An innovative device to support Politzer manoeuvre

Politzer manoeuvre causes retrograde inflation of the middle ear by forcing air through the Eustachian tube. It has been proposed as nonsurgical treatment of middle ear with effusion, Eustachian tube dysfunction and negative middle ear pressure from elevation changes. Even if Politzer manoeuvre can be considered a classical technique, it is generally performed without any feedback about its correctness neither about qualitative evidence about its efficacy. In this paper we describe an innovative device, named OTOFREE, specifically designed to support medical doctors during Politzer manoeuvre. OTOFREE provides information about the correctness of the manoeuvre and also useful hints about the treatments results.

Paediatric otitis media surgery in Norway

CONCLUSIONS

In Norway there are large, regional differences in the incidence of surgery and combinations of surgery for otitis media.

OBJECTIVES

A descriptive study of complete national administrative data on frequency of surgery for otitis media in 2002.

MATERIALS AND METHODS

This study analysed anonymous patient data from the Norwegian patient registry for 2002 and measured rates of tympanostomy tube insertions, myringotomy and the combinations of adenoidectomies and tympanostomy tubes and myringotomy, respectively. Surgical rates were assessed by region and variations within the country were evaluated.

RESULTS

The peak age for surgical treatment of otitis media was 5 years. Tympanostomy tubes were inserted in more than half of the children treated and the analysis showed considerable regional variation in the rates and in choice of surgical treatment.

First myringotomy with insertion of a modified Goode T-Tube: changing the perforation paradigm

BACKGROUND

Goode T-Tubes (Medtronic Xomed, Inc) have a bad reputation because of their residual tympanic perforation rate. However, these long-term tubes are mostly used in patients with chronic middle ear problems. On the other hand, "safer," short-term tubes may need to be reinserted in up to 20% of children.

OBJECTIVE

To demonstrate that modified Goode T-Tubes inserted at the first myringotomy in normal children leave a perforation rate comparable to the rate reported in the literature for short-term tubes and may be extracted safely in the outpatient clinic when eustachian tube function is thought to be adequate.

METHOD

This prospective study followed 58 children (100 ears) who had their modified Goode T-Tubes electively removed in the clinic, from October 2003 to November 2004.

RESULTS

We found only one persistent perforation at the third follow-up (mean time 5.2 months). The tubes had been in place for an average of 2.9 years. The perforation healing rate was inversely related to intubation duration. Adenotonsillectomy seemed to favourably influence the speed of healing. The perforations healed faster when tubes were inserted for chronic middle ear effusion compared with recurrent acute otitis media. Age, gender, and the site of intubation were not related to persistent perforation. All of the tubes spontaneously extruded (13) healed without perforation.

CONCLUSION

Modified Goode T-Tubes inserted at the first myringotomy and electively extracted allow for a longer middle ear ventilation period and have a perforation rate comparable to that of short-term tubes.

Medial migration of tympanostomy tubes: an overlooked complication

BACKGROUND

Frequently encountered complications associated with tympanostomy tube placement have been well documented and are globally recognized. The medial migration of tympanostomy tubes into the middle ear space is a rare complication for which pathogenesis, natural history, and management have not been clearly delineated.

OBJECTIVE

To describe our experience with the medial migration of tympanostomy tubes into the middle ear space. To propose a simple classification system and define management recommendations.

METHODS

A retrospective chart review of all patients with medial tube migration seen in a Pediatric Otolaryngology practice at a tertiary care university hospital between 1995 and 2005.

RESULTS

Six pediatric patients (ages 3-19) were found to have seven tympanostomy tubes within the middle ear space at various intervals following tube placement. One patient had a migrated tympanostomy tube deep to a large myringotomy incision. Five patients (six ears) had migrated tubes medial to intact, healed tympanic membranes. Fifty percent of the patients had symptoms attributable to the migrated tube. All six patients underwent middle ear exploration with successful removal of the migrated tube.

CONCLUSIONS

This process can be defined as primary, when the tympanostomy tube migrates due to a technical error, or secondary, when the tube is initially seen in the correct position but is later found medial to a healed, intact tympanic membrane. Medial migration is apparently independent of tube type and can occur at various intervals after placement. The process of secondary migration is most likely multifactorial but may in part be the result of persistent negative middle ear pressure. Migrated tubes should be removed surgically unless contraindicated.

Post-tympanostomy tube otorrhea: a meta-analysis

INTRODUCTION

Post-tympanostomy tube otorrhea is the most common complication of tympanostomy tube placement. The incidence of this problem varies from 3.4% to 74%. Trials that study post-tympanostomy tube otorrhea may involve valid randomization "by patient" or "by ear." In an attempt to define "best practice," we conduct a meta-analysis to quantify the benefit of using topical prophylactic antibiotic drops in the postoperative period. We then compare our findings with previous results found in the literature.

METHODS

We selected randomized studies for which antibiotic drops had been used for at least 48 hours after tympanostomy tube insertion. Nine studies, 3 "by ear" and 6 "by patient," met our inclusion criteria. The odds ratio and 95% confidence intervals were calculated for each to conduct the meta-analysis.

RESULTS

Overall, prophylaxis appears to be effective at reducing the incidence of post-tympanostomy tube otorrhea. The odds ratios for all studies were less than 1.0. However, none of the 3 "by ear" studies and only 3 of the 6 "by patient" studies were statistically significant. The mean odds ratio was 52%, suggesting that prophylaxis may reduce the incidence of post-tympanostomy tube otorrhea by half.

CONCLUSION

This meta-analysis suggests that routine post-tympanostomy tube prophylaxis is beneficial, but this finding is dependent on selection criteria used.

EBM RATING

A-1a.

Relationship between transducer type and low-frequency hearing loss for patients with ventilation tubes

OBJECTIVE

To determine the relationship between the type of transducer used to perform pure-tone audiometry and the appearance of low-frequency hearing loss at 250Hz and 500Hz for patients with ventilation tubes.

