[Infection frequency and type of bacteria after tympanostomy tube drainage in childhood: gilded-silver tubes versus silicone tubes]

Otorrhea is the most common complication after tympanostomy tube insertions. In Germany there are currently two commonly used types of tympanostomy tubes: silicon tubes (ST) and gilded silver tubes (GT). Previously published in vitro studies by Tajima uncovered a positive correlation between the silicon concentration in culture fluid and the rate of growth of Staphylococcus aureus. Our study retrospectively evaluates the types of bacteria and rates of otorrhea after ST and GT insertions. The present study was undertaken to determine which of these tubes had a higher incidence of otorrhea and then whether silicon tubes stimulated the growth of certain types of bacteria, such as Staphylococcus aureus. In all, 186 ST and 59 GT were placed in 245 ears of 144 children. Both ST and GT were separated into three groups: first insertion of a tympanostomy tube, second implantation and insertion of a tympanostomy tube in an infected ear in the course of a mastoidectomy. No differences between ST and GT in causing otorrhea were found in the three groups. Nevertheless, ST in comparison to GT was associated with a higher incidence of infections with Pseudomonas aeruginosa. In contrast, a higher incidence of Staphylococcus aureus related to ST could not be proved. Twenty percent of the ears with mastoiditis were found to have Pseudomonas aeruginosa, but none of these ears implanted with a GT developed postoperative otorrhea. Our findings show that GT should be used when a ventilation tube is used during a mastoidectomy. Further, it is tenable to implant only GT because postoperative otorrhea in many cases is caused by insufficient water protection and water is frequently polluted with Pseudomonas aeruginosa.

Timing for removal of tympanic ventilation tube in children

The medical records of 220 ears of 137 pediatric patients (85 male and 52 female) in which three kinds of ventilation tubes were inserted for treating otitis media with effusion (OME) were reviewed. The tubes selected were the Shepard grommet (75 ears), Goode-T (39 ears), and Paparella type II tube (106 ears). The criteria for tube placement were as follows: (1) continuous conductive hearing loss with over 25 dB air-bone gap, (2) resistance to conservative therapy for over 6 months, and (3) retracted and glue-colored tympanic membrane with type B tympanogram. The tubes that remained in place for over 18-24 months were removed intentionally in combination with a freshening of the perforation edge and tape-patch technique using Steri-Strip tape (3M) for preventing permanent eardrum perforation, because the incidence of persistent perforation became higher after long-term intubation. Shepard grommets tended to be extruded earlier, while Paparella type II tubes tended to stay longer. The OME recurrence rate decreased 12 months or more after tubal insertion. There was a tendency for the recurrence rate to decrease the longer the tube stayed in the eardrum. The number of recurrences decreased when the patient's age at the tube removal or extrusion was 7-8 years old. Adenoidectomy did not influence the recurrence rate of OME. Although the Goode-T and Paparella tube II tubes showed high perforation rates, the perforation rate after extrusion or removal of the tube was decreased by the use of the tape patch technique in combination with a freshening of the perforation edge. From these findings, it was concluded that the appropriate intubation period for the treatment of OME in children is over 12 months with the use of a long-term tube, and that if the patient's age at the time of tube insertion was below 6 years, it might be better that the removal of the tube is postponed until the patient is 8 years of age.

Phenylephrine and the prevention of postoperative tympanostomy tube obstruction

OBJECTIVE

To determine the efficacy of phenylephrine hydrochloride, a topical vasoconstrictor, in preventing tympanostomy tube obstruction.

DESIGN

Prospective, randomized, double-blind, controlled trial of patients undergoing myringotomy with tympanostomy tube insertion.

SETTING

Academic, tertiary referral medical center.

PATIENTS

Two hundred eight patients were enrolled in the study; 157 patients (310 ears) returned for postoperative evaluation.

INTERVENTIONS

Myringotomy with tympanostomy tube insertion was performed in all ears: 139 control ears received ototopical antibiotics and 171 treatment ears received ototopical antibiotics plus topical phenylephrine.

MAIN OUTCOME MEASURE

Postoperative tympanostomy tube obstruction.

RESULTS

The overall incidence of tympanostomy tube obstruction was 5.2%: 8.6% in the control group and 2.3% in the treatment group. The treatment group demonstrated an odds ratio of 0.25 (95% confidence interval, 0.08-0.78; P= .02).

