Expert: Harriet B Jacobster, Au.D. - 9/18/2008

Question
QUESTION: I have a couple.  I have a 19 mth. old daughter who has Down Syndrome and Epilepsy.  She has had fluid in her ears off and on most of her life.  She has only had one ear infection that was recent following the first time she got sick.  We give her an osteopathic massage three times a day which stimulates her lymphatic system to help clear the fluid.  Her audiologist thinks that it has certainly helped keep the fluid moving to prevent ear infections.  However, she is recommending tubes now to prevent possible speech and language delays.  We were able to get a hearing test in one ear when free of fluid.  We were never able to get a hearing test done on the other ear.  There are no signs of a problem with hearing.  Do you think this merits tubes in her ears?  Shouldn't we find out if her hearing is compromised first?

Second question:  There has been some speculation about danger of general anesthesia on the CNS in an epileptic person. (i.e. possible long term effects)  My ENT doctors will only put the tubes in with general anesthesia, so I am a little fearful.  Do you know anything about this and can tubes only be put in with general anesthesia on a 19 mth. old? (It's not only just this one time that I am fearful about, but I hear that sometimes more sets are needed, which would require even more general anesthesia.)

Thank you, Wendy Fitzhenry

ANSWER: Hi Wendy,
to answer the first part, children with Down's Syndrome have a high incidence of middle ear problems, as I am sure you know. Tubes are placed to either remove and aerate an ear with fluid which is not resolving on its own, or to serve as a replacement for an improperly functioning Eustachian tube even when there is no fluid present.  Tubes, in this case, are a preventative action and are sometimes placed in normal hearing ears with a history of Eustachian tube dysfunction. The problem is, of course, just because there is no fluid present at this time, with your child's history, there is a very high chance fluid can appear later. As far as sedating a child with epilepsy, I do not know all the long term effects.  Children that young are generally put under general anaesthesia in order to prevent their moving around...as I'm sure you're aware, it is very hard to keep a 19 month-old quiet for a sufficient time.  There is something known as conscious sedation where the child is asleep but not in a deep sleep.  That is how we do our specialized testing on infants.  I don't know if this would work on your child.  My recommendation is to find an ENT that specializes in special needs pediatrics who might be able to give better choices.
Hope this helps.
Harriet B. Jacobster, AuD
Board Certified in Audiology

---------- FOLLOW-UP ----------

QUESTION: I have read on the internet that the Agency for Health Care Policy and Research, a component of the Public Health Service, issued new guidelines for treating otitis media with effusion.  The panel recommends ear tubes only if the OME lasts four to six months and there's hearing loss in both ears.  They go on to say that a child's hearing should always be tested before inserting tubes.  A loss of 20 decibels in ear ear warrants treatment, the panel said.

The audiologist did not do a hearing test in both ears because she said that a test cannot be done while there is fluid present.  Is this true?  And if so, how could a hearing test be done while fluid is present?

Thank you,  Wendy Fitzhenry

ANSWER: Hi Wendy,
Did you go to a pediatric audiologist? I do hearing tests in the presence of effusion all the time - we must in order to determine how much loss there is due to the fluid and what the hearing should return to once the effusion resolves.  The problem is, with a 19 month-old, we really cannot put headphones on in order to assess individual ears; when tested in soundfield, only the better ear will respond. Fluid is detected by a test called Tympanometry.  Individual ear assessment can be carried out by using tests of Otoacoustic emissions (OAEs), and Auditory Brainstem responses (ABRs). In OAEs, fluid will obliterate the response; however, so will an inner ear loss.  For the ABR, we can differentiate a loss due to fluid from a loss due to neural damage, but your child would have to be sedated.
As far as the new guidelines, they were essentially issued for children who have no other precipitating factors, such as Down's. These children have to be considered on an individual case.
May I ask, what type of hearing tests did the audiologist do?
Hope this helps.
Harriet B. Jacobster, AuD
Board Certified in Audiology

---------- FOLLOW-UP ----------

QUESTION: To answer your questions:  I did see a pediatric audiologist, and the hearing test she did in one ear when the fluid was clear was an OAE test.  She could not do it in the other ear because of fluid present.  At this point she recommended tubes.
Thank you, Wendy Fitzhenry

Answer
Hi Wendy,
Yes, doing OAEs with fluid in the ear will not give a true reading. If tympanometry was done, this would indicate if there is or is not fluid. The best way to determine true hearing in your daughter's ears is a sedated ABR including bone conduction.  As I mentioned before, we do not put the child into a deep sedation, so this may be okay.  You may also want to consult with a pediatric neurologist about the sedation as well as a pediatric anaethesiologist.
Hope this helps.
Harriet B. Jacobster, AuD
Board Certified in Audiology