METHODS

Air conduction thresholds at 250Hz and 500Hz were measured using Telephonics TDH-49 supra-aural headphones and EARTONE 3-A insert earphones for patients with normal ears (N=16) and patients with ventilation tubes (N=114). Tympanometry was performed on each patient prior to audiometric testing. Audiometric test results obtained in normal ears were compared to results for patients with ventilation tubes. For analysis, the ventilation tube patients were separated into two groups, representative of ventilation tube type.

RESULTS

Audiometric results obtained using the two transducer types at 250Hz and 500Hz revealed significant differences in threshold for patients with ventilation tubes. Thresholds obtained using insert earphones were generally worse than thresholds obtained using supra-aural headphones for this group. On average, difference in threshold was 14.15dB worse with insert earphones at 250Hz and 9.75dB worse with insert earphones at 500Hz for patients with Sheehy tubes. Average difference in threshold for patients with Donaldson tubes was 13.93dB worse with insert earphones at 250Hz and 8.93dB worse with insert earphones at 500Hz. In addition, thresholds were more variable for patients with ventilation tubes than normal ears at 500Hz. There were no significant differences in threshold for normal ears using both transducers.

CONCLUSIONS

When performing pure-tone audiometry, choice of transducer can influence the accurate identification of a low-frequency hearing loss in patients with ventilation tubes. Low-frequency thresholds were generally worse using insert-style earphones to test subjects with tubes, resulting in the apparent identification of a hearing loss. However, with supra-aural headphones, no low-frequency hearing loss existed. There were no significant differences in threshold values using either transducer in normal ears.

[Comparison of gold-plated silver- and silver oxide-impregnated silastic tympanostomy tubes: a randomized, prospective clinical trial]

The insertion of tympanostomy tubes is the most common surgical procedure in the world. A major complication of chronic intubation is infectious otorrhea. The present study compares the rate of infectious otorrhea and survival rate of gold-plated silver tubes (GPR) vs. Silver Oxide-Impregnated Silastic Tubes (SPR).

STUDY DESIGN

The prospective, randomized clincial trial was conducted with 116 children (59 female, 57 male) aged between 16 and 127 months (median: 51 months). Bilateral insertion of ventilation tubes was performed with SPR on one side and GPR on the other side in all children. The resulting data were compared using 2-tailed Wilcoxon-test.

RESULTS

Out of 116 children, 11 left the study, 26 children finished the study by extrusion of both tubes, 32 children lost one tube and 47 children lost no tube. Total follow-up of GPR and SPR amounted to 703 and 949 months, respectively. Mean survival rate of SPR and GPR was 9.9 +/- 4.6 and 7.0 +/- 3.4 months, respectively (p < 0.001). During the first postoperative week, 13% of children suffered from otorrhea; after the first postoperative week until extrusion of the tubes, otorrhea was observed in 55% of children. The ratio otorrhea/months amounted to 0.046 and 0.05 in SPR and GPR, respectively (p: n. s.).

CONCLUSIONS

Survival rate of SPR is significantly longer than compared to GPR. No differences in the otorrhea rate of SPR vs. GPR are detectable. The longer survival rate of SPR seems to be independent of the rate of infectious otorrhea but depends probably on other effects of biocompatibility.

Vitamin e-coated tympanostomy tube insertion decreases the quantity of free radicals in tympanic membrane

OBJECTIVE

Tympanosclerosis is a common sequela of ventilation tube treatment of otitis media with effusion causing hearing disability. It is associated with an increased production of free radicals (also known as reactive oxygen species) after myringotomy. Vitamin E is a scavenger of different free radicals by working as an antioxidant. The aim of the present study was to evaluate the effect of vitamin E-coated tympanostomy tube insertion at quantity of free radicals in rat tympanic membrane.

METHODS

This prospective, controlled animal study consisted of male Sprague-Dawley rats divided into two groups of 10 animals each. Ordinary silcone tubes were applied to the right ears of the first group and vitamin E-coated silcone tubes were applied to the right ears of the second group. The left ears were used as controls. Then, the animals were killed and chemiluminescence measurements were made for tympanic membranes.

RESULTS

Reactive oxygen species levels (ROS) were significantly increased in right ears of the first group when compared with the control ears (P < .0001), and the levels were statistically significant decreased in right ears of the second group as compared with the operated ears of the first group (P < .0001). The free radical levels of right and left ears in the second group were similar.

CONCLUSIONS

Our results indicate that vitamin E-coated tube insertion decreases the quantity of reactive oxygen species in tympanic membrane after myringotomy and tympanostomy tube insertion.

An easier way of inserting the Shah permavent grommet

Ventilation tube insertion plays an important role in the management of otitis media with effusion. In selected cases, repeated grommet insertion due to persistent eustachian tube dysfunction necessitates the need for longer-term ventilation. Insertion of such tubes can however occasionally be more difficult than insertion of standard grommets. One such long-term ventilation tube is the Shah permavent grommet. This paper describes a simple modification of the technique that is less time-consuming and less traumatic.

Management of hearing loss in Apert syndrome

Background: Apert syndrome is one of the craniosynostosis syndromes, with abirth prevalence estimated to be between 9.9 and 15.5/million, and accounts for 4.5 per cent ofcraniosynostoses. Although conductive hearing loss is common in Apert syndrome there are contradicting reports regarding the cause of this hearing loss. There is also no detailed informationavailable on the management of hearing loss in Apert syndrome.

Materials and methods: A retrospective analysis of case notes of Apert syndrome patients seen between 1970 and 2003 at Great Ormond Street Children’s Hospital, London, was undertaken.

Results: Seventy case notes were obtained. The incidence of congenital hearing impairment was between 3 and 6 per cent. Almost all patients had otitis media with effusion (glue ear), which tended to persist into adult life. More than 56 per cent of cases developed permanent conductive hearing loss by 10–20 years. Repeated grommet insertion was common; even though 35 per cent had trouble with ear discharge and persistent conductive hearing loss. Statistically, grommets made no difference to the risk of developing permanent hearing loss.

