I lost the reference).

3.  GETTING EAR TUBES

Ear tubes are small, trumpet shaped tubes that are put in the eardrums
and that allow air to reach behind the ear drum.

3A.  WHEN SHOULD A CHILD GET EAR TUBES?

When a child has persistent or recurrent ear infections, pediatricians
usually put the child on maintenance antibiotics.  If the ear
infections continue to "break through" the antibiotics (i.e., the
child gets ear infections while on the maintenance antibiotics) then
pediatricians will refer the child to an ear-nose-throat specialist
for evaluation.  The ENT may recommend ear tubes at this point.  You
should also get a second opinion, as with any surgery.

Ear tubes seem to work best in children that have chronic ear
infections that do not clear up compeltely.  In such children the
pediatrician will see a certain amount of fluid in the ears at all
times.  If your child suffers from frequent acute ear infections, with
total clearing up in between (no fluid), then it is less likely that
ear tubes will help as much.  (NOTE: I lost the reference to the
medical journal article on this one, so this is my paraphrase of what
I remember.)

Another indicator for ear tubes is that the infections are causing
temporary hearing damage (which may lead to permanent hearing problems
as well as speech delays).  Fortunately, in the early years, kids
speech depends somewhat on feedback -- you can tell when the child's
hearing is affected because they do not speak as much, and when they
do speak, their speech stays at the same developmental level (or
regresses).

3B.  WHAT IS A VISIT TO THE EAR-NOSE-THROAT (ENT) SPECIALIST LIKE?

My experience has been that ear-nose-throoat specialists like to see
the child when he/she is not on any antibiotics, which means that you
may need to finish up a course of antibiotics or go off the maintenance
antibiotics before you can see them.

3C.  WHAT IS THE OPERATION LIKE?

Before the operation, a child is usally required to give a blood
sample and a urine sample for analysis and testing.  This can be done
any time before the day of the operation. 

Because of the general anaesthetic, your child is not allowed to eat
or drink from midnight the night before the operation until the operation
is completed.  Usually, these operations are scheduled early in the 
morning, and a set of children are done youngest first.

Here are some testimonies (names removed):

"Our daughter got ear tubes when she was about 3 years old after almost
2 years of chronic infections and "prophylactic" antibiotic use in
between the infections.  She went in Sat. morning, they used general
anesthetic because it is a delicate operation and kids wiggle too
much.  She recovered in an hour or so (this was the heartrending part;
she was supposed to lie still which meant we couldn't hold her and her
throat hurt due to also having her adenoids removed so she cried and
we felt miserable).  Then we went home and ate ice cream :-)"

