Avoiding ear tube surgery

My 3-year-old son has had three ear infections over the past two months. First, he got a cold and then had a fever. I took him to the doctor, who said he had an infection in his left ear; he was given amoxicillin. A week later, his fever returned and I took him back to the doctor. The left ear was better, but his right ear was infected and we were given a different antibiotic. He was fine until a week after the antibiotic was stopped. His fever came back and his left ear was infected again. The doctor gave him another round of antibiotics and said he might need tubes in his ears if we couldn't cure his infection. Isn't there a stronger antibiotic that can get rid of the infection, instead of switching around? I don't want surgery if he doesn't have to have it.

There is normally air on both sides of the eardrums or tympanic membranes. This allows for its normal vibration in response to sound waves, which allows us to hear. The air behind the TM comes in from the throat area through the Eustachian tube, which curves up to the middle ear space. If the ET gets blocked from allergies or, more frequently, colds, fluid accumulates behind the TM. If the tube remains blocked, eventually, bacteria that are normally found in the nose and throat will start to grow in the middle ear fluid behind the TM and result in an infection. White blood cells will then attack the bacteria, causing pus and expansion of the fluid, stretching the TM into the ear canal. The stretching is painful. Occasionally, the TM will break or perforate, and the fluid will drain out of the ear canal, lessening the pain.

The antibiotics that initially are used are directed against the most common bacteria associated with otitis media. In the majority of cases, amoxicillin is used and will be effective. In some cases, the bacteria will not be sensitive to amoxicillin, but in those cases, the symptoms will not improve within the first few days of treatment. People sometimes think of antibiotics as being stronger than others, but the issue is really whether the germs are killed by the antibiotic or not.

Some antibiotics will kill a large number of different types of bacteria. But in most infections, you are really only trying to kill a single type of bacteria responsible for the identified infection. Killing other germs that are not responsible for the infection allows resistant germs to increase in number, taking over space vacated by the "innocent" bacteria killed off by the antibiotic.

In most cases, the bacteria responsible for the ear infection is not cultured to determine its sensitivity to antibiotics. In studies where it was suspected that the germs were resistant to the initial antibiotic chosen and cultures were taken, most often, the germs were sensitive. In these cases, it was suspected that the amount of antibiotic getting into the fluid might not have been sufficient to kill the germs. Since the real problem is the presence of fluid in the middle ear, in most cases of repeated ear infections, the infection is initially cleared but returns because the ET remains blocked.

Most children have ear infections under the age of 4, because, as they grow older, the ET also grows and is less likely to get blocked. If the child can avoid getting tubes before age 4, they are less likely to need them later. The tubes function to allow air from the outside into the middle ear space, preventing the fluid accumulation.

One of the concerns related to persistent OM is speech delay because of an inability to hear certain sounds from impaired TM vibration. This is most likely to occur when both ears are chronically involved. Tubes will fall out with time, but if and when the ET opens, they serve no function.

If your son recovers from his current infection, your pediatrician might want to follow him to see if the fluid persists, indicating continued blockage of the ET and the possibility of another infection. In most cases, the ET opens with time, as the inflammation associated with the cold or allergy resolves. I suggest you talk with your pediatrician about your concerns regarding tubes. Once a referral is made to an ear, nose and throat specialist for repeated infections, it is assumed that tubes are expected.

  Dr. Kendall Sprott, at New Jersey Medical School