Conclusion:This study, of the largest number of Apert syndrome cases assembled to date, showed that early optimization of hearing with possible hearing aids needs to be considered. Repeated grommet insertion does not help in optimizing hearing, especially if ear discharge complicates the picture.

Investigation of surface changes in different types of ventilation tubes using scanning electron microscopy and correlation of findings with clinical follow-up

OBJECTIVES

Like all biomaterials, ventilation tubes are subject to formation of bacterial biofilm on their surfaces. There might also be surface changes. This increases the risk of complications associated with ventilation tubes. In this study, we examined two groups of ventilation tubes using scanning electron microscopy (SEM) to investigate biofilm growth and surface deformations.

METHODS

There were two different types of ventilation tubes used, the first group consisted of 30 silicone tubes and the second group consisted of 16 ionized, processed silicone tubes. The tube samples included those that were either removed or those that were extruded into the ear canal. We investigated the association between scanning electron microscopy findings and the complications that developed during the treatment.

RESULTS

As a result of this study, it is found that the ionized, processed silicone tubes are superior to other silicon ventilation tubes in regard to biofilm growth (z=-3.925, p=0.000, <0.0001) and surface deformations (chi(2)=9.120, p=0.003, <0.01). Furthermore, we observed that as the duration of the ventilation tube application increases, bacterial biofilm growth (chi(2)=10.718, p=0.005, <0.01) and surface deformations (z=-2.940, p=0.003, <0.01) increase. We also observed that biofilm growth and occurrence frequency were related to "otorrhea" (chi(2)=10.258, p=0.036, <0.05) and "plugging" (chi(2)=7.952, p=0.019, <0.05) complications.

CONCLUSION

In this study, we show that ionized, processed silicone ventilation tubes are more robust to bacterial biofilm growth compared to other silicone ventilation tubes used in this study and that the "otorrhea" and "plugging" complications are reduced with the decrease of bacterial biofilm growth.

Experimental and clinical experience of albumin coating of tympanostomy tubes

OBJECTIVE

Otorrhea and tube occlusion are typical problems with tympanostomy tubes (TT). The purpose of this study was to test glue protein, fibronectin adhesion on albumin-coated and uncoated TT surfaces and to show the effect of this method on TT sequelae in vivo.

STUDY DESIGN AND SETTINGS

Fibronectin binding on TT surface was tested in two in vitro experiments. Thereafter 170 patients were randomized in a prospective clinical trial to test the effect of the method in vivo. The extruded TTs that could be collected from ears of some study patients were imaged with scanning electron microscopy (SEM).

RESULTS

Marked binding inhibition of fibronectin on albumin-coated TTs was found. Fewer tube sequelae were found in ears with albumin-coated TTs. SEM revealed thick crusts on uncoated tube surface.

CONCLUSION

Albumin coating of TTs can reduce unwanted adhesion on the tube surface in vitro and tube occlusions in vivo.

SIGNIFICANCE

TT sequelae can be reduced by surface coating with albumin.

How we do it: the Owa (Addenbrookes) grommet

. Grommet insertion is one of the most common procedures performed under general anaesthesia. . The authors describe an innovative grommet that, through an anatomically contoured and user friendly design has been designed to minimize anaesthetic time by facilitating and expediting its placement and/or removal.

[Local overpressure treatment reduces vestibular symptoms in patients with Menière's disease--secondary publication. A clinically randomised multicenter double-blind placebo-controlled study]

This investigation was performed to evaluate the efficacy of a new device, the Méniètt, in the treatment of Ménière's disease. The device delivers pressure pulses to the middle ear through a ventilating tube in the tympanic membrane. These pressure changes are conveyed to the inner ear, reducing the endolymphatic hydrops. The device is significantly effective in reducing the vestibular symptoms, as compared with the placebo device. Local overpressure treatment is a novel treatment that is non-invasive, non-destructive and safe. It should be offered to patients before more invasive surgical modalities are suggested.

Immediate repair of the tympanic membrane to prevent persistent perforation after intentional removal of long-lasting tubes

OBJECTIVE

Our purpose was to evaluate efficiency of immediate repair of the tympanic membrane perforation after intentional removal of the long-lasting tubes.

METHODS

This study was done in 36 ears of 27 patients who had either Goode-T or Paparella-II silicone tube insertion due to chronic OME or ROM and tube removal. Only the ears in which tube removal was performed due to no longer need for middle ear ventilation were included to the study. After removal of the tube, the perforation edges were refreshed and Steri-Strip (3M) patch was adhered on the perforation site. Otoscopic, tympanometric and audiologic data were reported.

RESULTS

Mean duration of the tube persistence was 49.58+/-11.94 months. It was found that there were two subgroups in the study group: those under regular follow-up (20 ears), and the ears which were out of regular follow-up (16 ears). Mean tube persistence times were 34.10 and 52.11 months in these subgroups, respectively (chi2-test, p=0.056). In six ears (16.67%), persistent perforation (PP) was found. PP rate (PPR) was higher in group-B (25%) than in group-A (10%) (chi2-test, p>0.1). The rest perforation was anteriorly marginal in five of six PP (83.33%). The PPR in the ears in which rest perforation was anteriorly marginal was 35.71% (5/14) while it was 4.54% (1/22) in the ears with central rest perforation (chi2-test, p<0.02).

CONCLUSIONS

Even immediate repair of the perforation after removal of the long-lasting tubes resulted in a high PPR. The data in this study documented that this high PPR was associated with type and localisation of rest perforation and tube persistence time. Anteriorly, marginal perforations had about eight times higher risk of PP and longer tube persistence caused higher anterior marginal perforations after tube removal.

Tympanic membrane healing process and biocompatibility of an innovative absorbable ventilation tube

OBJECTIVE

To investigate tympanic membrane healing process and biocompatibility of pressure-equalizing (PE) tubes, made of a novel biodegradable, absorbable material, in an animal model.

