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Dr. Todd Otteson from pediatric ENT joins us to discuss ear infections and the role of ear tubes in children with Down syndrome.
Dr. Vellody: Welcome back everyone to our next edition of the Down Syndrome Center of Western Pennsylvania podcast. I am your host Dr. Kishore Vellody. I can’t believe that we are already on our 10th podcast! Thanks to you, our dedicated listeners, we have just gone over 2000 individual downloads for these podcasts. I’m glad that you are finding these podcasts helpful but please continue to let us know the topics that you’d like covered or any other helpful suggestions you might have.
Well today, I’m glad to be joined by Dr. Todd Otteson who is a pediatric ENT physician here at Children’s Hospital of Pittsburgh. Dr. Otteson quickly became one of our favorite ENT doctors here at the Center. We like to call him the ENT “doctor to the stars.” Unfortunately for all of us, Dr. Otteson is going to be moving on towards a new career opportunity, but I though I should get him on the podcast before he leaves us. Thanks Todd, for joining us today on this podcast. Today, I’d like to get your approach to ear infections, otherwise known as acute otitis media. But before we get to the questions, could you please give our listeners an idea of your training background?
Dr. Otteson: Sure. After finishing medical school, I did one year of general surgery and then four years of otolaryngology (or ENT) residency. That was anything from sinus surgery to ear surgery to even a little bit of facial plastics surgery and head and neck cancer. So it was everything. Then I did a two year fellowship here in Pittsburgh at Children’s just for specialty in pediatric otolaryngology. That’s the more either complicated patients or complicated cases as it relates to the ear, nose, and throat problems.
Dr. Vellody: Ok, so it takes a few years to become a pediatric ENT specialist! Well, let’s jump right into this podcast. Can you give me your simplest definition for what an ear infection is?
Dr. Otteson: Sure. So an ear infection or otitis media basically is an infection of the ear drum where there is fluid, usually pus, in the middle ear space (behind the ear drum). It’s diagnosed by symptoms. So taking a good history, of course, is important, but also the physical exam with the look of the ear drum on physical exam.
Dr. Vellody: Thanks, Todd. I couldn’t agree more that the history and exam findings are extremely important. An ear infection is more than just a fussy child who is tugging at their ears. Their exam really needs to show a red, bulging ear drum from infectious fluid behind it, that prevents the ear drum from moving normally. With all the antibiotic resistance these days, it is more important now than ever to make sure the diagnosis is made correctly. Well, one thing we know is that ear infections seem to be more common in Down syndrome. Can you share why that might be?
Dr. Otteson: I think there’s probably a couple of issues. One is ear infections are more common in children who have abnormal Eustachian tube function. The Eustachian tube connects the middle ear to the back of the nose. It is an age related thing so the younger children don’t have as good Eustachian tube function. But even related to their peers, children with Down syndrome generally have worse Eustachian tube function so that’s a set up for additional infections. That’s the first thing. I feel like, in general, that the immunity of the children with Down syndrome is maybe a little bit worse, perhaps, than other children as well. It sort of two strikes. The one is the anatomy of the Eustachian tube and the other is just the natural immunity (the body’s ability to fight infection). I think that a separate issue, but I think also important, is children with Down syndrome have quite narrow ear canals, especially the younger infants obviously because they are smaller. That can make it more of a challenge to actually even diagnose the ear infection because, again, it was by our physical exam. That can sometimes be difficult. It sometimes takes some wrangling in the clinic to try and clean out ear wax and make sure that we get a good diagnosis and the correct diagnosis.
Dr. Vellody: Wrangling and cleaning out ear wax are not my favorite things so I’m glad that ENT is always just a referral away! But I digress . . . now onto the next question. Families often ask me about ear tube placement. Could you start us off with an explanation of what ear tubes are?
Dr. Otteson: Sure. So the tubes themselves we sometimes they’re known as ventilation tubes which actually describes their purpose quite nicely. Basically a tube is placed by making a small incision in the ear drum. We drain any fluid that’s there at that time and then the tube goes in. So basically the tube is a grommet that just spans the ear drum. It allows air or ventilates the middle ear space. Allowing that air in makes the whole lining of the middle ear healthier. It cuts down on the number of infections but also the severity. That pus behind the ear drum is what causes the fever and symptoms of the pain, all of that. With the tube in and inability for that fluid to recollect, that’s why tubes are helpful.
Dr. Vellody: Ok, which patients should get ear tubes? Are their guidelines that you follow to make those decisions?
Dr. Otteson: The criteria to consider placing tubes are if there have been 3 or more infections in 6 months or 4 or more infections in 12 months. That’s for the infections themselves. A separate reason but equally as valid is if we’ve had fluid behind the ear drum on both sides for longer than 3 months. I would consider both of those equally as important in children who have Down syndrome because I would be a little more aggressive in terms of recommending tubes in that case. I don’t want any middle ear fluid to cause any hearing concerns because I want to make sure that there’s not any strike against that child as it relates to communication and speech production and all of that. I want ears to be a non-issue with that type of development.
