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.

The role of ventilation tube status in the hearing levels in children managed for bilateral persistent otitis media with effusion

The study determined the effects on hearing of the status of ventilation tubes, using a combination of otoscopy and tympanometry to determine function, in children managed for bilateral persistent otitis media with effusion (OME). The subjects were aged between 3.5 and 7 years and had a documented history of bilateral OME over a 12-week watchful waiting period associated with a hearing impairment in both ears of >or= 20 dB HL. The children reported are those randomized to the two surgical arms, both of which had bilateral myringotomy, aspiration of middle ear fluid and insertion of Shepard ventilation tubes. One arm furthermore received adenoidectomy. The data were analysed 'as treated' to document therapeutic progress. Tubes confirmed to be functioning on otoscopy and tympanometry only partially alleviate the conductive impairment associated with childhood OME (AC mean 12 dB HL, SD 4; ABG 13 dB, SD 7, 3 months post operation). Thus, children with a functioning ventilation tube cannot be considered to have 'normal' hearing. Once the tube has extruded, ears that no longer have OME still have a small conductive hearing impairment (at 12 months AC 14 dB HL, SD 6; ABG 16 dB, SD 9) but this improves with time. In children with bilateral tubes, both remain functioning for a median duration of 21 weeks (IQR 10-40) and at least one for a median of 40 weeks (IQR 24-61). Tube blockage significantly (P = 0.001) increases the risk of extrusion (84% versus 44%). When inserted in children between 3.5 and 7 years for OME, the otoscopic incidence of tube infection is low (1%).

All that drains is not infectious otorrhea

It has been said that, 'All that wheezes is not asthma.' Thus, is also so of otorrhea. Bacterial infection most often causes otorrhea which, in turn, generally responds to treatment with ototopical antimicrobial therapy. When it persists, non-infectious etiologies must be considered. Although allergic causes of otorrhea have been described in the literature, inhalant environmental allergens (Type I Allergy) causing eustachian tube dysfunction or ototopical drops, most notoriously neomycin containing formulations, causing contact dermatitis are those usually mentioned. Further, most reports of contact allergic reactions of the ear have involved the external auditory canal skin or pinna and have been attributed to non-medicinal triggers like shampoos and metals used in ear rings. A search of the literature failed to reveal a reported case of recurrent or chronic otorrhea without cholesteatoma due to an allergic reaction to the components of a tympanotomy tube (TT). Such a case is presented here.

Durability of the binding inhibition of albumin coating on tympanostomy tubes

OBJECTIVE

Occlusion and prolonged otorrhea are typical problems associated with the use of middle-ear ventilation tubes. Albumin coating of ventilation tubes has been introduced to prevent tube occlusions by granulation tissue, blood clot, or pus. In this study, the durability of the binding inhibition (BI) of fibronectin was examined on the tube surface in albumin-coated tubes in different environments during an 8-month trial.

METHODS

Human serum albumin (HSA) was used to coat silicone tympanostomy tubes. Fibronectin, a typical adhesive protein in serum and exudates, was used as a model representative of exudates of the ear. The durability of BI of this glue protein on the tube surface was tested in different time periods with radiolabelled fibronectin. Scanning electron microscopy (SEM) was performed on the tubes.

RESULTS

The BI of fibronectin, achieved with the albumin coating, was still strong after 8 months of storage at +4 degrees C. A slight decline in BI was noted between the first and third months of storage at +37 degrees C. A significant difference between HSA-coated and uncoated tympanostomy tubes was noted in SEM. The uncoated surface generally appeared to be rougher than that of HSA-coated tubes when either titanium or silicone tubes were tested.

CONCLUSIONS

Albumin coating markedly inhibits the binding of fibronectin on tube surfaces in vitro. A clear BI achieved by albumin coating on tube surfaces was shown to persist throughout an 8-month trial, although some reduction of the BI was seen over time. The result emphasizes the role of albumin coating in preventing the adherence of foreign material on tympanostomy tubes. No advantage was achieved by using a cross-linking chemical in the albumin coating.

[How do metallic middle ear implants behave in the MRI?]

BACKGROUND

Magnetic resonance imaging (MRI) has gained in frequency and importance as a diagnostic procedure. In respect to the close anatomical relationship in the temporal bone it is necessary to know whether it is hazardous to patients with metallic middle ear implants regarding displacement and rise in temperature. For the MR image quality artefacts caused by metallic prostheses should be low.

METHODS

Four different stapes prostheses made from titanium, gold, teflon/platinum and teflon/steel, a titanium total ossicular reconstruction prosthesis (TORP) and two ventilation tubes (made from titanium and gold) were tested in a 1.5 Tesla MRI machine regarding their displacement. All objects were first placed in a petri dish, then suspended from a thread and finally immersed in a dish filled with Gadolinium. Temperature changes of the implants were recorded by a pyrometer.

RESULTS

None of the implants moved when they were placed in the petri dish or suspended from the thread. On the water surface the teflon/platinum and the teflon/steel pistons adjusted their direction with their axis longitudinally to the MRI scanner opening and the teflon/steel piston floated towards the MRI-machine when put close enough to the scanner opening. No rise in temperature was recorded. All implants showed as little artefacts that would still make an evaluation of the surrounding tissue possible.

CONCLUSION

Patients with any of the metallic middle ear implants that were examined in this study may undergo MRI-investigations without significant adverse effects.

Ventilation tubes after surgery for otitis media with effusion or acute otitis media and swimming. Systematic review and meta-analysis

OBJECTIVE

To determine if the use of ear protection when swimming of children with ventilation tubes modifies the risk of acute otitis media (AOM) compared to not swimming.

METHODS

Systematic review.

DATA SOURCES

Search conducted in MEDLINE, EMBASE and The Cochrane Library databases.

STUDY SELECTION

Prospective cohort studies and controlled clinical trials of children with ventilation tubes, with a minimum follow-up of 2 months.

DATA EXTRACTION

Two reviewers independently assessed trial quality and extracted data.