BACKGROUND

Myringotomy and pressure-equalizing tube insertion is a frequent otologic procedure in children. However, results may vary because of the unpredictable extrusion rate of tubes. Furthermore, tubes that are no longer required need a surgical procedure to be removed. The ideal pressure-equalizing tube should remain in place for the time selected by the otologist, with no need for subsequent removal. This objective could be met with pressure-equalizing tubes made from a self-disintegrating material.

METHODS

Pressure-equalizing tubes, made of poly-bis(ethylalanate)phosphazene, were inserted in 55 ears of 28 Hartley guinea pigs, with survival times of 10, 30, and 60 days after tube insertion. In vivo reactions between the poly-bis(ethylalanate)phosphazene pressure-equalizing tubes and the tympanic membrane were studied. Tympanic membranes, middle ears, and tubes were examined by scanning electron microscopy.

RESULTS

There was neither infection nor inflammatory reaction to the tube in any animal. The healing process of tympanic membranes revealed neither residual perforation nor inward spread of skin epithelium into the middle ear cavity. At 30 days, 53% of the tubes had disintegrated. At 60 days, tubes were functioning in 25% of ears.

CONCLUSION

These new poly-bis(ethylalanate)phosphazene pressure-equalizing tubes are promising. The healing process of tympanic membranes is excellent, with no complications. The tube disintegration rate can be controlled by varying the formulation of the polymer, obtaining tubes with predictable resorption rates, to adapt treatment to the needs of each single patient.

Tympanic membrane changes in central tympanic membrane perforations

PURPOSE

The objective of this study was to evaluate the histopathological changes in central tympanic membrane perforations caused by chronic otitis media without cholesteatoma.

MATERIALS AND METHODS

Twenty-nine temporal bones from 25 patients (13 male patients and 12 female patients) with central tympanic membrane perforations-18 chronic otitis media with perforation and 11 chronic otitis media with perforation caused by ventilation tubes-and 30 aged-matched normal temporal bones were included in this study. A scale was used to evaluate the extension of the migration of stratified squamous epithelium in the inner surface of the tympanic membrane. The thickness of tympanic membranes was measured halfway between the annular ligament and the perforation and compared with that of the normal bones. The presence of tympanosclerosis and papillary projections of squamous epithelium was also noted.

RESULTS

The extension of the migration of stratified squamous epithelium in the inner surface of the tympanic membrane was observed in 11 of the 29 perforations (38%). The thickness of tympanic membranes was significantly different between the perforation groups and the control group. Of the 29 tympanic membranes, 13 (44%) had tympanosclerosis and 8 (28%) revealed papillary projections of squamous epithelium.

CONCLUSIONS

Our study shows that a central tympanic perforation should not merely be considered as a simple defect. Most of the tympanic membranes showed one or more signs of sequelae or persistent abnormalities such as tympanosclerosis, papillary projections, thickening, and ingrowth without significant differences between the 2 central perforation groups.

Differential Penetration of Ototopicals and Water through Tympanostomy Tubes

OBJECTIVE

To evaluate the penetration of ototopicals and water through tympanostomy tubes (TT) using a physical model.

STUDY DESIGN

An in vitro model was created to measure the ability of various solutions to penetrate a variety of TT.

METHODS

A TT was placed through a perforation (myringotomy) in a silastic sheet (tympanic membrane) fixed between the ends of two 1 mL syringes. Measurements were obtained of the maximum height various liquids (tap water, 2% soapy water, ocean water, ofloxacin otic, corticosporin otic, and ciprofloxacin/dexamethasone otic) achieved before penetrating different TTs (1.0 mm or 1.27 mm Paparella silicone, 1.14 mm or 1.27 mm Reuter Bobbin titanium, 1.27 mm Collar Button fluoroplastic or 1.14 mm T-type silicone).

RESULTS

Two percent soapy water was significantly more permeable than water and ocean water in all tubes studied. Ciprofloxacin/dexamethasone otic was significantly more permeable than tap water, ocean water, and ofloxacin otic in only the Collar Button fluoroplastic TT. Our results suggest that titanium TTs are more permeable than other TT. Otherwise, ototopicals, tap water, and ocean water behaved similarly across all TT studied.

CONCLUSIONS

Our results demonstrate that ototopicals, tap water, and ocean water behave similarly with regard to TT penetration. Ciprofloxacin/dexamethasone otic may have better penetration than other ototopicals. Titanium TT may be easier to penetrate than other TT.

Tympanostomy tubes for otitis media: quality-of-life improvement for children and parents

We measured quality of life issues for both children and their parents on the premise that parental quality of life should be an aspect of cost-effectiveness in otitis media treatment. The patients were less than 18 years of age and had had myringotomy with tube insertion at the head and neck surgery department of a large health maintenance organization. Quality of life for patients, parents, and caregivers was evaluated by telephone survey of parents or caregivers and by retrospective chart review of the number of pre- and postoperative healthcare visits and antibiotic usage. Chart review showed a significant postoperative reduction in the number of clinic visits and in use of antibiotic drugs after insertion of tympanostomy tubes. Improved postoperative hearing was noted, and tympanostomy tube insertion was shown to be safe. The chart-review cost analysis showed that tympanostomy tube insertion is a cost-effective treatment for otitis media in children, and the telephone survey results showed that it improves quality of life for children and their parents or other caregivers.

Middle ear pressure equilibration ability and spontaneous pressure changes in healthy ears with ventilation tubes

CONCLUSION

The results of this study give support to the theory that opening the middle ear (ME) to the atmosphere leads to a deterioration in its pressure regulation capacity. However, this is probably not the reason why a perforation of the tympanic membrane becomes chronic.

OBJECTIVE

Direct, continuous measurement is a method of studying ME pressure regulation. We found previously that subjects with chronic central perforation (CCP) had a negative ME pressure in the daytime, in contrast to subjects with healthy ears. In this study, in order to elucidate the cause of this negative pressure, measurements were performed in healthy ears with ventilation tubes (VTs).

MATERIAL AND METHODS

A VT was inserted 1 week prior to the measurements in 18 subjects. A hearing protector was tightly fitted deep into the external ear canal and connected to a portable system consisting of a pressure transducer and a memory.

