Interview with William Slattery M.D., Neurotologist, House Ear Institute, Los Angeles, California
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AO/Beck: Hi Dr. Slattery, thanks for speaking with me this morning.
Slattery: Hi Doug, nice to speak with you again.
AO/Beck: Bill, if you don't mind, let's start with a little biographical information? Where did you go to medical school and when and where did you do your residency and fellowship?
Slattery: I went to medical school at the University of Missouri and I graduated in 1988. I did my residency at the University of Florida in Gainesville, and then I did my neurotology and skull-based fellowship at the House Ear Clinic in 1993. I've been at House ever since.
AO/Beck: Thanks Bill. Today's discussion is on PE (pressure equalization) tubes. In particular, I'd like to stay focused on PE tubes in kids, as they are the primary beneficiaries for PE tubes. So with that as the introduction, what are the indications for PE tubes?
Slattery: There are essentially two indications for PE tubes. The first is recurrent acute otitis media (AOM). I define this as OM that recurs, but the fluid clears between episodes. That is, the infection actually goes away between episodes, but does come back. AOM has sudden onset, and indicates essentially an inflamed middle ear space. AOM has it's highest rate of occurrence during the first two years of life. The second indication is OM with effusion (OME), also called serous OM (SOM). It's important to differentiate the two because they are the two diseases which are most commonly associated with the need for PE tubes.
AO/Beck: Of course I jumped into tubes, but we should make it clear that the first line of defense, or rather the treatment protocol of choice is always medical first, and then patients who fail medical treatment would be the ones who might progress to PE tubes. Is that correct?
Slattery: Yes, that's true. The treatment of choice is always medical first.
AO/Beck: What about kids with plain old recurrent OM?
Slattery: There are three treatment options for children with recurrent AOM . The first is to treat each infection. If the infection goes away and the ear clears with medical treatment, no problem. But as you know, sometimes the child may have an episode once every month or so, and it can be a real problem for the child and the parent or guardian because they have to take time away from work and pre-school to bring the child into the office. If it's a significant hassle for the family to go back and forth, the second option is prophylactic antibiotics, and we can sometimes use antibiotics that are only administered once per day. We might use 6 to 8 weeks of antibiotics to break the cycle of infection. After they go through this once or twice, parents are aware that antibiotics can cause diarrhea, and there can be other side effects and long term issues with antibiotics, so sometimes parents just really want to avoid long-term use. Additionally, sometimes long-term prophylaxis doesn't work, and so PE tubes are the only option to manage AOM. If the parents don't want the child to be on antibiotics for that long, we may go straight to option number three, PE tubes.
AO/Beck: You mentioned kids who come into the office every month with OM. Does that mean it's a new infection every month, or is it the same infection every month, which was not effectively treated medically?
Slattery: That's why we differentiated the two types above. If it truly clears between episodes and it is a new infection, it's recurrent OM.
AO/Beck: What are the primary tube types?
Slattery: There are essentially two types of tubes. The Ruder-Bobbin and the T tube. The Ruder-Bobbin is the most common type of PE tube. It comes in different sizes and shapes, with different flanges and different openings to the lumen of the tube. The T tube is narrower and usually longer, and the top of the T goes into the middle ear space. Both tubes are meant to self-extrude. However, the T tube is meant to be more permanent and have a lower extrusion rate. However T tubes have a higher perforation rate. In general when we talk to parents about tubes, we tell parents there is about a one percent chance of a persistent perforation. However, with T tubes, the rate may be slightly higher.
AO/Beck: Can you tell the difference between the tube types via otoscopy?
Slattery: Yes, usually. The T Tube is typically not round. The Ruder-Bobbin tubes are usually round.
Sometimes tubes can be silastic, teflon, different metals, and there are new tubes that are antibiotic coated, which are supposed to prevent the risk of drainage through the tube. As you know, PE tubes are supposed to vent air, not liquids.
AO/Beck: Many times when I see PE tubes in a child's ear, there will be crusting and sometimes fluid present around, or in the tube. What does the otologist do to clear a crusty, plugged-up PE tube?
Slattery: There are two issues. If the tube has crusting around it, but the tube lumen is open, there is really not much that needs to be done. If the tube is plugged it can be cleared with chemicals and suction in the office.
AO/Beck: How long do tubes usually stay in place?
Slattery: Typically, they will self-extrude in 6 to 24 months. It varies quite a bit.
AO/Beck: At what point do you remove the tube?
