Ear infections and ear tubes
Two different things are both called an "ear infection", and they are treated differently. An acute ear infection hurts, comes with a fever and passes. The fluid that stays behind the eardrum after the episode doesn't hurt at all, but it reduces hearing for as long as it is there, which is why it goes unnoticed for months. Ear tubes are mainly about the second, not the first.
Acute ear infection or fluid in the ear?
The distinction is not just a detail, it decides every step that follows.
An acute middle ear infection (acute otitis media) is an infection. The child wakes at night in pain, often has a fever and is restless. Little ones pull or hit their ear. The episode lasts a few days and is treated according to the child's age and how severe it is.
Fluid in the middle ear, also called glue ear or otitis media with effusion, is what stays behind afterward. The ear doesn't hurt, there is no fever, the child plays normally. The only thing that happens is that they hear as if they had cotton wool in their ear, and this can last for weeks or months.
This is where the trap lies. Parents are relieved when the pain goes away and assume it is over. In reality, in most children the fluid stays for several weeks after the episode, and in some for even longer.
Why does it happen so often in children?
The Eustachian tube is the channel that lets air into the middle ear and connects it to the back of the nose. In children it is shorter, more horizontal and blocks more easily than in adults. Add large adenoids, which sit right next to its opening, and the ear stops getting air and fills with fluid.
That is why the problem peaks in the preschool years and fades as the child grows and their anatomy changes.
How can you tell?
Because the fluid doesn't hurt, your child won't tell you. You will be the one to notice.
- Asks you to repeat things or often says "what?"
- Turns up the TV
- Doesn't turn around when you call from another room
- Speaks louder than necessary
- Seems distracted at school or doesn't follow instructions
- Has become clumsier or loses their balance more easily
- Has one ear infection after another
What happens at the appointment?
The examination answers 2 questions: is there fluid, and how much does it affect hearing?
Looking into the ear (otoscopy)
A direct look at the eardrum. It shows whether there is inflammation, whether the eardrum is pulled inward and whether fluid can be seen behind it.
Tympanogram
It measures how the eardrum moves when the pressure changes. It takes seconds, needs no cooperation from your child and is the test that objectively confirms the fluid.
Hearing test
This is the key part, because the decision is not based on how much fluid can be seen but on how well your child hears. It is done with the method that suits their age and is repeated during follow-up.
Checking the back of the nose
The size of the adenoids is first assessed during the examination in the office and, in many children, that is enough. When the picture is unclear, or when the decision depends on their exact size, we use a thin, flexible camera (endoscopy), which shows them directly within a few seconds. An X-ray is never needed.
Treatment
The first 3 months
In most children the fluid clears up on its own. The right approach during this time is monitoring with follow-up visits and hearing tests, not waiting without an appointment. The time is counted from the date the fluid started or, if we don't know when it started, from the day of diagnosis.
In children at higher risk of speech and learning difficulties, hearing is tested from the start, without waiting for the 3 months.
What has not been shown to help
The guidelines explicitly advise against using antibiotics, oral or nasal steroids, antihistamines and decongestants for fluid in the middle ear. They don't make the fluid clear up faster and they have their own side effects. We mention it because these are among the most commonly prescribed.
When are ear tubes needed?
The criteria are specific:
- Fluid in both ears for 3 months or more, with documented hearing difficulty
- Recurrent acute ear infections, meaning 3 or more episodes within 6 months, or 4 within 12 months with at least 1 in the last 6 months. With one important condition: if there is no fluid in either ear at the time of the assessment, ear tubes are not recommended
- Children at higher risk, where the decision is made earlier and at a lower threshold
Likewise, a single episode of fluid that lasts less than 3 months is not a reason for ear tubes.
The procedure
It is done under a short general anesthetic and takes a few minutes. The doctor makes a tiny opening in the eardrum, removes the fluid and places the tube, which keeps the ear ventilated. Your child goes home the same day. Hearing usually improves immediately.
If the adenoids are judged to be keeping the problem going, they can be removed in the same procedure.
Frequently asked questions
Yes. Current guidelines advise against routine precautions for water, such as earplugs, headbands or avoiding swimming. Bathing, showering and swimming can go on as normal. There may be exceptions in individual cases, for example diving deep or swimming in water of doubtful cleanliness, and the doctor will tell you if this applies to your child.
They fall out on their own as the eardrum renews itself and pushes them outward, usually within 12 to 18 months. No second procedure is needed to remove them.
Your child is asleep and feels nothing. Afterward there is little or no pain, and children usually go back to their normal activities the next day.
Not for the fluid. Antibiotics are for an acute ear infection, depending on age and severity, and the decision is made by the doctor. For the fluid that stays afterward, they offer no benefit.
In most cases no, as long as the problem is found and monitored. The concern is fluid that stays for months without anyone knowing, especially at the age when speech is developing. στην ηλικία που χτίζεται ο λόγος.
It happens, and it usually shows differently: instead of pain, fluid comes out of the ear. It is treated with ear drops, and it is one of the reasons ear tubes help, because the ear drains instead of building up pressure.
When should you not wait?
Immediately
Swelling or redness behind the ear
When the area behind the ear is swollen, red or tender and the ear seems to stick out, your child needs to be seen at a hospital right away.
Soon
Fluid in both ears for more than 3 months
At this point monitoring stops and a hearing test is needed, because the decision depends on it.
Soon
Speech delay with a history of ear infections
We don't wait for them to "grow out of it". A hearing test comes before any other step.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Rosenfeld RM et al., Clinical Practice Guideline: Otitis Media with Effusion (Update), AAO-HNSF, 2016 · Rosenfeld RM et al., Clinical Practice Guideline: Tympanostomy Tubes in Children (Update), AAO-HNSF, 2022.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
