AAO-HNS Tympanostomy Tubes in Children Guideline Summary

Design and created by Guideline Central in participation with the American Academy of Otolaryngology - Head and Neck Surgery Foundation.

Document Overview

Document Title: Tympanostomy Tubes in Children

Authoring Society: American Academy of Otolaryngology - Head and Neck Surgery Foundation

Document Publication Date: Feb 9, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/01945998211065662

Source Citation: Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical Practice Guideline: Tympanostomy Tubes in Children (Update). Otolaryngol Head Neck Surg. 2022;166(1_suppl):S1-S55

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. All these conditions are encompassed by the term otitis media (middle ear inflammation). This guideline update provides evidence-based recommendations for patient selection and surgical indications for managing tympanostomy tubes in children. The guideline is intended for any clinician involved in managing children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes in any care setting as an intervention for otitis media of any type. The target audience includes specialists, primary care clinicians, and allied health professionals.

Scope: Diagnosis, Prevention, Treatment

Diseases/Conditions (MeSH)

D010033 - Otitis Media

Keywords: middle ear effusion, otitis media, tympanostomy tubes

Target Patient Population: Children, aged 6 months to 12 years, with tympanostomy tubes or children being considered for tympanostomy tubes

Target Provider Population: any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or children being considered for tympanostomy tubes

Inclusion Criteria: Male, Female, Child, Infant

Health Care Settings: Ambulatory, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

PICO Questions

Can we identify clinical factors that predict persistence of MEE in children who present with effusions of short duration?
What is the ideal timing of audiologic testing for a child being considered for tubes—before surgery, after surgery, or both?
If resources are limited and audiologic testing is done only after tube placement, how will this affect surgical decision making or counseling about “permanent” hearing loss diagnosed only after surgery?
Are there any caregiver questions, in addition to the two proposed in this CPG, that can predict hearing difficulties and quantify severity, without formal audiologic testing, in patients considered for tubes?
Can we identify the children with OME and speech and language delays who will benefit from tympanostomy tube placement?
What is the relationship of MEE and balance abnormalities, and how do these balance abnormalities change after tympanostomy tube placement?
Are there behavioral problems that correlate with the presence and duration of middle ear fluid problems, and can we screen for these problems in children who have OME?
What is the best time to evaluate children referred for possible surgical treatment of recurrent AOM with relation to the last episode of AOM?
Can we quantify the predictive value of the presence of middle ear fluid in one or both ears for likelihood of more episodes of AOM in children with a history of recurrent AOM?
What are the benefits of tympanostomy tube placement on frequency of AOM, prevalence of OME, and speech and language development for children in specific at-risk populations?
Does tympanostomy tube surgery present unique risks or greater complications in some of the at-risk groups?
What is the actual frequency of AOM and prevalence of OME in specific at-risk groups?
Is there the potential for underdiagnosis of OME because of attention to other conditions or overdiagnosis of OME because of greater clinical exposure for some of the at-risk populations?
How strongly is abnormal tympanometry at the initial clinical encounter associated with persistence of OME?
What are the clinical indicators that best predict the need for repeated tympanostomy tube placement?
What is the role of allergy testing in children with recurrent tube otorrhea or a need for repeated tympanostomy tube placement, and can managing allergy, if present, result in beneficial outcomes?
Are there certain types of long-term tubes that are more often associated with complications such as granulation or otorrhea?
Which subgroups of children should be considered for adenoidectomy at the time of the first set of tubes or when younger than age 4 years?
How do “face-to face” counseling, written materials, and online resources best inform parents and caregivers and facilitate shared surgical decision making?
What are the indications to prescribe postoperative ototopical antibiotics at the time of surgery?
Will the incidence of postoperative otorrhea and the causative microbiology change with adoption of the recommendation to limit routine drop use after surgery?
Are there predictors for failure of ototopical therapy as initial treatment for TTO?
Can we identify the children at risk for otorrhea, as well as other clinical indicators for posttympanostomy water precautions?
To what extent can recommendations regarding water precautions for children with tympanostomy tubes be generalized to adults with tympanostomy tubes?
What is the ideal follow-up schedule for examining patients with tubes?
How often should children be assessed in primary care settings, and how often should children be assessed by otolaryngologists, after tympanostomy tubes are placed?
How often should hearing be formally assessed after tympanostomy tubes are placed?
What is the duration of intubation that is associated with eardrum complications if the tube is not removed?
If a child has a retained tympanostomy tube for more than 3 years and has normal hearing, an otherwise normal eardrum, and no symptoms, should the tube be removed, or is additional observation a preferred option?
If the decision is made to remove a retained tympanostomy tube, when should a myringoplasty be performed?
If a myringoplasty is performed at the time of tube removal, is there a preferred artificial or autograft material for this repair?
What is the best management for an asymptomatic child with normal hearing who on examination has a tympanostomy tube that is medialized into the middle ear behind an intact eardrum?
Are there differences in access to surgical treatment of otitis media, as well as differences in surgical decision making, across socioeconomic, ethnic, and racial groups?

Number of Source Documents: 286

Literature Search Start Date: Wednesday, February 1, 2012

Literature Search End Date: Wednesday, April 1, 2020

Includes peer/external review process?: Yes

Includes public comment process?: Yes

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes