Meta-analysis of tympanostomy tube sequelae

Ear, Nose, and Throat Surgery: Postoperative Complications After Selected Head and Neck Operations

Unanticipated complications of ENT surgeries may have profound functional and esthetic consequences for patients. Herein, we provide a broad overview of postoperative complications after ENT surgery, illustrating their unique nature, impact, and principles of management. The discussion is organized by subspecialty to highlight the great anatomic complexity of the head and neck and the importance of critical neurovascular and sensory structures that make ENT an impactful, yet challenging surgical specialty.

Traumatic perforations are associated with previous tympanostomy tube placement

INTRODUCTION

Recognized late complications of tympanostomy tube placement include persistent tympanic perforation, tympanosclerosis, and focal atrophy. Based on clinical experience, we suspected that atrophy at healed tympanostomy tube sites might predispose to re-perforation following trauma.

METHODS

Computerized record review of children seen in an academic pediatric otolaryngology practice from January 2001 to December 2020.

RESULTS

33 children with confirmed traumatic tympanic perforations and complete follow-up were identified. All perforations were unilateral. 19 of 33 (58%) perforations were in children with tympanostomy tube placement in the past and 14/33 (42%) had never had tubes. 17/19 (90%) traumatic perforations in the tube group were due to blunt or barotrauma rather than penetrating trauma as compared with 6/13 (46%) in the non-tube group (p = 0.0147 by Fisher's exact test). One patient in the non-tube group had an unknown mechanism of injury. 15/19 perforations in the tube groups were in the antero-inferior or antero-superior quadrants (old tube sites) compared to 4/14 in the non-tube group (p = 0.0152). Perforations tended to be larger in the non-tube group (non-tube mean perforation size = 27%/tube group mean = 18%) The median time to re-perforation was 8 years (range 3-15 years). Boys predominated in both perforation groups.

CONCLUSION

Traumatic perforations in this series occurred more often in the antero-inferior quadrant (old tube site) in children with previous tympanostomy tube placement. These perforations tended to be smaller and less often resulted from penetrating injuries than in children who had never undergone tube placement.

LEVEL OF EVIDENCE

3B - individual case-control study.

Multifrequency multicomponent tympanometry in children with a history of ventilation tube insertion

OBJECTIVES

To use multifrequency multicomponent tympanometry (MF-MCT) for evaluating the middle ear mechano-acoustics of children with a history of ventilation tube (VT) insertion and to determine the effects of tube insertion sequelae on middle ear function.

METHODS

A prospective case-control study in a tertiary referral center involving 26 children (51 ears) aged 3-15 years. The children had undergone VT insertion surgery at least one-year previously and had no other known ear diseases. In addition, 13 age-matched healthy controls (26 ears) with no prior history of ear disease were included. The patients and control subjects underwent an otoscopic examination, standard 226 Hz tympanometry, and MF-MCT.

RESULTS

In 13.7% of cases, the VT was still in place in the operated ears. Post-operative myringosclerosis and/or eardrum retraction were noticed in 30% of ears with intact tympanic membranes in the patient group. While patients exhibited a great variability of tympanometric types (with standard 226 Hz tympanometry and tympanometric patterns with 1000 Hz MF-MCT), all cases in the control group had type A tympanograms and 3B1G patterns.

CONCLUSION

The effects of VT treatment on the mechano-acoustics of the middle ear have been revealed in this study. It has also been determined that VT application may increase the mass effect on the middle ear functions, which can be detected in the tympanometric shape and pattern.

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media

BACKGROUND

Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media.

METHODS

We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period.

RESULTS

In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial.

CONCLUSIONS

Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.).

A three-dimensional printed myringotomy, tympanostomy and ventilation tube placement simulator

OBJECTIVE

Tympanostomy is one of the most commonly performed surgical procedures in otolaryngology, and its complexity is challenging for trainee surgeons. Investing in medical education is a cornerstone of good patient safety practices. For trainees, use of simulators before operating on actual patients helps mitigate risks. This study aimed to develop a three-dimensional printed model simulator for myringotomy, tympanostomy and ventilation tube placement.

METHODS

An articulated model with a detachable portion, base and plastic bag to simulate the external auditory canal, middle ear and tympanic membrane, respectively, was modelled and printed.

RESULTS

The final simulator was made from acrylonitrile butadiene styrene polymer and measured 4 × 4 × 12 cm. It was designed to mimic the angulation of patient anatomy in the myringotomy position and simulate the texture and colour of the tissues of interest. The cost was low, and testing with an operating microscope and endoscope yielded satisfactory results. The advent of three-dimensional printing technology has made surgical simulation more accessible and less expensive, providing several advantages for medical education.

CONCLUSION

The proposed model fulfilled expectations as a safe, inexpensive, reproducible, user-friendly and accessible surgical education tool that can be improved and reassessed for further research.

Humanized Anti-DNABII Fab Fragments Plus Ofloxacin Eradicated Biofilms in Experimental Otitis Media

OBJECTIVES/HYPOTHESIS

To evaluate the ability of humanized monoclonal antibody fragments directed against a bacterial DNABII protein plus ofloxacin delivered directly into the chinchilla middle ear via tympanostomy tube (TT) to enhance the ability of ofloxacin to eradicate biofilms formed by nontypeable Haemophilus influenzae (NTHI).

STUDY DESIGN

A blinded pre-clinical study of comparative efficacy of single versus combinatorial treatment strategies.