RESULTS

The measurements revealed a mean ME pressure during the first 3 h of -27 daPa. Ten subjects showed an initial decrease in pressure leading to a considerable negative mean ME pressure and a poor ability to equilibrate pressure differences through the Eustachian tube, like the subjects with CCP.

Tympanostomy tube obstruction related to ototopical drug therapy

Obstruction of tympanostomy tubes is a potentially significant complication, sometimes requiring replacement of the nonfunctioning tube. Early blockage can occur secondary to bleeding during the tube placement procedure. Delayed obstruction is usually caused by inspissated secretions or epithelial casts. We briefly report our treatment of 9 cases of delayed ventilation tube obstruction that were associated with the use of an ototopical antibiotic/steroid suspension.

Grommets in otitis media with effusion: an individual patient data meta-analysis

AIMS

To identify subgroups of children with otitis media with effusion (OME) that might benefit more than others from treatment with ventilation tubes.

METHODS

An individual patient data (IPD) meta-analysis on seven randomised controlled trials (n = 1234 children in all), focusing on interactions between treatment and baseline characteristics--hearing level (HL), history of acute otitis media, common colds, attending day-care, gender, age, socioeconomic status, siblings, season, passive smoking, and history of breast feeding. Outcome measures that could be studied were mean time spent with effusion (n = 557), mean hearing levels (n = 557 in studies that randomised children, and n = 180 in studies that randomised ears), and language development (n = 381).

RESULTS

In the trials that treated both ears the only significant interaction was between day-care and surgery, occurring where mean hearing level was the outcome measure. None of the other baseline variables showed an interaction effect with treatment that would justify subgrouping. In the trials that treated only one ear, the baseline hearing level showed a significant but not pervasive interaction with treatment-that is, only with a cut-off of 25 dB HL.

CONCLUSIONS

The effects of conventional ventilation tubes in children studied so far are small and limited in duration. Observation (watchful waiting) therefore seems to be an adequate management strategy for most children with OME. Ventilation tubes might be used in young children that grow up in an environment with a high infection load (for example, children attending day-care), or in older children with a hearing level of 25 dB HL or greater in both ears persisting for at least 12 weeks.

The Effect of Radiofrequency and Mitomycin C on the Closure Rate of Human Tympanostomy

OBJECTIVES

To conduct a prospective, randomized, controlled trial determining the feasibility of radiofrequency with or without topical mitomycin C application in delaying the closure time of human tympanostomy and screening its efficacy in management of recurrent acute otitis media and otitis media with effusion.

METHODS

From November 2002 to January 2004, 96 patients (180 ears) who were to undergo surgical intervention for recurrent acute otitis media or otitis media with effusion were included in this study. Sixty ears with a diagnosis of recurrent acute otitis media were equally randomized to three procedures: cold knife myringotomy (Group A), radiofrequency tympanostomy (Group B), and radiofrequency tympanostomy with topical mitomycin C application (Group C). One hundred twenty ears diagnosed as having otitis media with effusion were equally randomized to the last two procedures only. Patients were followed-up every week in the first month, every 2 weeks in the second month, and monthly after that until closure of the tympanostomy. A special follow-up setting was designed 3 months after tympanostomy closure where tympanograms and pure-tone audiograms were obtained.

RESULTS

Groups B and C showed a significantly slower rate of closure than Group A. At the same time, Group C demonstrated a slower rate when compared with Group B. The mean closure time of Group B was 3.5 weeks, with no difference between recurrent acute otitis media and otitis media with effusion. In contrast, the mean closure times for Group C were 5.3 and 7 weeks in cases of otitis media with effusion and recurrent acute otitis media, respectively, with the latter demonstrating a significantly slower closure rate. No recurrence of acute otitis media was reported in 10, 45, and 80% of Groups A, B, and C, respectively. Fifty-nine percent of Group C showed no clinical or tympanometric signs of otitis media with effusion 3 months after closure of tympanostomy. In contrast, Group B reported a lower cure rate (28%), with a statistically significant difference between both groups. Absence of recurrence and improvement in tympanometry signs correlated significantly with the duration of patency of tympanostomy (p < 0.01). The success rate was higher in patients who underwent adenoidectomy, but this did not reach statistical significance except in Group C (p < 0.01).

CONCLUSION

Radiofrequency and mitomycin C delay the closure rate of human tympanostomy. The efficacy of mitomycin C seems to be amplified in the presence of an inflamed tympanic membrane. Radiofrequency-assisted mitomycin-enhanced tympanostomy is a precise, safe, and cost-effective procedure that provides a viable approach in the management of recurrent acute otitis media and otitis media with effusion, especially when used in conjunction with adenoidectomy.

A blindedin-vitrostudy to compare the efficacy of five topical ear drops in clearing grommets blocked with thick middle ear effusion fluid

OBJECTIVE

To compare the efficacy of 5% NaHCO3, 3% H2O2, Sofradex (dexamethasone sodium metasulphobenzoate 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%), 0.33% acetic acid and 0.9% NaCl eardrops in clearing grommets blocked with harvested thick middle ear effusion fluid.

STUDY DESIGN

A blinded in-vitro study.

SETTING

District general hospital.

PARTICIPANTS

A total of 473 grommets were blocked with freshly harvested unpooled thick middle ear effusion fluid obtained from 68 patients.

MAIN OUTCOME MEASURES

Patency of the grommets before and 7 days after intervention was ascertained by tympanometry and close visual inspection.

RESULTS

Instillation of eardrops leads to a statistically significant increase in the clearance of grommets as compared with not using any drops (chi2 = 14.3, d.f. = 5, P = 0.006). The numbers needed to treat were 2.8 for NaHCO3, 3.2 for 0.9% NaCl, 3.9 for 0.33% acetic Acid, 4.4 for Sofradex and 9.5 for H2O2 eardrops. Pair-wise comparison was only significant for comparison between 5% NaHCO3 and 3% H2O2 eardrops (Bonferroni corrected P = 0.01, odds ratio = 4.3, CI = 1.9-9.9).

