A comparison of performance of Shepard and Sheehy collar button ventilation tubes

This study was designed to confirm the longer in situ life of the Sheehy collar button compared with the Shepard tube and to assess the complication rates associated with the two tubes. Cases of bilateral otitis media with effusion had a Shepard tube inserted in one ear and a Sheehy contralaterally. The insertion position was allocated randomly. The patients were then assessed at three-monthly intervals for two years. In 71 per cent of those in whom at least one tube had extruded, the Sheehy remained in situ longer. The antero-inferior tube remained longer than the postero-inferior whichever type was used. There was no significant difference between complication rates, or recurrence rates of middle ear effusion after tube extrusion, for the two types. We conclude that use of a Sheehy rather than a Shepard tube carries no increased risk of complications and the patient may require further surgery less often in total.

A biointegrated hydroxylapatite ventilation tube for definitive treatment of chronic eustachian tube obstruction

A dense hydroxylapatite ventilation tube has been designed for the purpose of providing prolonged ventilation of the middle ear. The tube is placed beneath the fibrous annulus of the eardrum, into a groove within the bony annulus and canal. The device takes advantage of the documented biocompatibility of hydroxylapatite to achieve biointegration with the soft tissues of the fibrous annulus, drum, and canal skin, as well as the bone of the deep ear canal. The tube does not appear to cause a foreign body reaction, and does not seem to extrude over time. The device is proposed for patients with unresolving eustachian tube obstruction who require a permanent tympanic stoma for normal middle ear function.

Complications following ventilation of the middle ear using Goode T tubes

This is a 3.5-year retrospective review on the insertion of 210 Goode T tubes into 182 ears of 93 patients. Otorrhea was noted postoperatively in 35.2% of the ears treated, with chronic drainage lasting longer than 4 months developing in more than 7% of the cases. Perforations were found in 34 ears (18.7%) following removal or extrusion of the T tubes; in 13 (7.1%) of these patients, chronic perforations requiring tympanoplasties developed. The literature was screened for additional studies addressing the complications associated with tympanostomy tubes. The documented incidence of perforations between conventional tubes and Goode T tubes was emphasized, and comparisons were made. Our findings indicate that, even with the immediate placement of paper patches following removal of all Goode T tubes, the percentage of tympanic membrane perforations resulting from the use of Goode T tubes is significantly greater than previously reported.

Induced atelectasis of the middle ear and its clinical behavior

Atelectatic ears are often treated with ventilating tubes for long periods of time. However, a certain percentage of atelectatic ears and retraction pockets resolve spontaneously over time. In order to determine whether self-aeration had been achieved in atelectatic ears previously fitted with ventilating tubes, the tubes were sealed and the ears were then closely followed. Out of 37 such tests, atelectasis did not recur in 4 ears, allowing their ventilating tubes to be removed. In 33 tests atelectasis redeveloped within 1-2h after the ventilating tube was sealed, with ears reverting to the same degree and shape as the original atelectatic condition. The seals were then removed, resulting in resolution of atelectasis. These observations were enforced by previous observations of similar changes and suggest that the partial pressures of the blood gases may be an important factor in controlling the level and possibly also the pathogenesis of atelectasis. The method of testing described also can be used in selected cases to determine whether or not a given atelectatic ear still requires a ventilating tube.

The influence of ventilating tubes on the surgical treatment of atelectatic ears

Forty children and 53 adults having 111 atelectatic ears were operated on and followed up. All patients underwent a tympanoplasty operation, while 27 patients underwent concomitant various mastoid operations. A ventilating tube was inserted in 55 out of the 111 atelectatic ears, while in 56 ears the tympanoplasty was left without a ventilating tube. After an average of 53.1 months of post-operative follow-up we found that all ears were adequately aerated as long as a ventilating tube was in place. However, at the final check, once all ventilating tubes extruded, it was found that insertion of a ventilating tube at operation did not change the natural evolution of the atelectatic condition after surgery. Our conclusion is that the only way to overcome the atelectatic prone condition is to reinsert a ventilating tube whenever atelectasis reformation occurs.