RESULTS

11 studies were selected. No difference was found in risk of AOM in children who swim without ear protection compared with those who do not swim: Odds ratio=0.78, 95% confidence interval 0.42-1.44; nor compared with those who use earplugs and swimming caps, odds ratio=0.75, 95% confidence interval 0.38-1.48; nor in those who use ear drops after swimming compared with those who used earplugs or swimming caps, odds ratio=0.76, 95% confidence interval 0.56 to 1.02. The use of ear drops after swimming increases the risk of AOM in children with ventilation tubes as compared with those who do not swim, odds ratio=3.14, 95% confidence interval 1.40 to 7.05.

CONCLUSIONS

There is no evidence to suggest that protection when swimming with earplugs, swimming caps or ear drops in children with ventilation tubes reduces the risk of AOM. Ear drops may even increase this risk.

Synchronous fat plug myringoplasty and tympanostomy tube removal in the management of refractory otorrhoea in younger patients

OBJECTIVE

Tympanostomy tubes are associated with many complications, the most common being recurrent otorrhoea, in many cases resistant to medical treatment. With the associated vestibulo-cochlear toxicity of many topical antibiotics, their use is dose limited. Removal of the tympanostomy tube has been shown to cure the otorrhoea, however, it is associated with a high persistent perforation rate of 10-28%. A synchronous fat plug myringoplasty was performed with tube removal in an attempt to reduce the residual perforation rate.

METHODS

A retrospective study of 13 consecutive children, nine male and four female, mean age 9.1 years (median=9, range 2-15), with a total of 15 ears (left=6, right=9) had either Shah Tubes (n=5), Shepard Tubes (n=1) or Shah Long Term Tubes (n=9) in-situ for middle ear effusions. The tubes were removed for recurrent otorrhoea. The tubes had been in-situ for a mean of 38.8 months (median=31, range 9-84 months). All ears had recurrent infections, with a variable response to topical antibiotics. All were under the care of one specialist, who performed all the procedures. At the time of tube removal, a standard fat graft myringoplasty was done.

RESULTS

The procedure was successful in 15 of the 15 ears, and all perforations had closed by 3 weeks. Pure tone audiometry improved in 11 ears, remained the same in two and worsened in two (0-10 and 11-15 dBA, respectively). There were no complications arising from the procedure. Mean follow up was 13.7 months (median=9, range 3-31). None of the patients have re-perforated, but two have required re-ventilation of their middle ear for middle effusions, and one of these two has also undergone subsequent adeno-tonsillectomy.

CONCLUSIONS

Our experience in this small series shows that the removal of a tympanostomy tube for recurrent otorrhoea can be successfully managed with a fat plug myringoplasty, with the benefit of a reduction in the persistent perforation rate following tympanostomy tube removal. It is a simple technique that requires little extra operating time with no significant morbidity.

Tympanostomy tube placements, sociodemographic factors and parental expectations for management of acute otitis media in Iceland

BACKGROUND

Widespread antimicrobial use is a risk factor for development of antimicrobial resistance. Antimicrobial treatment of acute otitis media (AOM) may not always be necessary. Little is known about the influence of parental expectations on physicians' decision-making in relation to treatment of AOM. Evidence is insufficient as to whether tympanostomy tube placement reduces antibiotic consumption.

METHODS

We randomly selected 1,030 children 1 to 6 years old living in 4 geographic areas in Iceland to be invited to participate in the study. Information about sociodemographic factors, antimicrobial prescriptions and their indications during the preceding 12 months, tympanostomy tube placements and parental views on antimicrobial use and bacterial resistance were obtained from a questionnaire completed by the parents and medical records.

RESULTS

The incidence of AOM episodes resulting in antimicrobial prescription for 804 children recruited into the study was 0.7 (95% confidence interval, 0.6 to 0.8) per child per year, highest among children age 1 year, i.e. 1.8 prescriptions (95% confidence interval, 1.4 to 2.2). The cumulative incidence of tympanostomy tube placements was approximately 30%. Antimicrobial use during the preceding 8 weeks for children with and without tubes did not differ (P = 0.36). Fifteen percent of children with tubes had received antimicrobials during the preceding 8 weeks at last once for AOM compared with 14% of those without tubes (P = 0.97). Parents in the area where antimicrobial consumption was lowest were less likely to accept antimicrobial treatment than parents in the other areas (P = 0.005). Parents of children who had previously received antimicrobials for AOM were more likely to accept antimicrobials (P = 0.04).

CONCLUSIONS

Parental expectations to antimicrobial treatment and awareness about resistance development appear to influence treatment strategies for AOM. The high rate of tympanostomy tube placement in preschool children does not result in reduced antimicrobial consumption.

Retained ventilation tubes: should they be removed at 2 years?

OBJECTIVES

To assess the complications of ventilation tubes that were retained in children for 2 years or longer and the necessity of removal.

DESIGN

A retrospective chart review of all patients who underwent ventilation tube removal from 1997 to 2000, with the exclusion of patients with craniofacial anomalies.

SETTING

A tertiary children's hospital.

PATIENTS

One hundred twenty-six children with ventilation tubes that were retained for 2 years or longer.

INTERVENTIONS

Ventilation tube removal and tympanic membrane (TM) patching.

MAIN OUTCOME MEASURES

Otorrhea, formation of granulation tissue, TM perforation, development of cholesteatomas, and tube reinsertion.

RESULTS

A total of 126 patients aged 2(1/2) to 14 years (59 girls and 67 boys) underwent removal of their ventilation tubes after 2 years or more. The patients were divided into 2 groups. Group 1 included 67 patients (29 girls and 38 boys) who were younger than 7 years at the time of tube removal. The tubes were retained for 2 to 5(1/2) years (mean retention time, 3.3 years). Group 2 included 59 patients (30 girls and 29 boys) aged 7 years and older at the time of tube removal. The tubes were retained for 2 to 10(1/2) years (mean retention time, 4.2 years). Complications such as otorrhea, formation of granulation tissue, and TM perforation were seen in 10.3%, 13.8%, and 5.2% of the patients with tube retention of 2 to 3 years, compared with 40.0%, 40.0%, and 46.7% of patients with tube retention of more than 5 years. In group 1, transient otorrhea, formation of granulation tissue, and TM perforation occurred in 13.4%, 7.4%, and 6.0% of the patients, respectively, after 2 years of tube retention. In group 2, similar complications occurred in 23.7%, 25.4%, and 27.1% of the patients, respectively. Forty-six patients in group 1 underwent TM patching (31 with paper and 15 with absorbable gelatin film, with a success rate of 91.3%; however, 8 patients (11.9%) required tube reinsertion. In group 2, patching of the TM was done in 40 patients (13 with paper, 24 with absorbable gelatin film, and 3 with fat), with a success rate of 67.5%. Tube reinsertion was necessary in 1.7% of the patients in group 2. No cholesteatoma was encountered.

CONCLUSIONS

Higher complication rates are seen in children when ventilation tubes are retained longer than 2 years. Children 7 years and older have a higher incidence of complications from the tube retention than children younger than 7 years. Early removal of ventilation tubes in children younger than 7 years of age, when the risk for otitis media is still present, may result in the need for tube reinsertion.

A new ventilation tube for long-term middle ear ventilation

OBJECTIVES

The treatment of secretory otitis media often requires repeated tubulation of the tympanic membrane as the standard ventilation tubes are extruded before the disease of the middle ear has remitted. The T-tube and its modification have been developed to remain longer in situ, often requiring surgical removal. The rates of subsequent persisting tympanic membrane perforations and granulations around the tube have been unacceptably high. In the search for a long-term ventilation tube with fewer complications, the Duravent tube (Smith and Nephew) has been developed. The aim of the study was to estimate duration in situ and observe complications in using the Duravent tube compared with standard tubes and T- tubes.

STUDY DESIGN

Retrospective study.

METHODS

In all, 51 patients have been treated with the Duravent tube over a 2-year period. In all, 72 Duravent tubes have been inserted. All patients were subsequently invited for a follow-up examination at a median time of 28 months (range, 11-43 mo) after the tube insertion and were followed up for 5 years.

RESULTS

The duration in situ was optimal with a median duration of 17 months. The Duravent tube was extruded spontaneously in all but four cases in which surgical removal was necessary. The rate of persisting perforations of the tympanic membrane was low (4.2%) compared with 24% after the use of the T-tube. Likewise, the usual complications connected with long-term ventilation tubes were less frequent (14% compared with 35% when using the T-tube).

CONCLUSIONS

In the present study, the Duravent tube has proved superior to other known long-term ventilation tubes. The problem of granulations, otorrhoea, and tube occlusion was significantly less than reported in other studies using the T-tube.

Long-term ventilation tubes: results of 726 insertions

Patients with chronic or recurrent otitis media with effusion who do not respond to treatment with conventional ventilation tubes are often treated with long-term ventilation tubes. The aim of this retrospective study was to determine the extrusion and complication rates of long-term ventilation tubes. The median ventilation time of the tubes was 31.5 months. The most common complication was otorrhoea. One episode of otorrhoea occurred after 24% of all tube insertions, and recurrent otorrhoea occurred in 29%. A persisting perforation developed in 19% after extrusion or removal of the tube. Other, mostly minor, complications occurred in 36% with the tube in situ and in 3% after extrusion or removal of the tube. Long-term ventilation tubes provided prolonged ventilation of the middle ear, but also resulted in a considerable number of complications. For each individual case, one should therefore determine whether the advantages of long-term ventilation tubes outweigh the possible complications in view of the available alternatives for middle ear ventilation.

Opening plugged tympanostomy tubes

OBJECTIVE

To determine the most effective solvents for dissolving plugged tympanostomy tubes.

STUDY DESIGN

In vitro laboratory study.

METHODS

Twelve solvents (including ototopical antibiotics and water) were applied to fluoroplastic tympanostomy tubes (n = 260) plugged with dried mucoid middle ear effusion in an ear canal-tympanic membrane model. Time to clearance of the tympanostomy tubes was both visually and tympanometrically determined.

RESULTS

Vinegar (P =.0030) and hyaluronidase solutions (P =.0030) were significantly better solvents than water.

CONCLUSION

Vinegar and hyaluronidase solutions are more likely to clear plugged tympanostomy tubes than water and ototopical antibiotics, but vinegar is the preferred solution because of its known relative safety for use in the ear.

Laser office ventilation of ears with insertion of tubes

OBJECTIVE

Myringotomy with insertion of pressure equalization tubes has proven to be extremely effective in treating persistent serous otitis media (SOM). This study compares the advantages and disadvantages of this procedure when performed in the operating room or with a laser in an office setting.

PATIENTS AND METHODS

Patients selected either traditional myringotomy and tube (M & T; n = 29) done in an operating room under general anesthesia or Laser Office Ventilation of Ears with Insertion of Tubes (LOVE IT; n = 35) done in an office setting with only topical anesthesia. The reasons for selecting either M&T or LOVE IT and satisfaction with the procedure chosen were evaluated by survey, the results of which were compared statistically. Chart review was performed to determine the time and cost of the procedures, time interval from diagnosis to treatment, tube longevity, and complications.

RESULTS

Overall satisfaction was similar with both procedures. Patients and families were more likely to choose LOVE IT based on the anesthetic technique involved (P < 0.001, chi(2)). M&T required less time to perform, whereas the cost of LOVE IT was less. Tube longevity and complication rates were similar between the two procedures, and all complications were minor.

CONCLUSIONS

LOVE IT is a potential alternative to traditional M&T in the treatment of SOM. LOVE IT is most likely to be selected by patients/parents who wish to avoid a general anesthetic and provides a level of satisfaction similar to that of traditional M&T.

A new absorbable pressure-equalizing tube

OBJECTIVE

We investigated pressure-equalizing (PE) tubes made of biodegradable, absorbable material in an animal model.

METHODS

PE tubes, made of poly-bis(ethylanate)phosphazene (PBE) 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 PBE-PE tube and the tympanic membrane (TM) were studied. Tubes, TMs, and middle ears were examined by scanning electron microscopy and light microscopy.

RESULTS

There was neither infection nor an inflammatory reaction to the tube within the middle ear in any animal. At 30 days, 53% of the tubes had disintegrated. At 60 days, tubes were still functioning in the 25% of ears.

CONCLUSION

More research must be performed before these new PBE PE tubes can be considered for clinical use. Nonetheless, these tubes are promising. The disintegration rate can be controlled by varying the formulation of the polymer, so treatment can be adjusted to the needs of each patient.

Ventilation tube removal: does treatment affect perforation closure?

OBJECTIVE

The study goal was to determine whether treatment of the tympanic membrane at the time of ventilation tube (VT) removal affects closure of the perforation.

STUDY DESIGN

We conducted a retrospective chart review and telephone follow-up of children who underwent VT removal from 1995 through 1998.

RESULTS

Among 109 patients (162 ears; 58% male), the mean age at VT removal was 6.7 years. Most VTs (59%) were T-tubes, and most (91%) were removed because of prolonged retention (mean 2.3 years). After VT removal, 111 ears (69%) received treatment, most commonly (44%) with 25% trichloroacetic acid (TCA). At the latest follow-up, 151 of the ears (93%) had healed without additional treatment. Treatment failure occurred more frequently in ears not initially treated with TCA (TCA 3% failure, other treatment 13%, no treatment 8%) and in ears with VTs removed because of otorrhea.

CONCLUSIONS

Most perforations healed. TCA may promote closure, but a large randomized clinical trial is needed to eliminate physician bias.

Histochemical, immunohistological and scanning electron microscope analysis of tissue retained on spontaneously extruded ventilation tubes

The aim of this study was to analyse the tissue surrounding prematurely extruded ventilation tubes (grommets). Thirty-one ventilation tubes, including 21 Shah and six Shepherd tubes, that had been extruded naturally into the ear canal were examined. After formalin fixation, material adhering to the tubes was retrieved and processed to paraffin wax. Five tubes were processed for scanning electron microscope (SEM) analysis. Sections were stained using histochemical methods for collagen, keratin and keratohyaline. In addition, the presence of collagen (type I and III), keratin, vimentin, fibronectin, tenascin, factor VIII-related antigen, CD31 and CD45 was tested for by immunohistochemistry. Results showed that all specimens consisted of an acellular fibrous material, oriented in concentric rings parallel to the tube surface that was often associated with small collections of CD45+ inflammatory cells. Two specimens contained collagen that was detectable by histochemical and immunohistological methods. Twelve specimens contained identifiable desquamated epithelial cells containing keratin and keratohyaline. Only one specimen stained positively for connective tissue markers (vimentin, fibrous fibronectin, tenascin) or showed the presence of vascular epithelium. SEM revealed adherent clusters or sheets of plate-like structures, consistent with the presence of epithelial squames, on three of the five ventilation tubes examined. It is concluded that tissue retained on extruded grommets consists of orthokeratinitizing epithelium infiltrated by inflammatory cells, a finding that is consistent with the theory that tube extrusion occurs as a result of squamous epithelial proliferation, medial migration, differentiation and desquamation.

The feasibility of office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion: the duPont Hospital experience

OBJECTIVE

To determine the feasibility of inserting tympanostomy tubes in children using office-based laser-assisted tympanic membrane fenestration.

METHODS AND MATERIALS

Study consisted of a retrospective review of the charts of all children who underwent office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion from July 1, 1998 to August 31, 2000. Tetracaine eardrops were used for topical anesthesia. Fenestration was achieved with the OtoLAM flashscanner laser (ESC Sharplan, Yokneam, Israel).

RESULTS

Of the 127 patients (185 ears) who underwent laser-assisted tympanic membrane fenestration, 61 ears underwent tympanostomy tube insertion. Ten ears were treated for otitis media with effusion, 43 for recurrent acute otitis media, and eight for acute otitis media not responding to antibiotics. Fifteen ears had purulent effusion, five had a serous effusion, and 23 had mucoid middle ear fluid. Eighteen ears had no middle ear fluid. At the first follow-up visit, all tested ears had hearing of 20 dB or better. Two children had tubes that were blocked. Blockage occurred in ears that required more than one laser firing to penetrate the tympanic membrane. Otorrhea was present in 13 ears (21%). Otorrhea occurred exclusively in ears with purulent or mucoid middle ear fluid.

CONCLUSIONS

Office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion is a safe and effective alternative to tube placement in the operating room. The outcome compares favorably with previously published data.

Eustachian tube dysfunction after tobacco smoke exposure

OBJECTIVE

To examine the effects of tobacco smoke exposure on eustachian tube (ET) function.

STUDY DESIGN

ET pressures of Sprague Dawley Rats (n = 16) were measured after 1, 7, and 15 exposures and in control animals. Passive opening pressure, passive closing pressure, active clearance of positive pressure, and active clearance of negative pressure were measured. Mucociliary clearance times were also quantified (n = 32).

RESULTS

Passive opening and passive closing pressures of smoke-exposed animals were greater than controls (P < 0.05). Passive opening pressure in smoke-exposed animals increased with increasing exposure (P < 0.001). Animals with 1 exposure had an active clearance of positive pressure higher than controls (P = 0.005) and those with 7 and 15 exposures had more negative active clearance of negative pressure than controls (P = 0.002, 0.03) Mucociliary clearance time was significantly elevated in experimental animals with 7 exposures (P = 0.006).

CONCLUSIONS

Alterations in ET function exist in animals exposed to tobacco smoke.

SIGNIFICANCE

ET dysfunction after tobacco smoke exposure may predispose children to the development of otitis media.