CONCLUSION

The use of phenylephrine following tympanostomy tube insertion greatly reduces the incidence of tube obstruction.

[The CO2 laser otoscope. A new application device for paracentesis]

The CO2 laser myringotomy is a current low-pain procedure for middle-ear ventilation for secretory otitis media (SOM) that can be performed under topical anesthesia, even in children. The duration of middle-ear ventilation is essentially determined by the size of the perforation created. Perforations with a diameter greater than 2 mm ventilate the tympanic cavity for approximately 3 weeks, thus avoiding tympanic ventilation tubes. To date, the CO2 laser beam can only be reliably applied to the tymapanic membrane via a micromanipulator system coupled to an ear microscope. The CO2 laser otoscope is a new application system that markedly reduces the technical complexity of surgery and improves the mobility and availability of the system. The incorporation of a small inexpensive CO2 laser in the otoscope represents a significant development in SOM therapy.

Tympanostomy tubes and water exposure: a practical model

OBJECTIVE

To determine whether water exposure causes middle ear contamination in patients with collar button tympanostomy tubes (TTs).

METHOD AND DESIGN

An in vitro model of a human head that contained an auricle, external auditory canal, tympanic membrane with TT, middle ear, eustachian tube, and mastoid cavity was developed. Two electrodes connected to an external ohmmeter resided in the middle ear to detect water entry. The model was tested with 4 types of water exposure: showering, bathing, hair rinsing, and swimming. Statistical analysis was performed by the Fisher exact test.

MAIN OUTCOME MEASURES

A positive test result corresponded to water entering the middle ear via the TT, confirmed by a resistance reading of zero on the ohmmeter. A negative test result indicated no change in the initial high resistance reading.

RESULTS

No positive test results were obtained for showering (0 of 60 tests), hair rinsing (0 of 60 tests), or head submersion (12.7 cm) in clean tap water (0 of 60 tests). Ten positive test results were obtained for head submersion in soapy water (10 of 97 tests), which was statistically different from clean water (P< or =.007). Swimming pool depths of 30, 45, 60, and 75 cm elicited positive test results in 2 of 16, 3 of 18, 2 of 20, and 11 of 20 tests, respectively. A higher incidence of water entry into the middle ear occurred at depths of more than 60 cm (P< or =.001). No statistical difference between depths of 60 cm or less occurred (P= .88).

CONCLUSIONS

Showering, hair rinsing, and head submersion in clean tap water do not promote water entry into the middle ear. Submersion in soapy water increases the probability of water contamination. Pool water infrequently enters the middle ear with head submersion, but the incidence increases with deeper swimming (>60 cm). These data provide further evidence that many water precautions frequently advised in patients with TTs are unnecessary.

Resistance to biofilm formation on otologic implant materials

New materials and coatings are now being developed to resist permanent bacterial contamination of implanted medical devices. This study exposed several styles of middle ear ventilation tube materials and coatings to high concentrations of Pseudomonas and Staphylococcus. Electron microscopy was then used to evaluate these tubes' resistance to bacterial biofilm formations. Ionized, processed silicone tubes were the only tubes resistant to Pseudomonas adhesion. Tubes that were made of fluoroplastic or that were ionized processed were very resistant to Staphylococcus contamination when compared with untreated silicone or silver oxide-treated silicone. This study suggests that ionized, coated fluoroplastic would be a highly effective tube material in preventing bacterial biofilm contamination of implanted ventilation tubes.

Relationship between tympanic membrane perforations and retained ventilation tubes

OBJECTIVES

To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral academic institution.

PATIENTS

Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion.

INTERVENTION

Ventilation tube removal under general anesthesia, with or without concomitant patching.

OUTCOME MEASURES

All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history.

RESULTS

The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate.

CONCLUSIONS

Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques.

Middle ear laser office ventilation (LOV) with a CO2 laser flashscanner

BACKGROUND

Laser assisted ventilation of the middle ear with a defocused laser beam has been performed on adults in an office setting without anesthesia.

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of a highly controlled, char-free CO2 flashscanner technology for the ventilation of the middle ear in young children, at this stage under general anesthesia, and later without anesthesia.