Slattery: I remove very few tubes, but as you can imagine, there are many opinions on this. In general, I like the tube to come out on it's own. One issue is that sometimes you'll takes a tube out, and then the next thing you know, someone else is putting a tube back in. Another consideration I like to use as a guide is the maturation of the eustachian tube(ET). The ET is anatomically mature at about age 5 or 6, so prior to that I think it's just premature to take it out. Another issue is that for kids with one tube, the opposite ear can often help determine the status of the ET. If the ear without a tube has done well for a year or two and been infection free, that may indicate it's OK to take the opposite tube out.
AO/Beck: What about cautions for kids with PE tubes.
Slattery: Each physican has their own preferences. I tell parents to try to keep water out of the ear and to keep the ear dry. I tell them to use earplugs during bathing and to use a hairdryer after swimming or bathing. Regarding swimming I tell them surface swimming only, no underwater swimming or diving. There is probably a slight increase in the risk for external otitis, but we just need to be careful and keep an eye on it.
AO/Beck: Any issues regarding lake/pond swimming versus pool swimming?
Slattery: I don't know of any studies that truly document higher bacterial or viral incidence in kids based on swimming in lakes or ponds versus chlorinated water. There may be something there, but I haven't read it.
AO/Beck: What do you recommend for the audiologist who sees children with recurrent AOM, or SOM or OME month after month after month, and the child is not improving?
Slattery: I think if the child has been documented with AOM or SOM or OME for three to four months, they probably should be referred for ENT care and management. Personally after three to four months with no improvement, I'm in favor of PE tubes. You know how important it is for the child to have normal hearing with regards to speech and language development. Imagine a 2 year old with a 30 or 40 dB loss for 6 months or more - they can easily fall behind their peers with regards to speech and language development, and it's very difficult to catch up. Another issue is that of the child has a SN loss to begin with, and they develop AOM, that additional hearing loss may put them over the edge where they are simply not hearing conversational speech at all. We tend to be aggressive in managing kids with known SN losses when they develop AOM or OME.
AO/Beck: Can you list the website of the House Ear Clinic for audiologists who would like to learn more about HEC and some of the resources available? Additionally, if you don't mind, I'll invite the readers to send me questions on PE tubes, and then I will send them to you and we'll post the questions and the answers in the ATE (Ask The Expert) section of the Audiology Online website. They can send questions to me at audsx2@aol.com.
Slattery: Sure Doug, the website is www.hei.org. Additionally, if the readers have specific questions on PE tubes, please feel free to send those in and I'll do my best to answer them.
AO/Beck: Thanks very much for your time this morning. I'll look forward to speaking with you in July on Cochlear Implants.
Slattery: Thanks Doug, it's been fun.
Slattery: Hi Doug, nice to speak with you again.
AO/Beck: Bill, if you don't mind, let's start with a little biographical information? Where did you go to medical school and when and where did you do your residency and fellowship?
Slattery: I went to medical school at the University of Missouri and I graduated in 1988. I did my residency at the University of Florida in Gainesville, and then I did my neurotology and skull-based fellowship at the House Ear Clinic in 1993. I've been at House ever since.
AO/Beck: Thanks Bill. Today's discussion is on PE (pressure equalization) tubes. In particular, I'd like to stay focused on PE tubes in kids, as they are the primary beneficiaries for PE tubes. So with that as the introduction, what are the indications for PE tubes?
Slattery: There are essentially two indications for PE tubes. The first is recurrent acute otitis media (AOM). I define this as OM that recurs, but the fluid clears between episodes. That is, the infection actually goes away between episodes, but does come back. AOM has sudden onset, and indicates essentially an inflamed middle ear space. AOM has it's highest rate of occurrence during the first two years of life. The second indication is OM with effusion (OME), also called serous OM (SOM). It's important to differentiate the two because they are the two diseases which are most commonly associated with the need for PE tubes.
AO/Beck: Of course I jumped into tubes, but we should make it clear that the first line of defense, or rather the treatment protocol of choice is always medical first, and then patients who fail medical treatment would be the ones who might progress to PE tubes. Is that correct?
Slattery: Yes, that's true. The treatment of choice is always medical first.
AO/Beck: What about kids with plain old recurrent OM?
Slattery: There are three treatment options for children with recurrent AOM . The first is to treat each infection. If the infection goes away and the ear clears with medical treatment, no problem. But as you know, sometimes the child may have an episode once every month or so, and it can be a real problem for the child and the parent or guardian because they have to take time away from work and pre-school to bring the child into the office. If it's a significant hassle for the family to go back and forth, the second option is prophylactic antibiotics, and we can sometimes use antibiotics that are only administered once per day. We might use 6 to 8 weeks of antibiotics to break the cycle of infection. After they go through this once or twice, parents are aware that antibiotics can cause diarrhea, and there can be other side effects and long term issues with antibiotics, so sometimes parents just really want to avoid long-term use. Additionally, sometimes long-term prophylaxis doesn't work, and so PE tubes are the only option to manage AOM. If the parents don't want the child to be on antibiotics for that long, we may go straight to option number three, PE tubes.