Local pressure protocol, including Meniett, in the treatment of Ménière's disease: short-term results during the active stage

Treatment of Ménière's disease (MD) is still controversial and pressure changes transmitted to the inner ear have been reported to have effects similar to those of other non-surgical therapies. This paper reports on a clinical trial of MD patients which has been carried out using a portable piece of equipment, called Meniett, which delivers a pulsed, controlled, positive pressure to the middle ear, provided that a ventilation tube (VT) has previously been inserted. A comparison was made of the number of vertigo spells during the 2 months before treatment and during the 40-day treatment period. In addition, within this latter period a comparison was made between use of VT and use of VT + Meniett. Use of VT only had a positive effect in 90% of patients, with either absence (n = 10: 50%) or marked reduction (n = 8; 40%) in episodes of vertigo. When Meniett was also applied, stabilization of the positive effect on vertigo was registered, with a concomitant improvement in hearing threshold in 2 patients (10%). Although a longer and more reliable long-term follow-up of this treatment is needed, it is possible to propose the use of this therapeutic approach as it has been proven to induce a dramatic improvement in the symptoms affecting patients with Ménière's disease during reactivation of the disease.

Tetracaine topical anesthesia for myringotomy

OBJECTIVES/HYPOTHESIS

To study the efficacy and safety of topical tetracaine anesthesia for office myringotomy and myringotomy with a tube.

STUDY DESIGN

Retrospective review of patients undergoing office myringotomy, with or without tube insertion, performed over a 4-year period.

METHODS

A topical solution of 8% tetracaine base in 70% isopropyl alcohol was used in 381 ears. Five to 10 drops of the solution were applied to the tympanic membrane for 10 to 15 minutes and aspirated. Myringotomy was performed either with a myringotomy knife or with a CO(2) laser (OtoLAM).

RESULTS

Topical tetracaine was used in all 231 ears (100%) undergoing myringotomy without a tube and 150 of 212 ears (71%) undergoing myringotomy with a tube. Tetracaine alone was effective in providing tympanic membrane anesthesia in 95% of myringotomy without a tube (220 ears) and in 93% of myringotomy with a tube (139 ears). There were six complications, including five cases of severe vertigo and one unusual prolonged, transient facial nerve weakness.

CONCLUSION

Topical tetracaine is efficacious and safe for use in office myringotomy.

Medium-term middle ear ventilation with self-manufactured polyethylene T-tubes for the treatment of children with middle ear effusion

We present the results of the insertion of self-made polyethylene T-tubes for a period of 15-24 months for the treatment of chronic middle-ear effusion. We compare the outcome of our patients to the reported outcome of patients treated with other commonly used ventilation tubes for either shorter or longer periods of time. In a retrospective review of 603 T-tubes inserted in 306 children up to the age of 12 years, charts were reviewed for age, sex, surgical procedure performed, duration of ventilation and complications. In all cases the indication for surgery was chronic middle-ear effusion. The tubes were electively removed by the authors after 15-24 months of ventilation. Spontaneous extrusion was considered a complication. The mean period of ventilation was 20 months. Post-operative otorrhoea was experienced in 6.6 per cent of ears; 4.8 per cent of tubes extruded spontaneously, whereas 3.15 per cent had to be removed earlier than originally planned; 4.9 per cent of ears were re-ventilated at a later date, and 1.49 per cent of ears developed a persistent perforation. We demonstrate that the outcome of patients treated with our self-manufactured tubes for a period of 15-24 months is, in many respects, better or at least comparable to the reported outcome of patients treated with other commonly used ventilation tubes for either shorter or longer periods of time, and that the many complications associated with the conventional T-tube can be reduced. We suggest that our favourable outcome may be due to the duration of ventilation, which was controlled to be shorter than the conventional long-term T-tubes and longer than that of grommets.

[Duration of middle ear ventilation after laser myringotomy with the CO2 laser otoscope Otoscan]

BACKGROUND

The most important principle in treating secretory otitis media (SOM) is ventilation of the tympanic cavity. CO2 laser myringotomy achieves this via a self-healing perforation whose diameter essentially determines the duration of transtympanic ventilation.

PATIENTS, METHODS

In this study, laser myringotomy was performed with the CO2 laser otoscope Otoscan in a homogeneous patient collective comprising 81 children (159 ears) suffering from SOM. The tympanic intervention was combined with an adenoidectomy or a CO2 laser tonsillotomy and therefore performed under general insufflation anesthesia. In all ears, approximately 2 mm circular perforations were created in the lower anterior quadrants with a power of 12-15 W and a pulse duration of 180 ms.

RESULTS

None of the children showed postoperative impairment of inner ear function. Otomicroscopic and videoendoscopic monitoring documented the healing process. The mean closure time was found to be 16.35 days (8-34 days). As a rule, an onion-skin-like membrane of keratinized material was seen in the former myringotomy perforations at the time of closure. At the follow-up 6 months later the laser myringotomy sites appeared normal and irritation-free. Two of the tympanic membranes (1.6%) examined showed atrophic scar formation, one (0.8%) a perforation with a diameter of 0.5 mm. In 19 ears (14.7%) there was a recurrence of SOM within the observation period.

CONCLUSIONS

Laser myringotomy competes with ventilation tube insertion in the treatment of SOM. It may be an useful alternative in the surgical management of secretory otitis media.

New method for coating tympanostomy tubes to prevent tube occlusions

OBJECTIVE

tympanostomy tube insertion is currently the most common surgical procedure requiring general anesthesia performed on children. Occlusion of the tube and prolonged otorrhea through the tube are typical problems associated with the use of middle-ear ventilation tubes. In this study, a new method for coating ventilation tubes is introduced that prevents occlusion of the tube lumen by granulation tissue, blood clot or pus.

METHODS

human serum albumin (HSA) was used to coat standard tympanostomy tubes of different materials. Fibronectin, a typical protein in serum and exudates and one of the most adhesive glycoproteins, was used as a model representative of exudates of the ear.