Radial versus circumferential incision in myringotomy and tube placement

Pressure equalization tubes are a well-recognized treatment for persistent otitis media with effusion and recurrent acute otitis media. Ideally, the tube should remain in place until the Eustachian tube function returns. Efforts to improve the functional life expectancy of tubes have concentrated on tube design with little attention directed at modification of the surgical technique. Some authors have noted that a radial incision offers theoretical advantages over a circumferential incision. A randomized study comparing radial and circumferential incisions in myringotomy with tube placement was conducted. Two hundred and twenty-eight patients had a circumferential incision performed in one ear and a radial incision in the opposite ear. On follow-up examinations the tube position and time to extrusion were noted. Using the sign test, there was no statistical difference in extrusion rates between the two groups. This study does not support the theoretical advantages espoused in the literature.

The effect of treatment with ventilating tubes on language development in preschool children with otitis media with effusion

The effect of bilateral tube insertion on language development was studied in a randomized controlled trial of 43 preschool children with persistent bilateral otitis media with effusion (OME). Improvement in language scores was observed in both the treatment and non-treatment groups. There was a minor difference in favour of the treatment group which did not reach statistical significance. Although there is a growing consensus that otitis media with effusion can have negative effects on language development in young children, it has not yet been proved that this effect can be reversed by treatment with ventilating tubes.

[Treatment of eustachian tube using a remodelled fiberscope conformed to the anatomical variety of its orifice]

The structure of the opening of the Eustachian tube of 702 cases were observed with fiberoptic endoscope, and the relationship between the difficulty in ear douche by Eustachian tube catheterization and the shape of the orifice was discussed. The shape of pharyngeal orifice of the tube was classified into two types. The one which is well-known as ordinary shaped was named as type I, while the other which has an arched upper edge by torus tubarius was termed as type II. Type II orifices were found more frequently (54.3%) than type I. Insertion of a catheter was difficult in type II ones because the tip of catheters was apt to slip down from the tubal elevation. Moreover, anatomical irregularities in the nasopharynx, which is observed quite often, seem to be a factor of difficulties in douching the tube. In case of a failure in ear douches, it is necessary for us to detect its cause, and in case of type II orifice, the way of probing the orifice should be changed. I have treated some patients who were suffered from tubal obstruction with an injection of remedies into the auditory tubes, observing with remodelled Olympus NPF-S3 fiberscope, and have got a good result.

The mini-grommet and tympanosclerosis

One hundred and sixteen children with otitis media with effusion underwent myringotomy and insertion of a conventional pattern of Shah grommet in one ear and the much smaller Mini Shah grommet in the other. Close observation post-operatively determined the comparative rate of extrusion, recurrence of effusion, and of onset and degree of tympanosclerosis. At one year review, the Mini Shah shows a significantly earlier extrusion and a greater tendency to recurrence of otitis media with effusion. However, this is compensated by a decreased incidence of tympanosclerosis and reduced severity in those affected. This tends to support the view that shear forces produced by heavier patterns of ventilation tube promote tympanosclerosis.

Preventing perioperative obstruction of tympanostomy tubes: a prospective trial of a simple method

The intraluminal obstruction of tympanostomy tubes by hemorrhage incurred in the perioperative period is not a rare problem. The exact frequency, however, is unknown and methods of prevention have not been studied. We prospectively investigated a method of unilaterally coating one grommet with antibiotic ointment in 128 children undergoing bilateral tympanostomy tube placement; the contralateral tube was not treated. We established the incidence of intraluminal obstruction by blood in untreated grommets to be 4.7%. The incidence of hemorrhagic obstruction of the coated tubes was less (2.3%) but did not achieve statistical significance (P less than 0.20). The technique of antibiotic ointment application to the tympanostomy tube at the time of surgery was not sufficiently efficacious to justify routine use.