METHODS

A CO2 flashscanning laser, in conjunction with a micromanipulator, was used on 21 SOM patients ages 3-7 years old, with followup at 2 months. Operating time is approximately 5 minutes.

RESULTS

Postoperative results show average patency of 2-3 weeks without adverse effects. Of the treated patients, 53% did not require a second treatment, whereas 47% still suffered from otitis media and needed a second treatment.

CONCLUSION

The CO2 flashscanner laser technology is effective and safe for middle ear ventilation and provides excellent control of the perforation diameter. It is already being performed in an office setting with sedation on a limited basis with very promising preliminary results. Based on the current study and on 70 additional cases with longer interval followup, we anticipate the office technique to become widely used in the future.

Permanent mastoid vent: a new treatment for persistent eustachian tube obstruction

To date, there is no satisfactory treatment for persistent eustachian tube blockage or negative pressure in the middle ear. Conventional ventilation tubes are usually either occluded or extruded with time. A new treatment of percutaneous mastoid vent provides permanent ventilation to the middle ear cleft without putting a tube through the eardrum. A titanium tube is inserted through the skin into the mastoid antrum using the established technique of osseo-integration and hence becomes truly permanent. It can also be connected to a CPAP machine to re-inflate a collapsed eardrum. Initial trials consist of six vents inserted and followed up for 6-16 months. There was no sign of extrusion or a foreign body reaction. However, an inner Teflon tube is essential to keep the vent patent for permanent ventilation to the middle ear cleft.

Immediate effects of middle ear pressure changes on the electrocochleographic recordings in patients with Menière's disease: a clinical placebo-controlled study

OBJECTIVE

The aim of the study was to evaluate effects of middle ear pressure changes on the electrocochleographic responses in patients with well-defined Menière's disease. STUDY DESIGN AND INTERVENTIONS: The investigation was conducted as a placebo-controlled, randomized clinical study. Electrocochleographic measurements were performed before and after the insertion of a transtympanic ventilation tube and immediately after the exposure to active or placebo treatment.

SETTING

The study was carried out in one secondary referral center and one tertiary referral center on an ambulatory basis.

PATIENTS

Thirty-nine patients with well-defined Menière's disease were included in the study.

MAIN OUTCOME MEASURES

The summating potential/action potential ratio of the electrocochleographic response complex was chosen as the main variable for statistical evaluation of results. Other parameters of the recordings such as responses to low-frequency burst stimulation also were evaluated. Subjective symptoms (e.g., vertigo, tinnitus, and aural pressure) were assessed before and after insertion of the ventilation tube and before and after exposure to treatment.

RESULTS

A statistical difference was shown in the electrocochleographic response in the active group before and after exposure to middle ear pressure changes. In the placebo group, no change was found. Changes in electrocochleographic parameters in the active group indicated an improvement in inner ear electrophysiology. No significant changes were found in subjective symptoms in the active or the placebo group. Evaluation before and after insertion of the ventilation tube showed no significant improvement in any variable.

CONCLUSIONS

This is the first study in which electrophysiologic parameters were evaluated in a placebo-controlled clinical trial of overpressure treatment in Menière's disease. The results show that electrophysiologic parameters can be improved by the application of positive pressure pulses of low amplitude in the middle ear.

Ventilation tube duration versus site of placement

BACKGROUND

The duration a ventilation tube remains in the tympanic membrane is thought to be related to the design of the ventilating tube, and to the site of placement of the ventilation tube into the tympanic membrane. Theoretically a ventilating tube placed superiorly should remain longer than one placed inferiorly.

METHODS

A prospective study was designed to test the hypothesis that ventilation tubes placed into the antero-superior quadrant of the tympanic membrane remained longer than those placed into the antero-inferior quadrant.

RESULTS

In 106 children no statistically significant difference in duration was identified using three designs of ventilation tube.

CONCLUSIONS

Ventilating tubes placed antero-superiorly into the tympanic membrane do not have a longer duration than those placed antero-inferiorly.