CONCLUSIONS

Use of eardrops leads to a clinically and statistically significant increase in the clearance of blocked grommets. Of the five drops used, 5% NaHCO3 was the most efficacious and 3% H2O2 the least efficacious. Limitations of this in-vitro study are recognized and a prospective in-vivo double blind randomized controlled trial is planned.

Local Overpressure Treatment Reduces Vestibular Symptoms in Patients with M??ni??re's Disease: A Clinical, Randomized, Multicenter, Double-Blind, Placebo-Controlled Study

OBJECTIVES

To evaluate the efficacy of a new device, the Meniett, in the treatment of Meniere's disease. The device delivers pressure pulses to the middle ear through a ventilating tube in the tympanic membrane at a frequency of 6 Hz for 0.6 second. After rising to a pressure level of 1.2 kPa, the pressure oscillates between 0.4 and 1.2 kPa. It is believed that the pressure changes are conveyed to the inner ear, inducing a transport of fluids via the pressure outlets and thus reducing the endolymphatic hydrops.

STUDY DESIGN

A clinical, randomized, multicenter, double-blind, placebo-controlled study. A total of 40 patients were included that had active Meniere's disease according to American Academy of Otolaryngology-Head and Neck Surgery criteria, aged between 20 and 65 years, with a history of at least eight attacks during the past year. After insertion of the ventilation tube, the patients should have had attacks of vertigo for 2 months before entering the study.

OUTCOME MEASURES

Primary study endpoints were change in frequency of vertigo, change of functionality profile, and change in patient perception of vertigo (visual analogue scale); secondary endpoints were perception of tinnitus, aural pressure, and hearing, as well as an audiologic evaluation of hearing before and after the treatment period.

RESULTS

The functionality level improved statistically significantly in the active group compared with the placebo group (p=0.0014), as did the visual analogue scale evaluation of vertigo (p=0.005). There was a trend toward a reduction of the frequency of vertiginous attacks that was not significant (p=0.090). With regard to the secondary endpoints, there was no statistical difference between active and placebo groups.

CONCLUSION

Local overpressure treatment is a novel treatment that is noninvasive, nondestructive, and safe. It significantly reduces vestibular symptoms in patients with Meniere's disease. The Meniett was cleared by the Food and Drug Administration in 2000.

Subannular Ventilation Tubes: Retrospective Study

OBJECTIVE

To evaluate the efficiency of a subannular tube insertion technique in a group of pediatric patients with adhesive otitis or severe atelectasis of the tympanic membrane.

DESIGN

Retrospective nonrandomized case series.

SETTING

Tertiary referral centre.

MAIN OUTCOME MEASURES

The main outcomes of this study are tube duration according to the type of tube used, the complication rate, and the audiometric gain associated with this procedure.

RESULTS

The study group consisted of 190 patients (316 tubes) aged between 3 and 19 years (average 9 years old) and operated on between 1993 and 1999 by four pediatric otolaryngologists. The average follow-up was 53 months. The tubes remained in place for an average of 21.8 months, with fluoroplastic tubes lasting 17.8 months and Goode T tubes lasting 23.8 months. When used in children between 5 and 9 years of age and in cases of adhesive otitis, Goode T tubes showed statistically significantly better results than fluoroplastic tubes. The complications of this technique were otorrhea (17.7%), perforation (7.9%), a plugged tube (7.0%), and cholesteatoma (1.6%). The 5- to 9-year-old group and the reintervention group of patients showed statistically higher complication rates compared with all other groups. Sixty-four patients (128 tubes) were eligible for audiogram analysis, which showed a gain of 13.4 dB (speech reception threshold).

CONCLUSIONS

The technique of subannular tube insertion is a safe and effective method for long-term middle ear ventilation in cases of adhesive otitis or severely atelectatic tympanic membrane or for patients with pathology related to dysfunction of the eustachian tube. It offers an alternative to repeated short-term tube insertions for otitis media with effusion or recurrent acute otitis media.

P-100 in the treatment of Ménière's disease: a clinical study

Patients suffering from Ménière's disease are particularly sensitive to negative pressure in the middle ear. For example, attacks of vertigo can be triggered by a descent in an aircraft when ventilation of the middle ear can become critical. Positive-pressure pulse treatment has been shown to have a beneficial effect on the symptomatology and is now a true alternative in the treatment of Ménière's disease. In this study, we compared two devices that produced positive-pressure pulses delivered to the inner ear via the external ear canal and after the insertion of a middle-ear ventilation tube. Both devices (Meniett and P-100) were equally successful and confirmed that positive-pressure pulse treatment is a true alternative to current treatment modalities. However, the P-100 is the preferred device, particularly for its convenience of use and its cost, which is considerably lower.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes

OBJECTIVE

To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes.

METHOD

Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears.

RESULTS

In all 27 cases, complete healing of the perforation was attained.

CONCLUSION

A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.

Otic drops used to clear a blocked grommet: an in vitro prospective randomized controlled study with blinded assessment

Clinicians often prescribe otic drops anecdotally to try and clear grommets blocked with blood. We carried out an in vitro double-blind randomized controlled study comparing the efficacy of sodium bicarbonate, Locorten Vioform and olive oil drops in clearing Shah grommets placed in 'artificial ears' and blocked with blood in a standardized fashion. There were 33 grommets in each group, and drops were inserted three times a day for 7 days. Olive oil drops cleared 17 of 33 (51.51%), Locorten Vioform cleared one of 33 (3%) and sodium bicarbonate cleared zero of 33 (0%) blocked grommets. Statistical comparison between pairs indicates that olive oil was significantly better than both Locorten Vioform (P < 0.001) and sodium bicarbonate drops (P < 0.001) at clearing grommets blocked with blood.

The Yung Percutaneous Mastoid Vent: Results of a Multicenter Trial

OBJECTIVE

The primary goal of the study was to find out whether the Yung vent would remain patent long-term. The secondary goal was to find out whether mastoid ventilation could overcome permanent ventilation disorder within the middle ear.