Incidence of perforation with Goode T-tube

Two groups of patients from the same era were retrospectively studied in Cincinnati and Chicago. In Cincinnati two subgroups were studied. The first group received myringotomy with insertion of a 'T'-shaped ventilating tube (75 patients, 140 ears, 147 insertions). Fifty-eight ears still had the tube in place, 31 had healed after spontaneous extrusion, 17 had healed after removal of the tube, 20 had persistent perforation after the tube was gone, 2 had a cholesteatoma, and 4 patients (7 ears) were lost to follow-up. The second set received myringotomy and insertion of a small grommet (Donaldson tube, 71 patients, 140 ears, 164 insertions) tympanostomy tube. None could be documented to still have the tube in place, 156 ears healed after spontaneous extrusion, none required removal, 3 ears had a persistent perforation after the tube was gone, none had cholesteatoma, and 5 patients (5 ears) were lost to follow-up. The perforation rate for the T-tube is 13.6% and for the grommet is 1.8% (P = 0.0005). In Chicago, 93 patients who received the Goode T style tube (175 ears, 175 insertions) prior to March, 1986 were evaluated. The degree of retraction of the tympanic membrane preoperatively was recorded. No ears still had the tube in place, 145 had healed after spontaneous extrusion or removal of the tube, 30 had persistent perforation 12 months after the tube was gone, 4 had a cholesteatoma, and 8 patients (15 ears) were lost to follow-up. The rate of perforation is 18.8% which is not statistically different from the Cincinnati rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Swimming and ear infection

Surface swimming in fresh or ocean water is not contraindicated in children with otitis media or in children with tympanostomy tubes. Diving should be prohibited in children with acute or chronic otitis media or in children with tympanostomy tubes. Hot tub water, bath water, chlorinated water, or water from stagnant ponds may pose a risk for either otitis media or otitis externa.

Ventilation tube duration versus design

Two ventilation tube designs were simultaneously compared in children in order to determine their relative rates of extrusion. The results show a twofold difference between the extrusion of the Shepard compared to the "Sheehy" or collar-button pattern of tube. Subjected to statistical analysis, these findings are highly significant.

Vitreous carbon: a new material for middle ear ventilation tubes

Synthetic allotropic carbons have been used for nearly 20 years as biomedical implants. Vitreous carbons in particular appear to possess very favourable biocompatibility characteristics. The middle ear compatibility of Sigradur has been tested in the mastoid bulla of gerbils. The period of implantation varied from 1 to 13 months. Light and electron-microscopic examination revealed good middle ear tolerance of the material, especially when the surface had not been modelled. Our animal experiments suggest that this material could be suitable for ventilation tubes, but was less ideal for ossicular replacement prostheses, particularly because of the specific surface properties. Consequently, we have used such carbon ventilation tubes in 38 patients. The results obtained using this material were excellent thanks to the favourable biocompatibility, advantageous surface properties, and low weight.

Ear drops and grommets

The relative ease with which different ear drops pass through grommets of different designs has been investigated using a laboratory model. The viscosities of the various ear drop preparations tested have also been determined. There is a considerable variation in the volume of ear drops required to penetrate ventilation tubes. Their ease of passage is determined by the size of the tube and is probably also related to the ease with which a preparation wets the surface of the grommet. There is no relationship between ease of penetration and viscosity. The penetration of ear drops through grommets during episodes of aural discharge was studied in vivo. Penetration into the middle ear was observed only when the drops were introduced using the displacement technique. It was more readily achieved when the grommet lumen was free of discharge.

Comparison of the Goode T-tube with the Armstrong tube in children with chronic otitis media with effusion

Treatment of otitis media with effusion is focused on reaeration of the middle ear cavity. In achieving long-term aeration, the insertion of ventilation tubes that have a long duration of stay can be beneficial. The results are presented of a trial in which the Goode T-tube was compared with the Armstrong tube. Fifteen children were treated between 1981 and 1986 with a T-tube in one ear and a conventional tube in the other. The results are different with regard to duration of stay in the tympanic membrane. Re-insertions were necessary in 47 per cent in the Armstrong group and in 20 per cent in the T-tube group. Otorrhoea occurred in 20 per cent of the Armstrong and 13 per cent of the T-tube intubated ears. A persistent perforation was present in 6 per cent of the ears in both groups. It is concluded that the Goode T-tube is indicated primarily in cases when long-term ventilation is needed.