Results of middle ear ventilation with 'Mangat' T-tubes

Tympanostomy tube placement has been shown to be an effective treatment for recurrent acute otitis media and chronic otitis media with effusion. The Senior author, (K.S. Mangat), considered stiffness and the longer inner limbs of the Goode (Xomed) or Treace (Treace Medical) T-tubes as important factors in the high incidence of complications, and used smaller soft silicone. Mangat-tube (Xomed) with shorter inner limbs. A prospective study was undertaken over a five year period (July 1987-July 1992) which was a continuation of a previous retrospective study of Goode and Treace T-tubes (Mangat, K.S., Morrison, G.A.J., and Ganiwalla, T.M. (1993) Int. J. Pediatr. Otorhinolaryngol. 25, 119-125). 322 Mangat tubes (M-tubes) were inserted in 191 patients with persistent otitis media with effusion. The peak ages for insertion were between 4 and 6 years. Spontaneous extrusion occurred in 240 ears (66.5%; 154 patients) at a mean time of 29.3 months. Of these, there were 60 perforations at three months follow-up (18.6%) which fell to 31 perforations after six months (9.6%). Surgical extraction of the M-tube was necessary in 82 ears (22.7%; 50 patients) following persistent otorrhoea or resolution of the condition. Otorrhoea, requiring treatment, was noted in 36 ears (11%). No association was found between the occurrence of infection and the incidence of perforation persisting after a year. There was a higher incidence of persistent perforation in those requiring surgical extraction. The overall persistent perforation rate of only 9.6% would appear to be less than that experienced with Goode or Treace T-tubes.

An unusual complication of T-tubes

The morbidity of long-term ventilation tubes (Goode T-tubes) is often discussed with reference to otorrhoea, tympanosclerosis and long-term perforation. We report three cases of the T-tube slipping into the middle-ear cleft. In two of the three patients this was asymptomatic and the T-tubes were left in situ. In the third patient this complication was documented on three occasions when the T-tube was removed and reinserted for recurrent effusions. We are unaware of this complication being previously reported in the literature.

Prevention of persistent ear drum perforation after long-term ventilation tube treatment for otitis media with effusion in children

The effect of tape patch technique using Steri-Strip tape in combination with freshening of the perforation edge after removal of long-term ventilation tubes for preventing permanent ear drum perforation was evaluated. The longer the tubes remained in place, the higher the incidence of persistent perforation after tube removal. The perforation rate after Goode T-tube treatment was 4.0% in the spontaneous extrusion group and 14.3% in the intentional removal group. In the ears treated by tape patch application, none of the perforations persisted after removal of the Goode T-tube. After removal or extrusion of Paparella Type II tube, perforations did not close in 13.2% of the group without tape patch application. When a tape patch was applied, only one perforation (3.3%) did not close. From these results, tape patch technique in combinations with freshening of the perforation edge at the time of tube removal was useful to promote healing and prevent persistent ear drum perforation.

Care of the child with tympanostomy tubes

More than two million tympanotomy tubes are placed annually in the United States, making this operation the most common performed on children. This article provides an overview of the applications of tympanotomy tubes for the treatment for otitis media in childhood. The indications for tube placement are discussed; a visual guide for managing children with tympanostomy tubes is presented; an approach to dealing with tube complications is outlined; and guidelines for referral to a pediatric otolaryngologist are suggested.

Bilateral ear canal stenosis from retained Goode T-tubes

A 14-year old white male presented with a 2-year history of bilateral otorrhea. Purulent otorrhea with very stenotic external auditory canals (EAC) were found, and the patient was treated with topical otic solutions. Bilateral conductive hearing loss was found on audiometric studies. Biopsies were taken after the patient failed medical treatment. The results were consistent with granulation tissue and chronic inflammation. A CT scan revealed complete bilateral EAC stenosis. At surgery the patient was found to have bilateral retained Goode T-tubes, which were placed at 2 years of age. After removal of the tubes, the patient made a good recovery with improved hearing. This case illustrates a severe complication of retained tympanostomy tubes. Patients with these tubes require close long-term follow-up with careful management of problems such as granulation tissue or otorrhea to prevent this type of complication.

[Golden tube wire for temporary or permanent implantation]

Abnormal eustachian tube function has been a major problem in improving hearing with middle ear surgery. In 13 patients, a newly developed gold tube conductor was placed in the eustachian tube via the middle ear cavity. Patients were examined 2-50 months postoperatively, at which time middle ear aeration was found to be significantly improved in 11 of the cases.