"Both our kids had the tubes put in at a "one day surgery" type center,
attached to a regular hospital.  In both cases, from the moment they
took the child from us to the time at which the doctor came to talk to
us was well under 15 minutes; I think the surgery took about 5-7
minutes.  They have to use a general -- there are no other choices.
Neither child received any pre-op medication (they used to, but the
side effects aren't worth it.)  By far, the worst part is when they
come to take your child (I've heard of parents that got to carry their
child in to the operating room, and stay with the child until they
were put under, but I've never experienced it.  Plus, it means they'd
have to be under longer, while the parent gets out of the room, before
they can start the surgery.)
  As I said, they have to use general anesthetic, and they use a quick
acting gas, in our cases (you will talk to an anesthesiologist before the
surgery, in all likelyhood).  The mask is simply put near the child's face,
and they go right to sleep.  We were told that the gas is usually stopped
about the time they start on the second ear (if both are being done); in
our cases, they were never breathing only from the mask (i.e. the mask
was close to, but never completely covering, their nose and mouth, meaning
that they were breathing some regular air, which reduces the risk of
accidentally cutting off the appropriate flow of oxygen.)
  For both our kids, they were wisked off to a recovery room as soon as
the surgery was over, and they got oxygen for a few minutes.  As soon as
they were even slightly awake, we were allowed to be with them.  Different
age kids react differently, and of course, even within a single age group,
each kid has their own reaction.  In my kid's age range, fury is generally
the reaction -- my kids were both major big time MAD -- my daughter switched
back and forth between crying (ok, screaming) and blowing raspberries, which
is how she expresses fury!  It was sad and funny.  Also, neither had yet
regained full control of their heads/necks when we first went in, and you
have to support it the way you would a newborn.  For my daughter, I'd
taken along our hip carrier (Sara's Ride), and was glad I did -- the way
she threw herself around, I don't think I could have held onto her, but the
carrier made it much easier.  With both kids, there were slightly older
children recovering at the same time (>18 months, but less that 2.5 years),
and they seemed much more like an adult -- calm and groggy.  The nurses
told me ours were typical of their age.  Oh yes, my kid's eyes rolled
wildly at the beginning too.  I was perfectly willing to put up with the
lack of full motor control for the chance to be with the child as soon
as I could.  
 I know other people that didn't see their child for 30-45
minutes, and they were already past all those effects.
  They keep them in the recovery area until they seem more back to normal,
including the ability to drink a bit from a cup or bottle, and not throw
it up (most kids don't, but they want you to give the child a bit to drink,
and then wait 15 or 20 more minutes, just in case).
  Both my kids crashed the second they got home, and woke up **completely
normal** in about 90 minutes.  Appetite, sleeping habits, and behavior
were all perfectly normal.  In my daughter's case, we noticed the difference
in her hearing immediately -- in the first 2 hours after her nap, she
added 3 new words to a vocabulary that had stalled out months before.
In my son's case, it was a little more subtle -- after about 10 days, we
looked back and said "WOW".  Both became far more attentive to the way
we said things, and watched our mouths intently for several days -- you
could tell things sounded different to them, and they wanted to figure out
why."

"I think [my son] was away from me for about 20 minutes.  The actual
procedure of inserting the tubes takes maybe 2 minutes.  The rest of
the time was mostly due to them waiting until he had gotten most of
the anesthetizing gas out of his lungs (they wanted his lungs cleared
out sufficiently before they brought him back to me).  We needed to
stay around for about another 30 minutes or so until they checked him
once more, then we got to leave.  He fell asleep on the way home and
ended up sleeping for about 2 or 3 hours (his usual nap at that age).
When he got up, he acted the same as he always had.  No nausea, no
signs of any pain or irritation at all.  Before he fell asleep, he had
been upset, mostly due to being away from me in a strange place.  None
of those signs were there after he woke from his nap."

"The operation was not traumatic.  We arrived at outpatient surgery at
7:00 a.m., operation scheduled for 8:00, home by 10:30.  We had met
previously with the anesthesiologist, who explained in detail the
procedure and the risks.  I went into the operating room and held [my
daughter] while the anesthetic was administered (and I regret that I
don't recall what it was); in fact, I held the mask over her face.  As
soon as she was "out" she was whisked from my lap to the table and I
was whisked out the door.  Fifteen minutes later the physician was
explaining to us that there had been lots of heavy fluid behind the
eardrum, she'd probably have improved hearing, etc.  Fifteen minutes
later we were in the "outer" recovery room with her.  The
anesthesiologist and nurses had explained in detail that her behavior
would be odd for about an hour, and she was indeed thrashing and
crying and obviously not focusing.  But 45 minutes later she was her
normal, cheerful self.  We'd been cautioned that she might be cranky
the remainder of the day, but in fact she was even cheerier than
usual.  The next day she volunteered, "Ear doesn't hurt anymore, Mom.""

3D.  WHAT DOES THE OPERATION COST?

For the surgeon and anesthesiologist, people reported the total cost to
be about $1200-$1500 (in 1991).

3E.  DOES THE OPERATION HELP?

Most people report that their children had no ear infections for at
least the first nine months after the surgery.  In all cases, the ear
infections were never as acute or lonng-lasting as the ones the child
had before the ear tubes were put in.  With the tubes in, the ear
infections were much easier to spot, and were therefore caught
earlier.