Titanium grommets: a trial to assess function and extrusion rates

Titanium grommets have been promoted as having the advantage of a slower extrusion rate than other types of ventilation tube. A prospective trial was therefore designed to compare the function and extrusion rates of these grommets with those of the widely used Shepard design of Teflon grommet in a single group of patients. Thirty-one children had one type of grommet inserted in one ear and the other type in the opposite ear. After eight months there were significantly more Titanium grommets still functioning (p less than 0.05) but after 12 and after 16 months there was no significant difference in the extrusion rates of the two types of grommet. There was a higher incidence of infection with granulation tissue formation around the Titanium grommet. Accordingly it is concluded that the extra expense of the Titanium grommet is not justified, particularly as the long-term effects of these grommets on the tympanic membrane are not known.

Critical evaluation of Per-Lee tubes in children

A retrospective view of 37 Per-Lee tubes inserted into 29 patients over a period of four years. At the time of review all the tubes were in situ but eleven had to be removed due to recurrent otorrhoea or perforations causing increasing deafness particularly in children. Per-Lee tubes are not suitable for long-term ventilation of the middle ear cavity in children.

Lack of efficacy of middle-ear inflation: treatment of otitis media with effusion in children

A randomized controlled trial was conducted to evaluate the efficacy of autoinflation of the middle ear in the treatment of otitis media with effusion. Forty-one children with middle ear effusion not responsive to antimicrobial therapy enrolled in the study. Of these subjects, 75 percent had effusion duration over 3 months. A system consisting of a disposable anesthesia mask attached to a flowmeter was used to teach children to perform autoinflation based on a modified Valsalva technique. Subjects were stratified according to their ability to achieve tubal opening as assessed by tympanometry and tubosonometry. Subjects were randomly assigned to either treatment or observation group and were followed weekly for 2 weeks; subjects in the treatment group attempted inflation three times each day for 2 weeks. Of the 19 subjects who were in the autoinflation group, only one (5.3 percent) was effusion-free at the two-week endpoint and of the 21 subjects in the control, only two (9.5 percent) were without middle-ear effusion. Autoinflation was ineffective for treatment of children with otitis media with effusion in our study.

A prospective randomized study of four commonly used tympanostomy tubes

Tympanostomy tube placement has clearly been shown to be an efficacious treatment for recurrent bouts of acute otitis media or chronic otitis media with effusion. However, there are few objective, prospective, randomized studies present in the literature to aid the clinical otolaryngologist with the proper tube choice for middle ear aeration. A prospective, randomized study was undertaken of four commonly used tympanostomy tubes. Shepard Teflon grommet, Armstrong beveled tube, Reuter-Bobbin tube, and Goode T-tube. This study was undertaken to determine which of these tubes had the fewest number of postplacement complications, including otorrhea, plugging, residual perforation, or chronic persistence in the tympanic membrane. Average follow-up was 17 months. The Shepard and Armstrong tubes showed a comparatively low rate of plugging and otorrhea. Both tubes had extrusion times that averaged less than 1 year. The Reuter-Bobbin tube had a much greater rate of plugging, compared to the other tubes. The T-tube had an increased incidence of otorrhea and persistence in the tympanic membrane well beyond 1 year. The T-tube was also the only tube in this study associated with residual perforations.

Perforations of the tympanic membrane following the use of Goode-Type 'long term' tympanostomy tubes

A retrospective review of 64 Goode 'T' tube insertions is presented. These were inserted into 61 ears of 48 patients over a period of four years. At the time of review of these 61 ears, 34 tubes were found to be in situ, 27 had extruded spontaneously and three had been removed surgically. Ten ears in which the tube had been extruded or removed had central perforations of the tympanic membrane of which eight had been present for more than six months. The number of previous myringotomies or grommet insertions did not increase the likelihood of developing a perforation. Tympanostomy tubes of this type should not be used indiscriminately.

