To the Editor: The study by Paradise et al on tympanostomy tubes for persistent otitis media,1 which was expertly reviewed by Morris and Leach in the Journal recently,2 has since been updated.3 The findings of both studies from Pittsburgh should only be applied with caution in Australia. Indications for inserting ventilating tubes (VTs) can be divided into three:

• bilateral hearing loss of more than 25–30 dB continuously for 3 months after failed non-operative management;

• structural damage to the tympanic membrane (TM) which may lead to irreversible hearing loss or cholesteatoma; and

• a miscellany which includes under-lying sensorineural hearing loss or learning difficulties or similar conditions with deterioration associated with bilateral middle ear effusion (MEE), and recurrent middle ear infections with use of VTs as an alternative to antibiotic prophylaxis, among others.

The conclusion of the more recent article by Paradise et al3 — that there was no difference in expressive or receptive speech or cognition between children in whom VTs were inserted early or late — is valuable, but may not readily be extended to Australian practice. Although 6350 children were enrolled, only 397 were actually randomly allocated into the early or late treatment groups. Thus, the numbers are not large.

Of more concern is that only 18% of those analysed had bilateral continuous MEE (40 in the early and 32 in the late treatment group), with the remaining 82% having unilateral (continuous or discontinuous) or bilateral discontinuous MEE. Only the 18% with bilateral continuous MEE would ordinarily be candidates for VTs in Australia, as Paradise et al underline the fact that intermittent and/or unilateral MEE is not associated with speech and language difficulties in the absence of other handicaps to learning. An abnormal hearing test result was identified by the study as a 15 dB loss. This could well fall in the normal range for the Australian Hearing Service for children wearing headphones, and a minimum threshold of 25-30 dB should typically be required for considering VTs in Australia. As Morris and Leach2 pointed out for the earlier study,1 the later study also excludes children “not otherwise healthy”,3 and the results cannot be generalised to such children, or to those with moderate rather than mild hearing loss.

Pointing to studies such as that of Paradise et al can be very helpful in reassuring parents who want VTs for their child with unilateral or intermittent hearing loss that not having VTs does not place the child’s speech and language development at risk.