Ear Tubes for Children With Bleeding Disorders

Ear tube surgery is a safe procedure for most children with bleeding disorders
Author: Sarah Aldridge

Fever. Fussiness. Feeling of fullness in the ear. Ear infections can cause pain and problems for children. While most acute ear infections can be treated with antibiotics, it’s the chronic ones that cause concern.

Caylee Yarnell, 8, of South Vienna, Ohio, had one ear infection after another when she was younger. The tip-off for ear tubes occurred when she was 3 ½. “We noticed one day that she went up to the TV and literally sat with her ear against it,” says Carrie Yarnell, 32, her mother, a clinical laboratory technologist at The Ohio State University in Columbus. An appointment with an otolaryngologist, or ear, nose and throat specialist (ENT), was revealing. “They did the various hearing tests and found out she only had 20% of her hearing capacity. She was hearing a yell as a whisper,” Carrie says. Six months later, it was tube time for Caylee, who has type 1 von Willebrand disease (VWD).

Ear tube surgery is minimally invasive and doesn’t involve much bleeding, making it a safe procedure for most children with bleeding disorders. But before considering it for your child, it’s important to understand how ear infections develop and what ear tubes can do.

Ear Anatomy

The ear has three parts: the external, middle and inner ear. The middle ear, where most ear infections occur, contains the components of hearing. The tympanic cavity, or eardrum, is covered by the tympanic membrane. It interacts with three small auditory ossicles, or bones, named for their shapes—the malleus (hammer), incus (anvil) and stapes (stirrup). Sound waves are transmitted from the external ear to the tympanic membrane, which vibrates and sets in motion the auditory ossicles, which are filled with air, vibrating and amplifying the sound. The sound signals are then carried to the inner ear, where the acoustic nerve relays them to the brain.

The middle ear also contains the eustachian tube, a canal connecting the nasopharynx (back of the throat) to the ears. Tiny hair cells in the eustachian tube move fluid in the middle ear away from the eardrum toward the throat, where it is swallowed.

Causes of Ear Infections

A young child’s immune system is immature, easily overwhelmed by a host of microorganisms. “A child between the ages of 6 to 24 months can get 11 to 15 colds or upper respiratory tract infections per year,” says Charles Elmaraghy, MD, interim chief, Department of Otolaryngology, at Nationwide Children’s Hospital in Columbus, Ohio. Those can turn into ear infections when the child’s eustachian tube—which is short, floppy and horizontal—readily moves microorganisms from the throat into the ear. By age 5, most children have had at least one ear infection, according to the American Academy of Otolaryngology-Head and Neck Surgery.

Once bacteria and viruses enter the middle ear, they can become lodged there. A partial vacuum then forms, drawing in more microorganisms, which can multiply, causing otitis media, or inflammation in the middle ear. The buildup of pus and fluid pushes on the eardrum, causing pain and preventing the transmission of sound vibrations, which results in hearing loss.

Ear infections in children are also linked to other causes. “Daycare and secondhand smoke from cigarette smoking are two of the biggest contributing factors,” says Elmaraghy. So is extended use of pacifiers. “The rest has to do with genetics and your unique anatomy.”

Cut-off Criteria

“When my boys had an ear infection, I could always tell because of fever and fussiness,” says Becca Robbins, 31, a stay-at-home mom from Rogers, Arkansas. Ben, 4, and Rhett, 2 ½, have severe hemophilia A. Prescription antibiotics temporarily stopped the infections, but not for long. “They had numerous, recurring ear infections that had gone on for the first 12 months of life,” she says.

The main criterion for ear tube surgery in children is frequency of infection. “Our pediatrician said if six occurred within the first 12 months of life, then it was time to get tubes,” Robbins says. “Our criteria for recurrent ear infections are three that require antibiotics in six months or four in 12 months,” says Elmaraghy.

Although criteria may differ, the rationale is the same: preventing the growth of antibiotic-resistant bacteria, and avoiding hearing loss and speech delays. Although Caylee’s speech was unaffected, she had significant hearing loss and experienced a complication with taking oral antibiotics. “She was on five antibiotics in an eight-week period and got a yeast infection,” Carrie says.

ENT Evaluation

A child with multiple ear infections should be evaluated by an ENT. “We usually do a hearing test, a physical exam and a very thorough history to rule out any other preventable causes of ear infections,” says Elmaraghy.

Chronic fluid in the ear can cause conductive hearing loss, preventing the transmission of sound waves to the middle ear. Signs of this type of hearing loss include speaking loudly, misunderstanding speech or not hearing certain words. Further testing can pinpoint problems or diagnose developmental delays. “I assess speech and language skills during the exam to evaluate if the child is age appropriate,” Elmaraghy says.

Treatment Plan for Bleeding Disorders

Once it has been determined that your child needs ear tube surgery, there should be a meeting of the medical minds. “My role as a hematologist is to communicate with the ENT the treatment plan for the child,” says Amy Dunn, MD, pediatric hematologist/oncologist, Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta. “For a patient with VWD, there are fluid guidelines that should be followed when taking DDAVP.” DDAVP is the synthetic hormone desmopressin acetate, which can cause hyponatremia, a low concentration of sodium in the blood.

Because the surgery is minimal and the ear does not contain a lot of blood vessels, the bleeding risk is low. “Factor coverage for patients with hemophilia is less important than in tonsil and adenoid surgery,” Dunn says. “For ear tube surgery, lower doses are needed, with less frequency.” (See “Tonsil and Adenoid Surgery in Children,” hemaware.org, Jan. 11, 2012.)