A prospective study of titanium ventilation tubes

A prospective controlled study was undertaken in which in 100 children a titanium ventilation tube was inserted in one ear, and a Paparella silicone tube was inserted in the contralateral ear as a control. The tubes were evaluated with respect to length of time of intubation, episodes of otorrhea, and early occlusion. Sixty-five patients were followed for at least one year, or until both tubes had extruded. Long-term follow-up of these patients has revealed little difference in the incidence of tube occlusion, early extrusion, or infection with otorrhea. Since the titanium tube is more than twice as expensive and has no proven advantages over a silicone tube of similar design, we have no reason to recommend its use over the less costly, standard silicon ventilation tube.

Goode T-tubes: do the benefits of their use outweigh their complications?

In this retrospective study of 130 ears over a 5-year period, the effect of intubation with the Goode T-tube was evaluated. The tubes improved the hearing in 86% of ears with a conductive loss secondary to a middle ear effusion to an average 5 dB airbone gap. They improved the early stage retracted tympanic membrane but had no effect on the established postero-superior retraction pocket. They were successful in treating barotrauma. The main complication with their use was otorrhoea which occurred in 28% of ears, and persistent perforation occurring in 6% of the ears. Seventy-seven per cent of tubes were in place after 36 months. Extrusion was significantly related to infection in the ear, and also to the presence of glue on insertion but there was no correlation between the number of previous grommets or the age of the patient. The Goode T-tube is advocated for use in middle ear effusion refractory to conventional grommet insertion or that due to cleft palate.

A comparison of audiometric performance and complications of T tubes and Shepard grommets

Since T tubes were introduced in 1972 their use in cases of chronic Eustachian-tubal insufficiency has been reported on several occasions, (Goode, 1973, 1983; Rothera and Grant, 1985). T tubes remain in-situ for longer than grommets, and they are frequently used in cases where multiple grommet insertions have failed to provide adequate middle ear ventilation. They have also been used when prolonged Eustachian-tubal insufficiency is anticipated, for instance in children with cleft palate. Shepard grommets continue to be the most commonly used type of ventilating tube for short-term use and a significant proportion of children with glue ear require repeated insertions. In an attempt to reduce the need for repeated myringotomy, and also to reduce the need for adenoidectomy in children with glue ear, it has been the recent practice of one Consultant (K.S.M.) to use T tubes routinely in all cases of glue ear. This study analyses the audiometric performance and complications of 32 children (60 ears) who underwent myringotomy and insertion of T tubes for glue ear. In all cases no previous treatment for glue ear had been undertaken. The results are compared with those of a control group who underwent myringotomy with insertion of Shepard grommets and adenoidectomy as a first-line treatment.

Surgical management of otitis media (recurrent and nonsuppurative)

In 1977 Paradise outlined the role of tympanostomy tubes in nonsuppurative otitis media. Over the intervening 10 years the role has changed little. Exceptions would be the demonstrated advantage of tube placement over myringotomy alone in those patients with effusion for longer than 2 or 3 months, or over prophylactic sulfonamide or placebo in recurrent otitis media.

Hearing results with the use of different tympanostomy tubes: a prospective study

The audiograms of 59 patients who had 15 different types of tubes implanted in a prospective study from 1982 to 1985 were reviewed. The audiograms were analyzed for changes in air and bone thresholds at 250, 500, 1000, 2000, 4000 and 8000 Hz. The first post-operative audiogram was tabulated for all the initial post-operative visits and for only the initial post-operative visits in which the tubes were functioning. The change in pure tone average air conduction showed a range in improvement from 22.1 dB for the Armstrong Grommet Tube to 1.9 dB for the Canoe Tube. A total of 8 tube types showed mean improvements of 10 dB or better. With the exception of the Reuter Bobbin, all mean air conduction thresholds in functioning tubes were below 20 dB. For 5 tubes the mean threshold was less than 10 dB. The Armstrong Beveled Grommet, Donaldson, and Richard's Wing tubes showed the largest improvements in air conduction threshold with mean decreases of 22.1, 18.7 and 18.3 dB, respectively. Pure tone average bone conduction for all functioning tubes improved 2.8 dB.