AO/Beck: You mentioned kids who come into the office every month with OM. Does that mean it's a new infection every month, or is it the same infection every month, which was not effectively treated medically?
Slattery: That's why we differentiated the two types above. If it truly clears between episodes and it is a new infection, it's recurrent OM.
AO/Beck: What are the primary tube types?
Slattery: There are essentially two types of tubes. The Ruder-Bobbin and the T tube. The Ruder-Bobbin is the most common type of PE tube. It comes in different sizes and shapes, with different flanges and different openings to the lumen of the tube. The T tube is narrower and usually longer, and the top of the T goes into the middle ear space. Both tubes are meant to self-extrude. However, the T tube is meant to be more permanent and have a lower extrusion rate. However T tubes have a higher perforation rate. In general when we talk to parents about tubes, we tell parents there is about a one percent chance of a persistent perforation. However, with T tubes, the rate may be slightly higher.
AO/Beck: Can you tell the difference between the tube types via otoscopy?
Slattery: Yes, usually. The T Tube is typically not round. The Ruder-Bobbin tubes are usually round.
Sometimes tubes can be silastic, teflon, different metals, and there are new tubes that are antibiotic coated, which are supposed to prevent the risk of drainage through the tube. As you know, PE tubes are supposed to vent air, not liquids.
AO/Beck: Many times when I see PE tubes in a child's ear, there will be crusting and sometimes fluid present around, or in the tube. What does the otologist do to clear a crusty, plugged-up PE tube?
Slattery: There are two issues. If the tube has crusting around it, but the tube lumen is open, there is really not much that needs to be done. If the tube is plugged it can be cleared with chemicals and suction in the office.
AO/Beck: How long do tubes usually stay in place?
Slattery: Typically, they will self-extrude in 6 to 24 months. It varies quite a bit.
AO/Beck: At what point do you remove the tube?
Slattery: I remove very few tubes, but as you can imagine, there are many opinions on this. In general, I like the tube to come out on it's own. One issue is that sometimes you'll takes a tube out, and then the next thing you know, someone else is putting a tube back in. Another consideration I like to use as a guide is the maturation of the eustachian tube(ET). The ET is anatomically mature at about age 5 or 6, so prior to that I think it's just premature to take it out. Another issue is that for kids with one tube, the opposite ear can often help determine the status of the ET. If the ear without a tube has done well for a year or two and been infection free, that may indicate it's OK to take the opposite tube out.
AO/Beck: What about cautions for kids with PE tubes.
Slattery: Each physican has their own preferences. I tell parents to try to keep water out of the ear and to keep the ear dry. I tell them to use earplugs during bathing and to use a hairdryer after swimming or bathing. Regarding swimming I tell them surface swimming only, no underwater swimming or diving. There is probably a slight increase in the risk for external otitis, but we just need to be careful and keep an eye on it.
AO/Beck: Any issues regarding lake/pond swimming versus pool swimming?
Slattery: I don't know of any studies that truly document higher bacterial or viral incidence in kids based on swimming in lakes or ponds versus chlorinated water. There may be something there, but I haven't read it.
AO/Beck: What do you recommend for the audiologist who sees children with recurrent AOM, or SOM or OME month after month after month, and the child is not improving?
Slattery: I think if the child has been documented with AOM or SOM or OME for three to four months, they probably should be referred for ENT care and management. Personally after three to four months with no improvement, I'm in favor of PE tubes. You know how important it is for the child to have normal hearing with regards to speech and language development. Imagine a 2 year old with a 30 or 40 dB loss for 6 months or more - they can easily fall behind their peers with regards to speech and language development, and it's very difficult to catch up. Another issue is that of the child has a SN loss to begin with, and they develop AOM, that additional hearing loss may put them over the edge where they are simply not hearing conversational speech at all. We tend to be aggressive in managing kids with known SN losses when they develop AOM or OME.
AO/Beck: Can you list the website of the House Ear Clinic for audiologists who would like to learn more about HEC and some of the resources available? Additionally, if you don't mind, I'll invite the readers to send me questions on PE tubes, and then I will send them to you and we'll post the questions and the answers in the ATE (Ask The Expert) section of the Audiology Online website. They can send questions to me at audsx2@aol.com.
Slattery: Sure Doug, the website is www.hei.org. Additionally, if the readers have specific questions on PE tubes, please feel free to send those in and I'll do my best to answer them.
AO/Beck: Thanks very much for your time this morning. I'll look forward to speaking with you in July on Cochlear Implants.
Slattery: Thanks Doug, it's been fun.