STUDY DESIGN

The study was an open prospective investigation.

SETTING

The study was a multicenter study involving three tertiary referral centers.

PATIENTS

Twenty-three subjects older than 12 years were included. The inclusion criteria were complete atelectasis, failed tympanoplasty because of persistent eustachian tube dysfunction, and persistent otitis media with effusion in spite of repeated ventilation tube insertion.

INTERVENTION

Tympanoplasty with insertion of the Yung percutaneous mastoid vent.

MAIN OUTCOME MEASURES

Patency of the vent, adverse effects, patient acceptance, hearing results, and appearance of the tympanic membrane were assessed every 3 months up to 18 months postoperatively.

RESULTS

: At 18 months, 20 of 23 vents were still patent. Overall, there had been no unacceptable adverse effect on any patient. Eighteen of 23 ears had improved hearing. The tympanic membrane had returned from a collapsed state to near normal in 13 of 17 completely atelectatic ears. There were five patients who had no benefit from the vent because of blockage within the epitympanum or middle ear effusion.

CONCLUSION

The Yung percutaneous mastoid vent can maintain long-term patency. It is effective in the treatment of complete atelectasis as an adjunct to tympanoplasty.

Albumin-Coated Tympanostomy Tubes: Prospective, Double-Blind Clinical Study

OBJECTIVES

Coating an implant with albumin prevents adhesion of proteins, bacteria, and platelets and thus may lead to its improved and prolonged function. Previously, we have demonstrated the inhibition of binding of fibronectin, one of the most adhesive glycoproteins, on human serum albumin (HSA)-coated tympanostomy tubes and the durability of this binding inhibition in a 8-month trial. We have also demonstrated that the HSA coating inhibits the binding of Staphylococcus aureus and Pseudomonas aeruginosa to titanium plates. This prospective study evaluated the effect of albumin coating on tympanostomy tube sequelae and on the outcome of tympanostomized patients.

STUDY DESIGN

Double-blind, prospective, randomized clinical trial.

METHODS

Two otolaryngological centers in southern Finland enrolled 179 pediatric patients. Number of tube occlusions and otorrhea and tube ventilation time in the ears with HSA-coated titanium tympanostomy tubes were compared with the contralateral ear with its uncoated, otherwise identical titanium tube during a 9-month follow-up period.

RESULTS

In HSA-coated tubes, average ventilation time was slightly longer and the number of early tube occlusions significantly less (P < .05). Moreover, in patients with perioperative bleeding, the coating prolonged average ventilation time of tympanostomy tubes significantly (P < .05).

CONCLUSIONS

HSA coating reduces early tube occlusions by preventing adherence of blood and secretion.

Influence of suction tube noise on hearing in pediatric patients who received ventilation tube insertion

BACKGROUND

Myringotomy with ventilation tube insertion is the most frequently used surgical procedure performed on children to treat otitis media with effusion. The risk of acoustic trauma caused by the suctioning noise during the procedure has not been clearly understood. The objective of this study was to investigate whether the suctioning noise during ventilation tube placement procedure damaged children's hearing.

METHODS

The study was conducted in a prospective manner. The ventilation tube placement procedures were performed on a series of 30 consecutive patients (60 ears). The electro-acoustic signals of the suctioning noises during the procedure were analyzed using a high quality digital tape recording system. The hearing threshold was measured using pure tone audiometry before and after the procedures.

RESULTS

The peak intensity of the suctioning noise ranged from 4 kHz to 10 kHz in frequency. The mean intensities of the suctioning noise were 86.4 +/- 9.6 dB for serous effusion and 96.4 +/- 9.6 dB for mucoid effusion, respectively. No noise-induced sensori-neural hearing loss was observed in this cohort.

CONCLUSIONS

Even though the peak intensity of the suctioning noise may reach a level of more than 90 dB, it is not likely that the suctioning noise during the ventilation tube placement procedure causes noise-induced sensori-neural hearing loss.

Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.

An evaluation of postural stability and the effects of middle-ear drainage on vestibulo-spinal reflexes of children with chronic otitis media with effusion

OBJECTIVE

Many authors agree that chronic otitis media with effusion (OME) are the main causes of vertigo and balance disturbances in children. The aim of this work was the stabilometric evaluation of postural stability and the influence of middle ear drainage on vestibulo-spinal reflexes in children with OME.

METHODS

Fifteen children with OME (5-14 years old, 13 males and two females) were selected for bilateral drainage of the middle ear after conservative treatment proved ineffective. The control group consisted of 15 healthy children of an analogous age range. Static and quasi-dynamic posturography was performed to evaluate balance. The tests were performed three times: 1 day before drainage, 1 day after drainage and 4 weeks after drainage. Parameters including the field of the developed area and the average velocity of body deflection were analysed.

RESULTS

There was statistically significant elevation of stabilogram parameters in almost all the tests in children with OME as compared to the control group. The changes in the stabilogram parameters were analysed with reference to the timing of the evaluation. Significant improvement was noted after the fluid was removed from the ear, although recovery was not complete after 4 weeks.

CONCLUSIONS

The presence of fluid in the middle ear impairs the functioning of the balance system in children. Postural stability and the quantity of vestibulo-spinal reflexes seem to depend on the functional condition of the middle ear. Prolonged cases of OME could potentially handicap a child's motor development.

Audit of the incidence of persistent perforation of the tympanic membrane following grommet removal or extrusion

The incidence of persistent perforation following grommet removal or extrusion in 210 ears was assessed, and found to be zero per cent. Collar button grommets were retained longer than Shepard grommets, and the percentage of ears requiring two or more tube insertions was 51.9 per cent.

Otitis media associated with Vibrio alginolyticus in a child with pressure-equalizing tubes

Vibrio alginolyticus is an unusual cause of otitis media. Infection usually occurs in the presence of a chronically perforated eardrum or patent pressure-equalizing tube. Infection with V. alginolyticus can occur after even mild, brief exposure to seawater, and the interval between exposure to seawater and onset of clinical infection can be prolonged.

