Tympanostomy Tubes—Where We Were,Where We Are,and Where We Will Be: A State-of-The-Art Review

With great interest I read the supplement and the editorial concerning tympanostomy tubes. ¹ For discussion sake, especially concerning the mentioned cost-containment, I advise readers to “sit down before some other facts” ¹ and “be prepared to give up every preconceived notion” ¹ before starting to think of inserting tubes.

In my opinion, the idea that OME is a disease that needs to be treated with tubes is, in the wording of the citation the editorial used, “an adopted creed.” ¹

Until now, many colleagues consider OME to be a disease in the same category as AOM, suggesting that it should be treated as such. However, the relation—if there is one—is only temporal in that OME often follows AOM.

It is in my opinion essential to discriminate AOM—a disease with otalgia, fever, and sometimes severe complications—from OME. The glue-like effusion, containing the most powerful factors our immune system can release, is the firewall that is set up by the middle ear in order to prevent the possible fatal complications of AOM. ²

What should we do with OME? Many cases resolve spontaneously. So the best treatment is reassurance, avoidance of unproved therapies, and parental education. ³

For those in need of therapy, treatment of OME should be aimed at the underlying conditions that necessitate building the firewall (URTIs and adenoiditis, GERD, allergy, craniofacial anomalies, immune-system diseases, etcetera, etcetera). Treatment should be individualized accordingly and aimed at the underlying problem, instead of lumped into a one-size-fits-all therapy with tubes. We need to fix the gap in the defense that allows the higher bacterial load to the middle ear to occur instead of ruining a near perfect firewall. ⁴

Furthermore, we should accept the facts that long-term follow-up does not show clinical relevant language problems in the general population ⁵ and that hearing loss can be overcome by hearing aids, that are mostly well tolerated ⁶ and do not ruin the defense.

Exceptions to the rule will always occur, so in individual cases tympanostomy tubes might constitute good treatment options. However, in the majority of cases of OME, tubes are unnecessary, produce tympanosclerosis, ⁷ perforations, CSOM, and are a major burden on direct and indirect costs of the health care system. Not to mention all the research time and money wasted by improper—with an incorrect pathophysiolocal idea in mind—studying of a disease that is not a disease after all.

Tubes for OME, in my opinion, are the perfect example of what Rosenfeld called “amusing parents while nature cures otitis media with effusion” already 2 decades ago. ³

So, “follow humbly wherever and to whatever abyss Nature leads” ¹ ; and learn that a paradigm change is necessary in our state-of-the-art concept of OME.