Dr. Vellody: Thanks, Todd. We know that hearing issues can result in speech difficulties. And we know that speech delays are more common in children with Down syndrome, even if they have normal hearing. However, something potentially preventable like hearing loss contributing to further speech delays should be avoided if at all possible. Can I just clarify one thing for our listeners? Are you saying that a child can have fluid behind the ear drum that is not infected but that this can also lead to hearing difficulties?
Dr. Otteson: That’s exactly right. Often there can be fluid behind the ear drum but it’s not necessary infected fluid. That’s where the physical exam is helpful. There have been studies done before to test exactly how long it takes for fluid to clear and reabsorb after an infection. I usually will tell families that about half of children will still have fluid 1 month after an ear infection. 25% will still have fluid at 2 months and 10 % will still have fluid at 3 months. Its at that 3 month point when we would consider placing tubes if there’s still fluid there.
Dr. Vellody: Ok, so let’s say the decision has been made to place ear tubes. Can you take our listeners through what to expect on the day of the procedure itself?
Dr. Otteson: Sure. They usually will have the child come probably an hour or hour and a half before the scheduled time for surgery so that they can be examined by the anesthesia team to make sure everything is good. Once we’re in the room, the anesthesia team will place a mask over the patient’s nose and mouth so that they can breathe the inhaled anesthesia. Really, its just a couple or three breaths and they’ll be off to sleep. Once they’re asleep, then we use a microscope and everything is just through the ear canal. I just would place a small incision in both ear drums. There’s a small suction so that we can suction out any fluid that’s there and then place the tubes that we said is a little bit like a grommet. Children who have Down syndrome, as we mentioned, have smaller ear canals so placing tubes can be a bit more of a challenge. I sometimes will tell families that it’s a little like doing jumping jacks in a closet. I’ll usually allot a few extra minutes just because I know that it’s going to be a little more of a challenge. Once the tubes are in, probably 5 minutes and we’re starting to wake up. We head off to the recovery room. From entering the door to the operating room to leaving the door of the operating room is anywhere from 10-20 minutes. Then they’ll be in the recovery room probably for an hour just to make sure that they’re waking up well and drinking well. Then they’ll be on their way home.
Dr. Vellody: And what about after they’re home . . . what do families need to be aware of in terms of taking care of the tubes?
Dr. Otteson: I usually recommend that we use some antibiotic ear drops for about a week and mostly that’s to help with any inflammation still that ‘s in the middle ear. Even though we’ve drained the fluid, sometimes there can still be some infection or inflammation there so the drops can be helpful. They also can be helpful about making sure that the tube doesn’t get blocked with any of the dried drainage. It’s not uncommon to have drainage for the first few days right after surgery. It can sometimes even be bloody drainage if that’s been inflamed or infected. The follow-up usually includes a visit in the ENT clinic about 1 month after surgery. We’ll check the tubes, check on the tube position, and make sure everything looks open. Then, if possible, we’ll get a hearing test on that day. Sometimes if we’re not so cooperative, the information is limited but we’ll take what we can get. With regard to precautions, we usually recommend that we protect the ears from having water go in. At the pre-op visit, we’ll usually fit the child with ear plugs that we like to have used for swimming or bathing.
Dr. Vellody: Ok, so there’s definitely some post-operative care that families are going to need to keep in mind. After the tubes are in place, do they typically need to be taken out in the operating room or will they fall out on their own?
Dr. Otteson: So the average length of time that the tubes stay in place is, there was a study done here in Pittsburgh, that it showed it to be 14.5 months. I’ll usually tell families between a year and a year and a half that the tubes are in place. The vast majority of the time they’ll fall out on their own. If the tubes have been in 3 years or more, that’s when I would recommend going back to the operating room and removing them and patching any hole that remains. Beyond 3 years, the chance of having a hole that doesn’t heal is higher. Taking all that into account though, children with Down syndrome, for whatever reason, they seem to extrude their tubes sooner than the average. I will usually have that discussion with the parents so we’re on the same page. It means I usually will check on children who have Down syndrome with their tubes more frequently. So instead of a yearly visit I’ll probably see them in 6 months and then every 3 months instead of every 6, something like that.
Dr. Vellody: That’s good to know. It’s already time to wrap up this podcast. Could you give us your top two reasons why you think ear tubes might be beneficial to a patient with Down syndrome who has recurrent ear infections or chronic middle ear fluid?
Dr. Otteson: I think the biggest one is just it cuts down on the number and the severity of the infections. That’s really the primary purpose of the tubes. I think a secondary benefit I alluded to the fact that it can help with keeping on track with speech and language development which I think is really crucial in children with Down syndrome. I think that’s the two big issues.
Dr. Vellody: All right. Todd, thank you so much for joining us here today to talk about ear infections in children with Down syndrome.
Dr. Otteson: Well I really appreciate the opportunity to be here. It’s been great.
Dr. Vellody: Awesome. Well, I’m looking forward to having you back again soon to discuss more ENT related issues in Down syndrome. Until then, let me say good bye to our listeners. We’ll talk to you soon.
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