The debate over tympanostomy tubes vs antibiotics for recurrent acute otitis media (AOM) in young children is long-standing. Now, results of a randomized controlled trial show that tubes do not significantly lower the rate of episodes compared with antibiotics, and medical management doesn’t increase antibiotic resistance.
“We found no evidence of microbial resistance by treating with antibiotics. If there’s not an impact on resistance, why take unnecessary chances on complications of surgery?” lead author Alejandro Hoberman, MD, from Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, told Medscape Medical News.
The study by Hoberman and colleagues was published today in The New England Journal of Medicine.
AOM is the most frequent condition diagnosed in children in the United States after the common cold, affecting 5 of 6 children younger than 3 years. It is the leading indication for antimicrobial treatment, and tympanostomy tube insertion is the most frequently performed pediatric operation after the newborn period.
Randomized controlled clinic trials were conducted in the 1980s, but by the 1990s, questions of overuse arose. The American Academy of Otolaryngology–Head and Neck Surgery Foundation published the first clinical practice guidelines in 2013.
Parents must weigh the pros and cons. The use of tubes may avoid or delay the next round of drugs, but tubes cost more and introduce small risks (anesthesia, refractory otorrhea, tube blockage, premature dislocation or extrusion, and mild conductive hearing loss).
“We addressed issues that plagued older studies: a longer-term follow-up of 2 years, validated diagnoses of infection to determine eligibility, and used rating scales to measure quality of life,” Hoberman said.
The researchers randomly assigned children to receive antibiotics or tubes. To be eligible, children had to be 6 to 35 months of age and have had at least three episodes of AOM within 6 months or at least four episodes within 12 months, including at least one within the preceding 6 months.
The primary outcome was the mean number of episodes of AOM per child-year. Children were assessed at 8-week intervals and within 48 hours of developing symptoms of ear infection. The medically treated children received oral amoxicillin or, if that was ineffective, intramuscular ceftriaxone.
Criteria for determining treatment failure included persistent otorrhea, tympanic-membrane perforation, antibiotic-associated diarrhea, reaction to anesthesia, and recurrence of AOM at a frequency equal to the frequency before antibiotic treatment.
In comparing tympanostomy tubes with antibiotics, Hoberman said, “We were unable to show benefit in the rate of ear infections per child per year over a 2-year period.” As expected, the infection rate fell by about half from the first year to the second in all children.
Overall, the investigators found “no substantial differences between treatment groups” with regard to AOM frequency, percentage of severe episodes, extent of antimicrobial resistance, quality of life for the children, and parental stress.
In an intention-to-treat analysis, the rate of AOM episodes per child-year during the study was 1.48 ± 0.08 for tubes and 1.56 ± 0.08 for antibiotics (P = .66).
However, randomization was not maintained in the intention-to-treat arm. Ten percent (13 of 129) of the children slated to receive tubes didn’t get them because of parental request. Conversely, 16% (54 of 121) of children in the antibiotic group received tubes, 35 (29%) of them in accordance with the trial protocol because of frequent recurrences, and 19 (16%) at parental request.
In a per-protocol analysis, rates of AOM episodes per child-year were 1.47 ± 0.08 for tubes and 1.72 ± 0.11 for antibiotics.
Tubes were associated with longer time until the first ear infection post placement, at a median of 4.34 months compared with 2.33 months for children who received antibiotics. A smaller percentage of children in the tube group experienced treatment failure than in the antibiotic group (45% vs 62%). Children who received tubes also had fewer days per year with symptoms in comparison with the children in the antibiotic group (mean, 2.00 ± 0.29 days vs 8.33 ± 0.59 days).
The frequency distribution of AOM episodes, the percentage of severe episodes, and antimicrobial resistance detected in respiratory specimens were the same for both groups.
“Hoberman and colleagues add to our knowledge of managing children with recurrent ear infections with a large and rigorous clinical trial showing comparable efficacy of tympanostomy tube insertion, with antibiotic eardrops for new infections versus watchful waiting, with intermittent oral antibiotics, if further ear infections occur,” said Richard M. Rosenfeld, MD, MPH, MBA, distinguished professor and chairman, Department of Otolaryngology, SUNY Downstate Medical Center, New York City.
However, in an accompanying editorial, Ellen R. Wald, MD, from the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, pointed out that the sample size was smaller than desired, owing to participants switching groups.
In addition, Rosenfeld, who was the lead author of the 2013 guidelines, said the study likely underestimates the impact of tubes “because about two-thirds of the children who received them did not have persistent middle-ear fluid at baseline and would not have been candidates for tubes based on the current national guideline on tube indications.”
“Both tubes and intermittent antibiotic therapy are effective for managing recurrent AOM, and parents of children with persistent middle-ear effusion should engage in shared decision-making with their physician to decide on the best management option,” said Rosenfeld. “When in doubt, watchful waiting is appropriate, because many children with recurrent AOM do better over time.”
Hoberman owns stock in Kaizen Bioscience and holds patents on devices to diagnose and treat AOM. One coauthor consults for Merck. Wald and Rosenfeld report not relevant financial relationships.
N Engl J Med. Published online May 13, 2021. Abstract, Editorial
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