3F.  HOW DO YOU CARE FOR THE EARS WHEN THE EAR TUBES ARE PRESENT?

Doctors differ a lot in how much you have to protect the child's
ears from getting water in them.  The loosest recommendation seems
to be to use the ear plugs if the child's head is going to be submerged
repeatedly.  Many people have found that their young children really
object to the ear plugs.

There are two kinds of ear plugs:  custom-fitted and over-the-counter.
The over-the-counter ones are good for keeping out casual trickles of
water and such, but do not always work when the head is submerged.
You can buy custom-fitted ones for $35-$40 apiece.  These are easy to use
and do keep the water out very well.  Most people seem to think they
are easier to use also.

To make the custom plugs, they make a mold of the child's ear and use
that to shape the plugs.  The plugs have a little "peg" handle
sticking out of them.  They are really easy to insert and take out.
Position them so the part that goes in the ear canal fits in there and
then rotate the plugs backward to where they fit into the outer ear
part which keeps them in place.  The people that make the plugs will
show you how to insert them.

Another tactic people have used for baths is to protect the ears
during hair washings using one of those foam rings that are normally
used for protecting a child's eyes (like the one found in the Lillian
Vernon catalog).

If the ear does get submerged or wet, you can put a few ear drops in
(which contain a liquid antibiotic).  You can also  use a few drops of
rubbing alcohol to dry out a wet ear.

3G.  CAN CHILDREN WITH EAR TUBES IN STILL GET EAR INFECTIONS?

Yes.  You can easily tell if this happens because fluid will start
draining out from the ear tube.

There is a study (I haven't actually seen the reference for this one)
that decided that ear tubes significantly lose their effectiveness
after nine months.

3H.  WHEN AND HOW DO EAR TUBES FALL OUT?

The ear tubes are trumpet shaped, and will work their way out eventually
(usually about 9 months to a year).  They are designed not to fall in.
Growth seems to be a factor in how soon they fall out -- as the ear
develops it pushes the tubes out.

In terms of the ear healing at that point, someone says:
"I had been under the mistaken impression that hearing would be
automatically damaged by any puncture to the ear drum, and had always
wondered why tubes didn't have this problem.  As it turns out, many
ruptures heal without scarring, and it is the presence of scar tissue
that makes the ear drum work at less than perfect capacity.  Generally
what happens is that as the ear drum grows, it slowly pushes the tube
out, and then heals perfectly."

Sometimes you can tell when the tube falls out because you find the
tube, but this is not very common as the tubes are very small (about
the size of a mechanical pencil lead).  Many people find out because
the child gets another ear infection.  If the parents are not watching
for the tube to fall out and therefore ignore the symptoms of the ear
infection in the child, this can be a problem.

The child is also checked periodically by the ear-nose-throat specialist
to see whether or not the tubes are still in.

After the ear tubes fall out, a child may need a second set if the ear
infections still persist.

3I.  WHAT ARE THE RISKS OF THE OPERATION?

First, there are the normal risks associated with general anesthesia.

Second, there is a risk of injury to the ear drum (usually heals
completely in a young child.)  Occasionally a second operation is
required to close the hole in the ear drum, but usually it closes on
its own.  There is also a risk of a very minimal (hard even to detect
with good testing) hearing loss if the ear drum does not heal
perfectly when the tubes come out.

There is a risk of post-operative infection.  I think they usually
prescribe liquid antibiotic ear drops to help prevent this.  They need
to be put in for 3-4 days after the operation.

4.  WHAT IS THE RELATIONSHIP BETWEEN EAR INFECTIONS AND ADENOIDS?

Adenoids usually grow larger as a child grows into his/her teenage
years, then stabilize and/or shrink.  Overly large adenoids in a young
child can cause ear infections.

5.  ARE THERE ANY GOOD BOOKS TO READ?

"Ear Infections in your Child"  (I don't know the author, sorry)