RESULTS

when compared with the binding on uncoated tubes, the binding of fibronectin on HSA-coated tubes was inhibited from 59 to 85%, depending on the tube material used.

CONCLUSIONS

HSA-coating markedly reduced the binding of fibronectin on tube surfaces in vitro. The study shows the potential role of HSA-coating in preventing the adherence of foreign material to tympanostomy tubes and reducing tube occlusions.

Hearing aids versus ventilation tubes in persistent otitis media with effusion: a survey of clinical practice

A postal survey was carried out to determine the current clinical practice amongst consultant otolaryngologists in the UK, regarding re-insertion of ventilation tubes or recommendation of hearing aids in cases of recurrence of otitis media with effusion (OME) after ventilation tube extrusion. Amongst the 319 respondents, 15 (4.70 per cent) routinely, 146 (45.77 per cent) sometimes, and 158 (49.53 per cent) either never, or very rarely, recommend hearing aids. Hearing aids and ventilation tubes were both suggested to be equally good options by some consultants but they preferred surgery for a number of reasons. There were inconsistencies in practice and some of the reasons for re-inserting ventilation tubes are not evidence-based. A hearing aid is a non-invasive option and this survey shows a need for a randomized control trial of hearing aids and ventilation tubes in the management of persistent and recurrent OME.

[Experimental and clinical experiences with the Er:YAG laser otoscope]

BACKGROUND AND OBJECTIVE

Laserotoscopes are suitable for low-pain outpatient surgery of otitis media with effusion (OME) under topical anesthesia. The myringotomy perforations should have a diameter greater than 2 mm to ventilate the middle ear for approximately 3 weeks.

PATIENTS/METHODS

In this study, the clinical applicability of a prototype of an Er:YAG laserotoscope (Baasel Lasertechnik, Starnberg, Germany) was tested. Formalin-fixed human tympanic membranes yielded the parameters suitable for clinical application of an Er:YAG laserotoscope in patients. With a focussed laser beam (beam diameter 500 microns), one is able to achieve perforations of 50-micron diameter with one single laser pulse applying pulse energies of 70 mJ (energy density 36 J/cm2). The ablation rate, i.e., the tissue layer that is ablated per laser pulse, is 100 microns using pulse energies of 70 mJ. This means that formalin-fixed human tympanic membrane can be perforated with one single laser pulse.

RESULTS

Ten patients with OME (otitis media with effusion) were treated under topical anesthesia of the tympanic membrane (8% tetracainbase in Isopropanol for 15 min) with focussed laser pulses (beam diameter 500 microns) with energies of 100 mJ (energy density 52 J/cm2). A sufficient perforation diameter of 2 mm could be achieved with an average of 15 juxtaposed laser applications. The enlargement of the perforations was made difficult by extruding middle ear secretions and slight bleeding of the tympanic membrane. Between laser applications, the target tissue had to be cleaned by suctioning using the operation microscope. The healing of the tympanic membrane was verified and compared in postoperative clinical follow-ups. With a perforation diameter of 2 mm, the Er:YAG laser myringotomies healed within 14 days. The used parameters did not generate side effects such as inner ear hearing loss.

CONCLUSIONS

An effective, easy, and practical performance of laser myringotomy is not currently possible with the Er:YAG laserotoscope.

Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Telescopic myringotomy and tube application

Otoendoscopy is a new technique in otological surgery. The traditional surgery for otitis media with effusion (OME) is myringotomy and tube insertion using an operating microscope. In 45 children and five adults presenting to our department with otitis media with effusion, rigid endoscopic myringotomy and grommet tube insertion were performed using 2.7 mm diameter and 0 degree and 30 degrees angle telescopes under general anaesthesia for children and local anaesthesia for adults. The use of rigid endoscopes provides a large field of view, that is of excellent resolution and fidelity of colour as well as giving good side views. It can be performed in the out-patient clinic with little inconvenience to the patient and minimal risks.

Attic aeration in temporal bones from children with recurring otitis media: tympanostomy tubes did not cure disease in Prussak's space

HYPOTHESIS

Blockage of the aeration pathways to the attic may cause circumscribed or widespread alterations that are difficult to diagnose clinically. The narrow route via the posterior pouch to Prussak's space is especially vulnerable to obstruction in recurring otitis media.

BACKGROUND

Recent studies of the epitympanic diaphragm and compartments have clarified the anatomy of the attic aeration and drainage pathways and emphasized the role of their patency in the healing process of middle ear infections. In neonatal otitis media, the amniotic fluid cellular content (AFCC) has proved to be a good indicator in outlining the areas where inflammation products concentrate, possibly causing early blockage of ventilation.

METHODS

Twenty-eight temporal bones from 14 children were studied; 4 of these children had experienced bilateral recurring otitis media. In the latter group, 1 ear was studied by microdissection and the other by serial sectioning.

RESULTS

Prussak's space was involved in all 4 pairs of bones and either contained thick mucus, contained secretion in the process of organization, or was obliterated. The tympanic isthmus was fully obstructed in 1, partially blocked in 2, and open in 5 specimens.

CONCLUSIONS

If a thick mature connective tissue mass develops under the epidermal layer of Shrapnell's membrane during an obliteration process of Prussak's space, the condition may stay stable and benign. Severe retraction of Shrapnell's membrane represents a likely forerunner of a retraction pocket cholesteatoma. Systematic otomicroscopy allows early detection, and cure can be achieved by minor surgery. In some children, despite the treatment of recurring otitis media with ventilation tubes, the attic and mastoid can be extensively involved, necessitating atticomastoidectomy and the creation of new pathways for attic aeration.

Medial displacement of grommets: an unwanted sequel of grommet insertion

Grommet insertion is one of the commonest surgical procedures performed in the UK. We have come across three cases in which grommets have displaced medially in the middle ear after establishing a satisfactory post-insertion position. We suggest that an abnormally long myringotomy incision and improper placement of the grommet are responsible for this unwanted outcome.