[Identification of middle ear implants in high-resolution computerized tomography]

As a result of the increase in the use of computed tomography and the possibility of demonstrating very small structures, x-ray diagnosis is becoming more and more important in investigating complications after examined in patients as well as cadaver temporal bones by using high resolution middle ear computed tomography: 1. autologous/allogenic ossicular implants, 2. alloplastic implants made of ceramic, plastic or metal. As can be seen from our investigations the homografts and some of the implants are easily identifiable (autologous/allogenic ossicular implants, Ceravital and Frialit PORP/TORP and metal devices), are only partly identifiable (Fisch-Tef Platinum and Stainless Steel as well as Titan stapes pistons), hardly or not at all identifiable (PORP/TORP and stapes pistons made of plastic, e.g. teflon, silicone, plasti-pore). The same applies to ventilating tubes. Thus the position in the middle ear of metal tubes which have slipped can be seen clearly, whereas plastic tubes cannot be seen so well. It is of clinical importance that prosthesis dislocation is visible in CT so that should complications occur it is better possible to determine whether revision surgery is necessary. As, however, identification of various devices in CT is still not satisfactory, the manufactures must soon fulfil our demands for a contrast agent to be added to prosthesis.

Otorrhoea in children with middle ear ventilation tubes: a comparison of different types of tubes

Otorrhoea is a troublesome complication of middle ear ventilation tubes. This investigation of children with various ventilation tubes shows that the incidence of this complication varies with the type of tube used. In particular, Paparella type 2 tubes are associated with a higher rate of otorrhoea, and should be reserved for use when long-term ventilation is necessary.

The prevention of tympanic membrane perforation following the removal of long-term Paparella type II ventilation tubes

Residual perforation following the extrusion or removal of a long-term ventilation tube may occur in between 8.5% and 25% of cases. This prospective clinical trial concerns Paparella II ventilation tubes and demonstrated that (a) extracting (pulling) a tube from the tympanic membrane gives a 6-month perforation rate of 20%, (b) excising (freshening) the edge of the defect at the time of removal decreases the 6-month perforation rate to 3%, and (c) excising the edge significantly accelerates the healing of the tympanic membrane. There was no correlation in this study between the incidence of perforation and age, sex, ear affected, tympanosclerosis, ventilation tube position, tube in situ time or discharge. The study confirmed a high rate of tympanosclerosis (76%) to be associated with ventilation tubes. Long-term discharge (68%) was identified as a problem of Paparella II ventilation tubes.

A clinical evaluation of gold-plated tubes for middle-ear ventilation

Gold-plated tympanostomy tubes have been recently marketed as possessing qualities making them ideal for middle-ear ventilation. The performance of these tubes was compared with that of similarly designed Teflon tubes in a controlled, prospective study. Twenty-eight children underwent bilateral myringotomy and tube placement. One ear was randomly chosen for intubation with a gold-plated tube, and a Teflon tube was inserted into the other ear. Patients were examined monthly for 12 months and evaluated for otorrhea, tube occlusion, and early tube extrusion. Although the incidence of otorrhea and tube occlusion were higher for the gold-plated tube, these differences were not statistically significant. The gold-plated tube had a significantly higher rate of early extrusion than the Teflon tube. Based on these findings, there appears to be no advantage to using gold-plated tubes for middle-ear ventilation.

Autoinflation of eustachian tube in young children

Inflation of the middle ear has long been thought to be beneficial in the treatment of otitis media. We describe a new system of autoinflation based on a modified Valsalva technique consisting of an anesthesia mask and a flowmeter which can be used successfully by children. An objective method to record eustachian tube opening during autoinflation using frequency spectrum analysis of the ear canal sounds is also presented. Tubal opening results of this method were compared to the traditional method using preinflation and postinflation tympanometry. Study subjects included 20 adults with normal otologic findings and 35 children with middle-ear effusion; all together 107 ears of children and adults with and without effusion were tested. Using the frequency spectrum analysis, tubal opening was recorded in 75% of adult ears and 56% of children's ears. Also, in both groups, a sound pressure peak with the same characteristic frequency around 2 kHz was associated with tubal openings. The methods described are incorporated into a clinical trial being conducted at the Children's Hospital of Pittsburgh.