Safety of silver oxide-impregnated silastic tympanostomy tubes

Otorrhea occurs after the insertion of tympanostomy tubes in as many as 50% of ears. Although topical antibiotic solutions minimize otorrhea in the immediate postoperative period, recurrent otorrhea is sometimes a clinical problem. The antimicrobial effects of silver oxide when impregnated into a tympanostomy tube may decrease the incidence of recurrent otorrhea. This study demonstrates that silver oxide-impregnated silicone elastomer is well tolerated within the middle ear of gerbils when implanted for 1 year, and the tissue reaction is no more than silicon elastomer without silver oxide. When applied directly to the round window of guinea pigs, there was no evidence of ototoxicity of silver oxide as measured by electrocochleography (N-1 thresholds) and cytocochleography (hair cell counts). These animal studies indicate that silver oxide-impregnated silicone elastomeric tympanostomy tubes may be used safely in clinical trials to determine efficacy.

Tympanosclerosis and mini grommets: the relevance of grommet design

Fifty children with otitis media with effusion undergoing grommet insertion had into one ear a Mini-titanium grommet inserted and into the other ear a Mini-teflon grommet. Post-operative follow-up until after extrusion of the grommets demonstrated only a small difference between the extrusion times of the two grommets (a significant difference of 41 days) and no difference in the degree of tympanosclerosis seen with each grommet. We propose that the mass of a grommet appears to play less of a role than has previously been suggested in the pathogenesis of tympanosclerosis following grommet insertion and that duration of intubation may be the most significant factor.

[Use of tarflen ventilation tubes in treatment of secretory otitis media in children]

The results of operative treatment of secretory otitis media in 32 children at the II Department of Laryngology of the Silesian Medical Academy in Zabrze are presented. Ventilation tubes made from a plastic called "tarflen", for temporary tympanic cavity drainage and middle ear ventilation were used. Satisfactory results confirmed by otomicroscopic, audiometric and tympanometric examinations were obtained. It is pointed out that surgical treatment is necessary in chronic cases. The possibility of serious complications in case of desistance from this kind of treatment are indicated. The quality of Polish ventilation tubes, making treatment successful, in emphasized. The problem of difficulties in diagnosing secretory otitis media is also presented.

[Middle ear ventilation with the Otovent latex membrane system]

Epidemiological studies have shown that up to 80% of all pre-school children develop Eustachian tube dysfunction with middle ear effusion and corresponding conductive hearing loss. The therapy of choice for hyperplastic adenoids is adenoidectomy, often in combination with paracentesis. The objective of this study was to determine whether regular middle ear aeration (Otovent-system) could obviate the need for paracentesis. To this end treatment of 146 children from four to ten years old was conducted within the guidelines of a study protocol. In one group of children, Otovent-supported middle ear aeration was carried out before and after adenoidectomy. In the control group, adenoidectomy was followed by paracentesis. Parents and children were then assigned to follow-up treatment. As additional supportive therapy, children in both groups received decongestant nose drops and a mucolytic agent for a period of 2 weeks. The success of the treatment was evaluated by tympanometry, tone-wave audiometry and ear microscopy. The patients were followed-up at intervals of two and four weeks after the initiation of treatment. The results show that within the study time frame, Otovent treatment compares well to paracentesis. In summary, regular Otovent-supported aeration of the middle ear in many cases can be an alternative to paracentesis.

Antimicrobial activity of silastic tympanostomy tubes impregnated with silver oxide. A double-blind randomized multicenter trial

OBJECTIVE

To test the null hypothesis that impregnation of tympanostomy tubes with silver oxide did not alter the rate of postintubation otorrhea.

DESIGN

Multicenter, double-blind, randomized clinical trial.

OUTCOME MEASURE

Rates of postoperative otorrhea during a 1-year study in ears implanted with Silastic tubes compared with contralateral, identical tubes impregnated with silver oxide.

SETTING AND PARTICIPANTS

Eight sites in the United States, 125 children aged 1.5 months to 12 years who had bilateral otitis media with effusion or bilateral recurrent acute otitis media.

RESULTS

The overall incidence of postoperative otorrhea was 9.78% in the control ears and 5.08% in the ears with silver oxide-impregnated tubes (P = .01), but no effect was seen during the immediate postoperative period. Granulation tissue was seen adjacent to the tube during two visits in the ears with standard tubes (0.54%) and during two visits in the ears with experimental tubes (0.53%); cholesteatomas did not occur in either group.