A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.

Long-Term Results of Armstrong Beveled Grommet Tympanostomy Tubes in Children

OBJECTIVE

Many different tympanostomy tubes have been developed with different sizes, shapes, compositions, and coatings. Despite the frequency of ventilation tube placement, very few large studies have examined the outcomes of patients receiving this procedure. An ideal tube would be easy to insert and would extrude at a predictable interval without complications. This study was performed to assess outcome measures and complication rates of the Armstrong beveled grommet tube.

DESIGN

A retrospective case series of patients who had Armstrong beveled grommet tympanostomy tubes placed over a 3 year period by two Children's Hospital of Wisconsin pediatric Otolaryngology staff.

MAIN OUTCOME MEASURES

Patient age, diagnosis, operative findings, and time to tube extrusion were reviewed. Otorrhea, perforation, and cholesteatoma rates were also assessed.

RESULTS

Five hundred seven consecutive patients who had Armstrong tubes placed were reviewed. One thousand ninety-six Armstrong tubes were placed in these patients. Follow-up to extrusion rates were available for 756 tubes. The mean patient age at tube placement was 33.3 months, and the median age was 23 months. Mean and median times to extrusion were 16.5 and 15.5 months. One hundred sixty episodes of otorrhea were noted in 148 patients. Four patients had histories of cholesteatoma, none of which developed in conjunction with Armstrong tubes. Ten (1.32%) perforations that have not resolved over time were noted after Armstrong tube placement.

CONCLUSIONS

Armstrong beveled grommet tympanostomy tubes have complication rates comparable with those reported for Armstrong or other short-acting tubes in smaller series.

Evaluation of hearing thresholds in 3-month-old children with a cleft palate: the basis for a selective policy for ventilation tube insertion at time of palate repair

Hearing thresholds in children with a cleft palate prior to cleft palate repair are not widely documented, and audiological criteria for short-term ventilation tube insertion do not exist. The aims of this prospective study are to estimate hearing thresholds in 40 children with a cleft palate by 3-month developmental age with auditory brainstem responses (ABRs) under natural sleep and to estimate a hearing threshold guideline for short-term ventilation tube insertion. Our results show a wide range of air conduction hearing thresholds using click ABRs (2-4 Hz), which ranged from 25 to 102 dBnHL in the left ear and from 25 to 80 dBnHL in the right ear with means of 53 and 49 and standard deviations of 17 and 13 respectively. The bone conduction thresholds ranged from 0 to 55 dBnHL with a mean of 26 and a standard deviation of 13. Eighty-three per cent of children had flat, type B, on high-frequency tympanograms, indicative of middle ear effusion. Thirty per cent of the infants had a cleft palate associated with a known syndrome. Currently, it is the authors' practice to use short-term ventilation tubes on a selective basis at the time of cleft palate repair when there is a conductive hearing loss of more than 55 dBnHL in the better ear as determined by ABR with type B high-frequency tympanograms. This threshold level takes into account electrophysiological and auditory pathway maturation discrepancies. With this as the guideline, between 28% and 35% of the children in this study would be eligible for surgery. This criterion still requires further validation.

Laser myringotomy in otitis media with effusion: long-term follow-up

Otitis media with effusion is a leading cause of conductive hearing loss in children. Myringotomy and insertion of tympanostomy tubes is the accepted form of treatment. Recently, several studies utilizing laser myringotomy have been published, but few of them present late results. The objective of this study was to compare late results of the treatment with laser and classical myringotomy. A clinical effectiveness trial was conducted in three groups of children: (1) 37 children treated with laser myringotomy (ML), (2) 29 children treated with laser myringotomy and the insertion of tympanostomy tubes (ML+V) and (3) 43 children treated with classical myringotomy and the insertion of tympanostomy tubes (MC+V). All types of surgery were performed under general anesthesia because adenoidectomy and/or tonsillectomy was done at the same time. The results of treatment were assessed on the basis of the otoscopic examination (recurrences of effusion, condition of the tympanic membrane, and audiological examination (pure-tone audiometry, tympanometry and DPOAE). The minimum follow-up period was 1 year. The recurrence rate was lowest in the ML+V (11%) group, and highest in the ML group (36%). The difference between ML+V and MC+V was not significant. Permanent changes in the tympanic membrane were observed in 8% of the ears after ML, 19% after ML+V and 31% after MC+V. The difference was significant between the ML and MC+V groups. PTA was significantly higher in the MC+V group than in the control group of otologically healthy children. Mean amplitudes of DPOAE, measured in treated children with normal tympanometry results, were significantly lower than in the control group, but within the normal range. The use of CO(2) laser during myringotomy has no negative effect on the function of the cochlea. Healing of the tympanic membrane after laser myringotomy was uneventful with a low percentage of permanent sequelae.

Opening Plugged Tympanostomy Tubes: Effect of Tube Composition

OBJECTIVE: We sought to determine if tympanostomy tube (TT) composition impacts the rate of clearing mucoid plugs.

DESIGN: The study used an ex vivo model.

METHODS: TTs with a standard shaft length and inner diameter, varying only by composition materials, were studied. Thirty TTs of each biomaterial (stainless steel, titanium, silicone, fluoroplastic, ion-bombarded silicone, and phosphorylcholine-coated fluoroplastic) were plugged with middle-ear mucus and placed in a model ear chamber. Ofloxacin otic solution was instilled into the chamber to cover the plugged TT. Time to clear each plug was recorded.

RESULTS: Ion-bombarded silicone TTs cleared more rapidly than plain silicone TTs ( P=0.0042), but no other statistically significant difference among TT materials was observed.

CONCLUSIONS: TT composition does not significantly affect the rate or “ease”with which TTs may be opened after they become plugged with mucus ex vivo. The higher rate of plug clearance observed with ion-bombarded silicone relative to untreated silicone suggests that improvements may be possible with alterations in either TT composition or surface preparations.