Tube Types

There are a variety of tube types, shapes and sizes, but most are flexible plastic cylinders about 3 mm in diameter. Some have an antimicrobial coating to decrease infection risk. Others have flanges, or hooks, that anchor them in the eardrum for longer periods.

“For a child with very small ear canals, I use tubes that are smaller,” Elmaraghy says. “If I want a tube to last longer, I use a T tube, which is a more permanent ear tube that I can leave in there for years.” Most tubes fall out on their own after six to 18 months, but an estimated 5% to 10% have to be surgically removed, he says.

Ear tubes break the vacuum effect. “With an ear tube, or pressure equalization tube, you’re equalizing the pressure from the middle ear space to the environment,” says Elmaraghy. “You don’t have that negative suction effect, pulling things from the throat into the ear.” The new ear tube keeps the eustachian tube open, allowing air and sound waves to reach the middle ear. Fluid can then drain more easily into the ear canal, instead of stagnating and causing infection.

Ear Tube Surgery

To insert the ear tube, the surgeon creates a small hole in the eardrum, about 1.5 to 2 mm in diameter. Fluid and debris can be suctioned out before the tube is placed. The surgery is typically outpatient, even for children with bleeding disorders. “The procedure requires general anesthesia, but it’s fairly short,” Elmaraghy says. “It usually takes five to 15 minutes. There can be very minor bleeding, but it can be controlled pretty easily.”

Ben Robbins was 15 months old when he got ear tubes in January 2009. “We infused him no less than six hours before he went into surgery, then 24 hours after surgery,” says his mother, Becca. Handing her firstborn over to the surgical team was a little nerve-wracking for her, but everything went smoothly. “We were surprised by the short amount of time that it took and the ease at which Ben came out of the anesthesia. He was able to go home that day,” she says.

Some patients with bleeding disorders have other procedures done at the same time, requiring a longer hospital stay. “For her surgery, Caylee ended up inpatient for four days,” says Carrie. That’s because Caylee also had her tonsils and adenoids removed.

Post-op Problems

As with any surgery, there can be post-op problems. “The most common complication is drainage from the ears that is chronic in nature,” says Elmaraghy. This otorrhea, or pus drainage, is usually from resistant bacteria and can last weeks to months, he says. Once the fluid is suctioned out and antibiotic ear drops are applied, the drainage typically stops. For persistent drainage, a fluid sample may be diagnostic. “We can culture the bacterium to determine what type it is and then direct a specific antibiotic to use,” he says.

The second most common complication is a chronic perforated eardrum after the ear tube has fallen out. This occurs in about 3% to 5% of patients with ear tubes, says Elmaraghy. “You’re making a hole in the eardrum, so the hole may not heal by itself.” Some perforations heal spontaneously, but others require a tissue graft or patch, he says.

Although ear tubes are not guaranteed to prevent future infections, they lessen their severity. Most ear infections after tubes can be treated with antibiotics, either ear drops or oral medications. The difference in Caylee’s post-op infections is marked, says her mother. “We didn’t know she was having ear infections because she never had pain.”

But what Caylee’s parents didn’t know could hurt her. “She got one ear infection that was bad enough that it dislodged one tube and moved the other tube around,” Carrie says. The solution was a second set of larger tubes when Caylee was 6.

Why some patients do well after one set of ear tubes and others require subsequent surgeries has to do with their exposure to risk factors and genetics. “Some people anatomically have inherent dysfunction in the eustachian tube,” says Elmaraghy. They continue to experience problems and need adjustments.

Caylee’s second set of ear tubes was removed in October 2011 after a strep infection led to a suspected ear infection. “The ENT found that what we thought was a typical ear infection was actually debris that had lodged in the ear and had moved the tube.” Now tubeless, Caylee has had one ear infection, successfully treated with an oral antibiotic.

Night and Day Differences

Within the first week after surgery, the child’s hearing should improve. “Caylee’s hearing went back into a normal range,” says Carrie. Elmaraghy retests the child’s hearing one to two months post-op. “If the hearing test is normal, I then check it as needed,” he says.

Becca’s boys have fared well since their ear tube surgeries. “They’ve had no ear infections. There has been a night and day difference for us.”

Parents should be aware of a post-op precaution. “One thing all physicians are consistent about is if the child is going to swim in lake, ocean or untreated water, he needs ear plugs,” says Elmaraghy. Bath water and chlorinated pools, on the other hand, don’t require them, he says. 

However, Caylee is among the small percentage of children with ear tubes who experience severe pain with any water exposure. “The first time she had a bath after the surgery, I was washing her hair and she just screamed bloody murder,” says Carrie. “She always has ear plugs in if she goes swimming.”

Consider the Benefits

Although parents may dread ear tube surgery in their child, it can be beneficial. “Even in children with bleeding disorders, if you have an experienced surgeon and the appropriate precautions, it is a very simple and effective surgery,” says Elmaraghy.

Caylee now watches TV from a healthy distance. “She went from not being able to hear to being able to hear,” says Carrie. “Despite the issues that she has had, I still think it’s worth it to go get the tubes.”


Steps for Living: Consider the Whole Child

Visit the American Academy of Otolaryngology-Head and Neck Surgery Web site