Parental perceptions of grommet insertion in children with cleft palate

Otitis media with effusion is almost universal in children with cleft palate and can delay speech, language and educational development by causing hearing loss. Grommet insertion at the time of cleft palate repair is common. There is debate about whether the benefits of grommets outweigh the risk of complications. A postal questionnaire was used to investigate parental perceptions of middle-ear ventilation via grommet insertion in children attending the multidisciplinary cleft palate clinic. These children's case notes were reviewed. Many children had speech and language delay, but parents thought this improved after grommet insertion. Overall parents were pleased with the results. This confirms that grommets have an important part to play in the management of children with cleft palate.

The effect of ventilation tubes on stresses and vibration motion in the tympanic membrane: a finite element analysis

Finite element analysis is used to determine the mechanical behaviour of structures. The deformation of a structure caused by a force can be calculated, and the stresses and strains within the component can be found. In brief, a geometric representation-a 'drawing'-of the structure is loaded into a computer, and a component is divided into 'elements' which usually have the shape of 'bricks'. A common analogy is a 'lego' brick assembly. The deformation of an element can be determined using engineering formulae, and the deformation of the whole structure can be determined when the elements are re-asssembled. There have been very few analyses of the biomechanical behaviour of ventilation tubes, or grommets, even though clinical studies have indicated that tube design and material determines extrusion rates and may influence tympanosclerosis. This paper reports a comprehensive biomechanical analysis of the effect of a grommet on the tympanic membrane. Analytical and computer simulation techniques (finite element analysis) are used to determine the changes in the vibratory motion and stresses in the membrane when a Reuter-Bobbin ventilation tube is inserted. It is found that the presence of a ventilation tube significantly affects the motion of the membrane in the neighbourhood of the implant. When the effect of implant material is investigated, it is found that the amplitude of motion of a heavier metal implant is less than a lighter polymeric implant. If it is true that higher motion predisposes towards early extrusion, then the lighter implant (polyethylene) is predicted to have a higher extrusion rate. Regarding the maximum stresses in the tympanic membrane, they form a crescent-shaped region in the anterior and posterior quadrants in the regions where tympoansclerosis is observed. The magnitude and pattern of the stress is predicted not to depend significantly on the presence of the tube. This suggests that tympanosclerosis is not determined by the implant per se and therefore that no tube design feature can be expected to prevent it.

Modification of the inner flange of the Paparella type II ventilation tube for easier insertion

A simple modification of the inner flange of the Paparella type II ventilation tube is described to provide easier and faster insertion.

Relationship between severity of middle ear mucosal lesion and middle ear pneumatic space volume in patients with otitis media with effusion

If we assume that the state of suppression of pneumatic cells is the result of suppression of pneumatic cell growth by inflammatory stimulation in the middle ear pneumatic space, it is possible to improve the state of suppression by performing sufficient treatment during the growth period of the pneumatic cells. We indwelt a tympanic membrane ventilation tube (hereinafter referred to as tube) for treatment of otitis media with effusion (OME) in child patients aged 3-13 years and investigated the following points: i) relationship between the severity of inflammation of the lamina propria of middle ear mucosal specimens (hereinafter referred to as lamina propria) collected at the time of tube indwelling and the degree of growth of the pneumatic space; and ii) changes in the pneumatic space associated with treatment by tube indwelling, which was studied by comparing the above-described mucosal severity with the pneumatic space area of 2 years after tube indwelling, and with increase in the pneumatic space volume measured periodically after tube indwelling. The results indicated that mastoid cell growth suppression is higher in patients with a higher degree of inflammatory changes in the lamina propria. In association with treatment by tube indwelling, effusion accumulated in the pneumatic space and mucosal swelling disappeared early after the treatment, or 2 months of tube indwelling. After that, in patients with severe mucosal lesion, a long time, 1.5-2 years, was found to be required for repneumatization accompanying regrowth of the temporal bone. We confirmed that the severity of inflammation of the lamina propria is deeply involved in the growth and repneumatization of the pneumatic cells.

Insertion of ventilation tubes: does the site matter?

Several factors are known to affect the length of time a ventilation tube remains in the tympanic membrane. These include the design of ventilation tube, the insertion technique and the presence of intercurrent infection. In addition there are theoretical reasons to suggest that a ventilation tube placed superiorly should remain longer than one placed inferiorly. A randomised prospective study was undertaken on 54 children to test this theory. It showed that there is no significant difference in the extrusion rates for a particular type of ventilation tube (Shah grommet) when comparing the anterosuperior quadrant with the anteroinferior quadrant of the tympanic membrane.

The Yung percutaneous mastoid vent: a medium-term follow-up study

BACKGROUND

I designed a percutaneous mastoid vent to provide permanent ventilation to the middle ear. The vent consists of an outer titanium tube that osseointegrates with the mastoid bone and an inner Teflon tube that protrudes into the mastoid antrum.

OBJECTIVE

To follow up all patients who had the mastoid vent inserted since 1995.

STUDY DESIGN AND SETTING

Retrospective study of 14 patients with mastoid vents inserted at the ear, nose, and throat clinic of a district general hospital.

PATIENTS

All patients had ventilation problems of the ear that failed to respond to conventional treatment. Three patients had persistent otitis media with effusion; 10 had completely collapsed eardrums; and 1 had failed tympanoplasty with recollapsed eardrum. INTERVENTION AND OUTCOME MEASURE: The mastoid vent extrusion rate, surrounding skin reaction, patency of the vent, and functional results were assessed with a follow-up period of 9 to 36 months.

RESULTS

Only 1 vent was extruded in a patient who had a previous cortical mastoidectomy. There was no dermatitis around any of the vents. All vents remained patent, and 9 of the 14 ears underwent successful ventilation. Four ears had adhesions within the mastoid antrum, mainly due to a previous cortical mastoidectomy. Six of 8 ears with intact ossicles also had improved hearing.

