My 9 year old son was referred by our pediatrician to a ear-nose-throat specialist to have ear-vent tubes inserted. After our consultation visit with the specialist, he recommended not having the tubes placed since my son is only having ear problems 2-3 times a year. The reason the pediatrician wanted the tubes was because of the infections taking so long to clear up with each episode and having to take antibiotics for 1 month to sometimes 2 months in order to get rid of the fluid behind the ear drum that seems to always remain after the infection is gone. The specialist recommended taking out his tonsils and adenoids instead. He feels getting to the root cause will have better results. This makes me wonder why I’ve never heard of this sooner. I guess my question is, should we go ahead with removing the tonsils and adenoids even though they have not given him any problems before?
Pauline Davis – Vancouver, Washington
Dr. Greene’s Answer:
From the 1930’s through the 1960’s, tonsillectomies and adenoidectomies were considered routine surgeries. At that time, the tonsils and adenoids were thought to be useless organs, because their function was not understood, and because they often melt away after childhood. In the late ’60’s we discovered that the tonsils and adenoids play an important role in the immune system. Once this was understood, the practice of routine tonsillectomy and adenoidectomy declined.
In 1990, a very well-designed study by Jack Paradise, M.D. (and colleagues), published in the Journal of the American Medical Association, did show a clear but modest reduction of ear infections following adenoidectomies. In 1999, the same author published another study which showed a “limited and short term” effect. Now we are faced with a decision — is the short-term benefit of removing the adenoids worth the cost?
The adenoids (also called the nasopharyngeal tonsils) are positioned at the back of the throat as defenders against bacteria and toxic substances that come into the body through the nose and mouth. When they are active — fighting infections and producing antibodies — they can become quite enlarged. In this state they can block the eustachian tube and clog the drain from the middle ear. Typically this obstruction is not complete and will still allow some of the normal secretions from the middle ear to drain.
Because the risk of adenoid surgery is greater than that of tube placement, the American Academy of Pediatrics recommends tube placement before adenoid surgery for the initial surgical treatment of most children with persistent middle ear fluid (Pediatrics 2004). However in children over 4 years old who mouth breathe chronically, snore heavily, and/or have chronic nasal congestion, the likelihood of benefit from adenoid surgery is increased. Thus, some doctors may consider adenoid surgery with tube placement or with myringotomy (hole made in the eardrum) for children over 4 years old who have the above symptoms of problematic adenoids.
Tonsillectomies are another story.
In 1983, the British Medical Journal reported a controlled study performed by A.R. Maw. The authors compared those who had their adenoids taken out with those who had their adenoids and tonsils removed. They found that adenoidectomy did result in improvement in middle ear disease. However, there was no additional benefit from having the tonsils removed. At present, there is no evidence that tonsillectomy alone is of any benefit in the treatment or prevention of otitis media. If a child were suffering from some other concurrent condition, such as obstruction of the airway or sleep apnea, however, I would consider tonsillectomy in addition to adenoidectomy as a possible solution.
For your son, Pauline, it’s not really a question of antibiotics versus surgery (the long courses of antibiotics may not be necessary — they may not be speeding up the disappearance of the fluid). The question is fluid in the ear versus surgery. Surgery may well be the better option for your son. His 2 or 3 infections per year — each with 1 or 2 months of fluid — mean that his hearing may be decreased for up to 6 months each year. A formal hearing test and thoughtful assessment of his school performance may help you to reach a decision. The information here can be used as a starting point for discussion with your doctors about the best course of treatment for your son.