CONCLUSION

Silastic tubes impregnated with silver oxide seem to diminish the incidence of postoperative otorrhea in ears requiring long-term ventilation.

A prospective randomised trial of the use of sodium bicarbonate and hydrogen peroxide ear drops to clear a blocked tympanostomy tube

This randomised prospective trial compared the efficacy of sodium bicarbonate and hydrogen peroxide ear drops in clearing a blocked tympanostomy tube. Tympanostomy tubes, 110 in number, obstructed with blood or inspissated secretions were randomised into treatment and control groups. Details of the operative procedure were retrospectively collected from the patients notes. The patients were reviewed after 2 weeks for both clinical and tympanometric evidence of clearance of the tube and evidence of complications of the drops. There was no significant therapeutic advantage between the two drops (P > 0.9), but in both treatment arms there was a significant therapeutic advantage over a period of observation (P < 0.05 in both groups). Otorrhoea and pain on instilling the drops occurred with equal incidence in both treatment groups. As obstruction of tympanostomy tubes is a common occurrence which often prompts surgical reventilation, there is great potential for cost savings if conservative treatment can be used effectively. The treatments for obstructed tympanostomy tubes are reviewed and methods of prevention of this common occurrence are discussed.

Recovery of eustachian tube function and hearing outcome in patients with cleft palate

Eustachian tube dysfunction is a nearly universal complication of cleft palate, resulting in chronic ear disease and conductive hearing loss. Cleft palate repair is thought to result in recovery of eustachian tube function, but the length of time between repair and recovery of eustachian tube function is not known. Furthermore, the efficacy of tympanostomy tubes in the treatment of eustachian tube dysfunction and hearing sequelae has not been examined in a systematic way. To answer these questions, we performed a retrospective study that used serial audiometric data and tympanometry on 81 patients with cleft palates (162 ears), with follow-up ranging from 1 to 17.3 years. Average time to recovery of eustachian tube function was 6.0 years (range, 1.0 to 10.3 years) after cleft palate surgery. For children followed up for at least 6 years (longest follow-up, 17.3 years), 70% (67 of 85) had normal eustachian tube function at their last follow-up visit. Ears treated with Armstrong tympanostomy tubes required an average of 3.1 tubes per ear until recovery of eustachian tube function, whereas ears treated with Goode T tubes required only 1.1 tubes per ear (p < 0.05). Hearing evaluation revealed that 67% of ears had abnormal hearing thresholds (> 20 dB) before tympanostomy tube placement, whereas only 7.5% of ears demonstrated this loss after tube placement. Furthermore, more than 90% of ears maintained normal thresholds after recovery of eustachian tube function. These data indicate that most children with cleft palates eventually recover normal eustachian tube function after palatoplasty, but for the majority of children, this does not occur for many years.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the trimmed Shah permavent tube in the management of glue ear

Twenty-five children (mean age six years) with de novo bilateral ear effusions received a 'trimmed' high grade silicone (HGS) Shah permavent ventilation tube in one ear and a conventional polyethylene Shah grommet in the other. The extrusion rate and the degree of tympanosclerosis formation was examined. At 29 months the conventional grommet had extruded in 90 per cent of children and a recurrent middle ear effusion was found in over 50 per cent of these ears. The average length of stay for the conventional grommet was 12.5 months. Five permavent tubes had extruded, one was extruding but the remainder were all in place and patent. Comparing ears on each side the amount of tympanosclerosis was worse in the ear with the conventional grommet in 47 per cent of children and worse on the permanent side in 11 per cent of the children. The 'trimmed permavent' appears to act as a medium to long-term grommet which self extrudes without serious complications. Its use at the primary operation in young children may save repeated insertions of conventional grommets.

Management of ventilation tubes: preventing premature extrusion

The Goode T-tube provides a safe and efficient method of ventilating the middle ear space for an extended period of time without random premature extrusion. Each patient needs to be evaluated and followed closely while these tubes are in position. The criteria for the length of time that tubes are retained and the low complication rate are presented. Selective measures for removal of these tubes have provided a reasonable, safe and cost effective means of handling chronic secretory otitis.