CONCLUSION

The percutaneous mastoid vent can provide medium-term ventilation to the middle ear.

What your colleagues think of tympanostomy tubes--28 years later

OBJECTIVE

Assess the changing opinions of otolaryngologists about tympanostomy tubes, including indications, tube material and shape and size, placement sites, and complications.

STUDY DESIGN

Cross-sectional survey, compared to the same survey done 28 years earlier.

METHODS

Questionnaires mailed to the 441 active fellows and 86 candidates of the Triological Society. Response rate 69.3%.

RESULTS

The preference for polyethylene has decreased from 75% to 13% of respondents. Preferred insertion sites are more anterior. The proportion of respondents who have seen a permanent perforation as a consequence has increased from 26% to 93%. The proportion of respondents who have seen a tube-attributable cholesteatoma has increased from 8% to 38%. The average tube duration has increased from 4 months to 18 months. Teflon and Silastic are now the materials most often used. As 28 years earlier, about 19% of patients get a subsequent tympanostomy tube. Anesthetics most commonly used now are general or topical phenol.

CONCLUSION

The consensus on several aspects of tympanostomy tubes has changed during 28 years. Controversy continues about the indications for using tubes. Although not a not cure-all for otitis media, tympanostomy tubes have proved useful.

Tympanostomy tubes: types, indications, techniques, and complications

This article reviews current concepts and applications involving tympanostomy tubes. The various types of tympanostomy tubes, indications, complications, and techniques are discussed. Applications ranging from otitis media to dysfunction of the eustachian tube associated with nasopharyngeal carcinoma are included. Experience drawn from patient care and currently published studies support the conclusions made in this article.

Anterior subannular T-tube for long-term middle ear ventilation during tympanoplasty

OBJECTIVE

A technique for providing long-term ventilation of the middle ear (ME) during tympanoplasty is described, and the results using this technique in 20 patients with chronic Eustachian tube dysfunction (ETD) are reported.

STUDY DESIGN

This study was a retrospective, nonrandomized case review.

SETTING

This study was conducted at an otology clinic in a tertiary referral center.

PATIENTS

Twenty consecutive patients who underwent tympanoplasty with ETD, adhesive otitis media, or chronic otitis media with perforation were included in this study.

INTERVENTION

All patients had a subannular T-tube placed anteriorly at the time of tympanoplasty for long-term ventilation of the ME space.

MAIN OUTCOME MEASURES

The two main outcome measures were tube position and patency. Preoperative and postoperative hearing levels were also tested in most patients, and any complications were documented.

RESULTS

Twenty patients (20 ears) received anterior subannular T-tubes at the time of tympanoplasty. Fourteen females and 6 males were evaluated (median age, 36 years; range, 7 to 72 years). All patients had ETD; 7 had adhesive otitis media, 10 had chronic otitis media, 8 had cholesteatoma, and 2 had cleft palate. All patients had conductive hearing loss and previous surgery. All patients underwent tympanoplasty; 11 had concomitant ossiculoplasty, and 5 had mastoidectomy. Follow-up ranged from 8 to 22 months (mean, 13.4 months). One patient was lost to follow-up. One tube extruded after 16 months. Two patients had persistent mild retraction of the tympanic membrane. All other tubes are patent and have not migrated or plugged. There has been no evidence of anterior blunting or ingrowth of epithelium around the tube.

CONCLUSIONS

Anterior subannular T-tube placement is a simple, safe, and effective alternative for long-term ME ventilation in patients in whom standard transtympanic sites are not available. At their last follow-up visit, all but one patient had a patent tube. All MEs were aerated. This technique offers the advantage of ease of placement during simultaneous tympanoplasty, mastoidectomy, or ossiculoplasty. Longer follow-up is necessary to confirm these initial findings.

In vivo resistance to bacterial biofilm formation on tympanostomy tubes as a function of tube material

Adherent bacterial biofilms have been implicated in the irreversible contamination of implanted medical devices. We evaluated the resistance of various tympanostomy (pressure equalization [PE]) tube materials to biofilm formation using an in vivo model. PE tubes of silicone, silver oxide-impregnated silicone, fluoroplastic, silver oxide-impregnated fluoroplastic, and ion-bombarded silicone were inserted into the tympanic membranes of 18 Hartley guinea pigs. Staphylococcus aureus was then inoculated into the middle ears. An additional 8 guinea pigs were used as controls; the PE tubes were inserted without middle ear inoculation. All PE tubes were removed on day 10 and analyzed for bacterial contamination using culture, immunofluorescence, and scanning electron microscopy (SEM). All infected ears developed otitis media with otorrhea, but none of the animal control ears drained. Fluorescence imaging of the animal control tubes showed large cellular components consistent with inflammation. The infected tubes showed heavy DNA fluorescence consistent with bacteria and inflammatory cells. All animal control tubes except the ion-bombarded silicone tubes showed adherent inflammatory film on SEM. Also, all tubes placed in infected ears except the ion-bombarded silicone tubes showed adherent bacterial and inflammatory films on SEM. Nonadherent surface properties such as the ion-bombarded silicone may be helpful in preventing chronic PE tube contamination.

Transtympanic dexamethasone application in Ménière's disease: an alternative treatment for intractable vertigo

The aetiology of Ménière's disease still remains unknown and its therapy is therefore empirical. As a result of immunological abnormalities demonstrated, steroids are commonly used in Ménière's disease. The place of topical steroids is still controversial. In this investigation topical dexamethasone is applied for three months through a ventilation tube in patients with intractable vertigo. The results showed that this treatment controls vertigo in 72 per cent of cases. No patient was worse than before treatment. Only in 17 per cent of the patients was there an increase in hearing level. When compared to the reports which used only tympanostomy tubes, this procedure seems to have a placebo effect with minimal harmful effects. It appears that transtympanic dexamethasone application is a good alternative to vestibular nerve section. Topical treatment may be sufficient in most patients. Systemic treatment may be used in patients where topical treatment fails.