Consequences of using hyaluronan-coated tympanostomy tubes

The effects of hyaluronan-coated polyethylene tympanostomy tubes on the tympanic membrane structure were investigated and compared with non-coated polyethylene tubes without the coating. The tubes were inserted into the tympanic membrane (TM) and removed 3 weeks later. After 3 weeks the tubes were reinserted. This tube insertion and removal and reinsertion sequence was repeated 4 times and the tympanic membrane structure was examined histologically at 3 weeks and 12 weeks later. The study did not reveal any differences regarding the thickness and light microscopical appearance when comparing the TMs with the hyaluronan-coated tubes to those with the non-coated polyethylene tubes. However, the present way of evaluating the effects of different tube materials may be too crude. In future experiments aimed at elucidating the effects of different surface coatings of tympanostomy tubes other experimental designs must be employed, e.g. fewer tube insertion sequences and less traumatizing extractions.

A controlled study of a 'new' ventilating tube. The gold standard?

A prospective controlled study of a gold ventilation tube was undertaken in which a gold tube was inserted in one ear of 88 children and a Paparella silicone tube was inserted in the contralateral ear as a control. The tubes were evaluated with respect to length of time of intubation, episodes of otorrhea and early occlusion. Sixty-three patients were available for a follow-up of at least 6 months. The gold tube remained in place for a shorter period of time when compared to the control tube. Episodes of otorrhea were infrequent and there was not any significant difference between the two types of tubes. The gold tube became occluded more frequently than the control tube. Since the gold tube is approximately 3 times more expensive and has no proven advantages over our conventional silicone tube, we have no reason to recommend its use in preference to any other available tube.

Long-term tympanic ventilation by Per-Lee tube

The fate of 32 Per-Lee ventilation tubes inserted by a single surgeon for secretory otitis media in children and adults is analysed over a 15-year period. There were no extrusions and 25 tubes were still functional at the time of the survey. The total ventilation time achieved by the 32 tubes was over 157 years. Seven tubes were removed on account of either obstruction or infection. Spontaneous healing of the tympanic membrane was uncertain following removal of the tube and a considerable degree of scarring was inevitable. Hearing improvement occurred while the tube was functioning and there were no cases of hearing deterioration. It is concluded that the Per-Lee tube is a suitable prosthesis for long-term middle-ear ventilation.

The use of Per-Lee ventilation tubes in the management of refractory secretory otitis media

Per-Lee ventilation tubes have been used successfully for long-term ventilation in 35 ears, and none have been extruded although the maximum follow-up period is now in excess of 56 months. It is suggested that the benefits of this type of tube outweight any technical difficulty in insertion and that, if possible, the flange should be left untrimmed and the tube itself placed anterior to the malleus.

Middle ear semipermeable membrane tubes for prolonged retention

Our 1981 prospective study confirmed the success of semipermeable membrane tubes in ventilation of middle ears, while protecting them from moisture when the patients bathed or swam. That study employed modern membrane tubes, with membrane-pore size 2.5 to 5 times greater than tubes used in early studies with less favorable outcomes. Currently, 21 patients with effusion had placement of a Donaldson design (Xomed, Inc., Jacksonville, Fla.) membrane tube in one ear and the new T-grommet membrane tube in the second ear. The T-grommet membrane tube is found to outlast the Donaldson design tube significantly. We recommend Donaldson membrane tubes for patients having tubes placed for the first time. For subsequent procedures, we employ T-grommet membrane tubes. We also use the T-grommet membrane tube for adults with chronic eustachian tube problems. Both tubes continue to show a low incidence of complications and draw highest praise from patients for their water-resistant capabilities.