Middle ear ventilation with HydroxylVent tube: review of the initial series

Thirty HydroxylVent tubes were implanted in twenty-seven patients. The chief indications were unresolving eustachian tube dysfunction, with either collapse or perforation of the tympanic membrane. Every patient had undergone a lengthy course of treatment with conventional ventilation tubes. Twenty ears (66%) showed good results, with prolonged ventilation and restoration of middle ear function. Two tubes appeared to be open, with the development of a pinpoint perforation of the drum. Eight tubes occluded as a result of displacement of the tube, middle ear pathology, or debris. Indications and techniques of management are discussed, along with an analysis of complications.

Conservative treatment of otitis media with effusion by autoinflation of the middle ear

A total of 85 children on the waiting list for grommet insertion aged between 3 and 10 years with bilateral chronic otitis media with effusion (OME) were assigned at random to an observation or treatment group. Those in the treatment group were given the Otovent device to use three times a day for the duration of the study and both groups were then seen at monthly intervals for 3 months for pneumatic otoscopy and tympanometry. Statistically significant improvement was seen in those using the treatment with a compliance of more than 70%. This was detected on the outcome measures of tympanometry and pneumatic otoscopy after 1, 2 and 3 months. No side effects were demonstrated. We conclude that autoinflation is an effective short-term treatment for children with OME when used regularly under supervision.

Tympanostomy tubes: experience with removal

Whereas the clinical indications for tympanostomy tube placement are well-established, the indications for operative tympanostomy tube removal remain unspecified. A 1-year retrospective review done at the Massachusetts Eye and Ear Infirmary revealed 131 tympanostomy tubes to have been removed under general anesthesia. Chronic otorrhea, granuloma formation, tube nonfunction due to blockage, and migration of the tube into the middle ear constituted the surgical indications in 75 cases. The remaining 56 tubes were removed on the physicians' judgment that artificial ventilation was no longer required. Selected cases are presented. While the vast majority of tubes spontaneously extrude uneventfully, a comparatively small number of patients do require operative tube removal. Practice guidelines for surgical tube removal are suggested.

The cause of aural polyps in children

This 20-year retrospective review identifies 35 pediatric patients with aural polyps in an attempt to assess for clinical predictors of significant otopathologic conditions. Chronic otitis media (43%), cholesteatoma (29%), and retained tympanostomy tubes (23%) were the common causes. Unusual causes included mycobacterial infection and Langerhans' cell histiocytosis. Multivariate analysis revealed the co-occurrence of conductive hearing loss at presentation to be a significant clinical predictor (P = .03) of cholesteatoma; the histopathologic finding of keratin-induced giant cell reaction was nonspecific in this respect. Cholesteatoma was also prevalent in recurrent polyp cases, suggesting the need for prolonged follow-up in those children whose initial clinicopathologic evaluation does not yield a definitive diagnosis.

The mini-grommet and tympanosclerosis: results at two years

One hundred and sixteen children with otitis media with effusion (OME) underwent surgery with grommet insertion. A conventional Shah grommet was used in one ear, and a Mini-Shah grommet in the other. Final review of the subjects two years after surgery revealed a significantly lesser degree of tympanosclerosis in the ear into which the Mini-Shah grommet had been inserted. This benefit might have resulted from the lesser mass of the mini-tube or its shorter duration in situ.

Tympanic membrane perforation following ventilation tube removal in a pediatric setting: a historical study

This study is concerned with the rate of tympanic membrane perforation following the surgical removal of ventilation tubes. Consideration for inclusion in the study was given to all patients who had ventilation tubes surgically removed between 1982 and 1991 at The Hospital for Sick Children. All patients included in the study were followed for a minimum period of six months. The patients ranged in age from two to 13 years old, with a mean age of 4.7 years. Our study followed 203 ears which met the entry criteria. It was found that there were 21 (10.3%) documented perforations within this study group.

Sonotubometry with a tubal catheter as an index for the use of a ventilation tube in otitis media with effusion

Insertion of a ventilation tube is considered to be an effective treatment for otitis media with effusion (OME), although it may entail complications such as residual perforation and poor hearing after tube extrusion. In order to reduce problems associated with ventilation tubes, we examined the Eustachian tube function in 25 adults with OME by two methods. One was a sonotubometric measurement (sonotubometry) with both a tubal catheter and a nasal olive tip, and the other was an air-pressure equilization method (deflation test). Sixty percent of the ears showed poor tubal function in both types of sonotubometry. The number of negative cases in sonotubometry with a tubal catheter was higher in ears with a larger volume of effusion, and in ears with poor tubal function by deflation testing. Judging from the volume of effusion and results of the deflation tests, the prognosis could be fairly good in many positive cases. We conclude that sonotubometry with a tubal catheter is useful in the management of OME, especially in evaluating the efficacy of ventilation tubes.