Percutaneous healing of clinical tympanic membrane implants

Percutaneous healing is plagued by materials compatibility problems, epidermal reactions, and mechanical factors. To our knowledge, no studies have evaluated the effects of one of these factors while controlling the others. The tympanic membrane is an implant site where mechanical factors are minimized. Titanium has been shown to be a very histocompatible material, although no reports of the histology of percutaneous titanium implants exist. This study reports on aspects of the epidermal and connective tissue healing around titanium tympanic membrane implants that were explanted from human subjects. The lack of inflammation and the direct adherence of the tissues substantiate the materials compatibility and the absence of mechanical factors. Tissue healing patterns appear to reach an equilibrium which is suitable for the long-term existence of the percutaneous device. This implant location provides a suitable model for studying the tissue reactions to various percutaneous materials.

The extrusion rate of grommets

A prospective study was performed to determine the factors influencing the extrusion rate of tympanostomy tubes. Nine hundred thirty-nine tubes were inserted in 589 patients and the extrusion of these tubes was reviewed up to a period of 27 months. The eight tubes used in the survey were the Shepard, Exmoor, Bobbin, Armstrong, Paparella, Shah, Arrow, and collar button. These tubes were inserted in strict rotation, the operator using the designated tube. The position, type of incision, presence of fluid, quality of tympanic membrane, and degree of difficulty of insertion were all recorded at operation. The sex, age, side of operation, and any simultaneous operative procedures were also recorded. The patients were reviewed the day after operation and then every 3 months thereafter until the tube was extruded. A definite pattern was identified for the extrusion of each type of tube. At one end of the spectrum, Exmoor and Shepard tubes were, for the most part, extruded between 6 and 9 months after insertion, while at the other end, most of the collar button tubes were still functioning at 18 months. The design of the tube was the only factor found to be a significant determinant of the extrusion of the tube, although the experience of the surgeon affected the extrusion rate of the Arrow tube. The different dimensions of the Exmoor and collar button tubes are examined and compared.

A comparison of retention and complication rates of large-bore (Paparella II) and small-bore middle ear ventilating tubes

Large-bore myringotomy tubes are usually reserved for the treatment of refractory middle ear effusion. Theoretically, they have an extended intubation time and a higher complication rate. There is, however, scant support of this in the literature. The duration of intubation, efficacy, and complication rates of the large-bore Paparella type II tube were compared with Paparella type I, Shepard, and Armstrong tubes. The study included 242 patients with 600 intubations. In addition, a subpopulation of patients receiving their initial intubation during this study was reviewed. Findings were similar for both groups. Paparella type II tubes had a prolonged period of intubation and a decreased reintubation rate when compared with the smaller bore tubes. Larger bore tubes had an increased complication rate when compared with the smaller bore tubes. Complications included occasional or frequent otorrhea and an increased rate of permanent perforation of the tympanic membrane. There was no instance of cholesteatoma formation secondary to intubation. Guidelines are presented for the use of the Paparella type II tube.

Heat myringotomy

Heat myringotomy using a commercially available, battery powered device produced an opening in the tympanic membrane that persisted 1 to 3 weeks. The procedure was performed to treat chronic otitis media with effusion (COME) in lieu of ventilation tubes in 10 pediatric and 15 adult ears under office iontophoretic anesthesia. These patients were followed for a minimum of 3 months to assess efficacy. Fifty percent of pediatric ears were controlled, eliminating the need for general anesthesia and tube insertion. Forty percent of adult ears were controlled with heat myringotomy. A description of the procedure, discussion of possible reasons for failure, and analysis of potential cost savings are included.

Limitation of long term ventilation tube: in view of complications and hearing restoration

The silicon-rubber T-tube was applied to 181 ears in 116 patients with chronic otitis media with effusion within last 5 years. Among the 181 ears, 81 (46%) accepted the T-tube without problems. In the remaining 97 ears, complications such as otorrhea, occlusion of the tube, extrusion of the tube, enlarged perforation and cholesteatoma occurred. However, in 161 ears (89%), the tube could be stabilized in the middle ear and functioned as ventilating tube beyond 3 months. Based on the incidence and prognosis of the ears with the complications and the results of hearing, we conclude that insertion of the T-tube is valuable and reliable method of treatment in the ears with retractions or atelectasis but in the ears with adhesion or granulation, this method of treatment has only limited value.