Long-term results of Goode's tympanostomy tubes in children

The results of a retrospective study of the complications of middle ear ventilation by Goode's T-tubes in children are presented. 248 T-tubes were inserted into 119 patients. 16.9% progressed to spontaneous extrusion with a mean period of ventilation approaching 20 months. 54.9% of patients experienced otorrhoea which was found to be significantly more common in those ears with a mucoid effusion at the time of T-tube insertion. 21.1% of ears developed a persistent perforation where spontaneous extrusion had occurred or the T-tubes had been removed. Perforation also occurred more frequently in those with otorrhoea.

Treatment of tinnitus by intratympanic instillation of lignocaine (lidocaine) 2 per cent through ventilation tubes

Idiopathic subjective tinnitus (IST) is one of the most obscure otological pathologies. This paper presents the results of treating IST by intratympanic instillation of lignocaine (lidocaine) 2 per cent through a grommet, for five weekly courses. Fifty-two patients suffering from intractable tinnitus entered this therapeutic trial, but only nine finished all five courses. In one patient, the tinnitus was almost completely abolished, but in all the nine patients the decompensated tinnitus changed to a compensated one. We suggest this mode of treatment for patients that were previously treated by drugs, acupuncture and biofeedback, with disappointing results. Patients should be warned about the side effects of vertigo and vomiting, which subsides gradually with every new instillation, and that the tinnitus may not disappear but will be alleviated, enabling them to cope more easily with the disease and lead a more normal life.

Autoinflation as a treatment of secretory otitis media. A randomized controlled study

This study was undertaken to evaluate the effect of a new method of autoinflation as an alternative treatment of secretory otitis media. Up to 80% of all children experience one or more episodes of eustachian tube dysfunction and secretory otitis media before school age. Common treatment of this condition is insertion of a ventilation tube in the tympanic membrane. Because of the very high incidence of secretory otitis media in childhood, insertion of ventilation tubes is the most frequently performed operation under general anesthesia in children. In addition to possible anesthetic complications, insertion of ventilation tubes may be associated with purulent suppuration, pathologic findings in the eardrum, and hearing impairment. One hundred children were consecutively randomized to undergo either autoinflation, using a new device, or placed in a control group. The children were between 3 and 10 years of age and were entered into the study after having had secretory otitis media for at least 3 months, as verified by tympanometric findings. Tympanometry was repeated at 2 weeks and at 1, 2, and 3 months after the children were entered into the study. After 2 weeks of autoinflation, the tympanometric conditions were improved in 64% of ears, unchanged in 34%, and deteriorated in the remaining 2%. In the control group, tympanometric findings were improved in 15% of ears, unchanged in 71%, and deteriorated in the remaining 14%.

Recurrent otitis media: a cost-utility analysis of simulated treatment using tympanostomy tubes vs antibiotic prophylaxis

Using a cost-utility analysis, the effectiveness of tympanostomy tubes was compared to that of antibiotic chemoprophylaxis in young patients with recurrent otitis media. The tympanostomy approach (T-tubes) consisted of placement of a polyethylene grommet in the tympanic membrane, with systemic and local antibiotics administered for one week. The chemoprophylaxis approach consisted of antibiotics in full doses for seven to ten days, followed by continuous antibiotic chemoprophylaxis for six months. Because the T-tube strategy under the model assumptions was more expensive ($396.44 vs $281.30) and yielded slightly less benefit (net utility of .9325 vs. .9476 for initial antibiotic therapy), the chemoprophylaxis option was preferred. We conclude that the initial treatment for recurrent otitis media should consist of acute antibiotics followed by chemoprophylaxis, with T-tubes reserved for treatment failure. Extreme changes in the baseline probabilities of cure or recurrence with antibiotic therapy or in the cost of antibiotic therapy or tympanostomy surgery were required to alter this conclusion. Varying therapy preference (utility) values did not materially alter the conclusions.