METHODS

NTHI was allowed to form biofilms in the middle ears of chinchillas prior to TT placement. Ofloxacin, humanized Fab fragments against a bacterial DNABII protein that disrupts biofilms or Fab fragments plus ofloxacin were instilled into the middle ear via TT. For two consecutive days, ofloxacin was delivered twice-a-day, Fab fragments were delivered once-a-day, or these treatments were combined. Relative biofilm resolution (as determined via two outcome measures) and eradication of viable NTHI were assessed 1-day later.

RESULTS

Whereas ofloxacin alone did not resolve biofilms or eradicate NTHI from the middle ear, delivery of Fab fragments significantly reduced both biofilms and NTHI burden over this short course of treatment. Notably, co-delivery of ofloxacin plus humanized Fab fragments eradicated both NTHI and biofilms from the middle ear, an enhanced outcome compared to receipt of either treatment alone.

CONCLUSION

This study demonstrated a powerful combinatorial approach to release bacteria from their protective biofilms and rapidly render them vulnerable to killing by a previously ineffective antibiotic. An approach to combine ofloxacin with humanized Fab fragments that disrupt biofilms has tremendous potential to quickly resolve chronic otorrhea suffered by children with chronic suppurative otitis media or chronic post-tympanostomy tube otorrhea and thereby improve their quality of life.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Predictors of postoperative complications in paediatric patients receiving grommets - A retrospective analysis

BACKGROUND

Insertion of middle ear ventilation tubes (MEVT), tympanostomy tubes or grommets is one of the most common paediatric surgical procedures performed by ENT surgeons worldwide. Outcomes may be complicated by postoperative otorrhoea and ventilation tube blockage.

OBJECTIVE

To identify risk factors associated with early postoperative complications of MEVT insertion.

METHOD

In a case-control study, set in a tertiary hospital in Melbourne, Australia, 590 paediatric patients undergoing grommet insertion between February 2017 and February 2018, 311 patients (205 males & 106 females; median age of 3.86 years) met the inclusion criteria and had identical middle ear status bilaterally.

INTERVENTION

Tympanostomy tube insertion and postoperative topical otic antibiotic drops.

MAIN OUTCOME AND MEASURES

Patient age, gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, season of surgery, diagnosis and time to first medical review were examined. The duration of topical otic antibiotic drops used and tube patency and presence of otorrhoea at 6-week postoperative review were also recorded.

RESULTS

At the first medical review, 8.7% of patients (n = 27) developed otorrhoea from one or both ears, 6.4% of patients (n = 20) had an obstructed MEVT in one or both ears. Exposure to intraoperative [IO] and postoperative [PO] antibiotic drops were significantly less associated with developing postoperative otorrhoea compared to non-exposure (IO: Odds Ratio [OR] = 0.15, 95%CI 0.04 to 0.57, p = 0.005; PO: OR = 0.21, 95%CI 0.58 to 0.76, p = 0.017). There were no statistically significant associations between antibiotic drop exposure and grommet blockage (p > 0.05). There was a significant association between developing postoperative otorrhoea and patients receiving surgery during the colder months of Winter/Autumn (OR = 3.17, 95%CI 1.14 to 8.84, p = 0.028), as well as patients aged less than 3 years (OR = 2.66, 95%CI 1.01 to 7.03, p = 0.049). There was a statistically significant association between serous effusions and grommet blockage compared to no effusion (OR = 4.03, 95%CI 1.03 to 15.7, p = 0.045). There were no statistically significant associations identified between otorrhoea and gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, diagnosis and time to first medical review. There were no statistically significant associations between grommet blockage and age, gender, indication for surgery, concurrent surgery, season or number of previous grommets.

CONCLUSIONS

8.7% of patients developed otorrhoea within 6 weeks post-operatively. Undergoing the procedure during winter/autumn, age <3 years were associated with developing otorrhoea. Topical antibiotic exposure was inversely associated with developing postoperative otorrhoea. 6.4% of patients had grommet blockage. Presence of serous middle ear effusion intraoperatively was a statistically significant indicator for developing grommet blockage.

Subannular Tubes in Children With Cleft Palate

OBJECTIVE

To investigate subannular tube (SAT) placement as an alternative treatment of chronic middle ear disease in children with cleft palate.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All children with cleft palate with intractable otitis media with effusion and/or with tympanic membrane retraction, operated for insertion of 1 or more sets of transtympanic tubes followed by SAT in a tertiary center.

MAIN OUTCOME MEASURES

Audiological outcomes, average duration of tubes, and postoperative complications were analyzed.

RESULTS

This study included 21 children with cleft palate, aged 3 to 14 years. A total of 38 ears was evaluated. The median time of follow-up was 42 months. During follow-up, 69.2% of the patients had no complications. Observed complications were otorrhea (13.5%) and tube obstruction (7.7%). In 7.9% of the cases, otitis media with effusion relapsed after tube extrusion. By the end of the study, 76.3% of the tubes remained in situ and 68.4% of the tympanic membranes had the SAT in place and had no significant alterations. The mean duration of SATs was 16 months, which was significantly superior to transtympanic tube duration. A significant sustained improvement in the hearing of children with SATs was observed.

CONCLUSION

Subannular tube insertion results in hearing improvement to normal range and tympanic retraction pockets reversion in children with cleft palate with persistent otitis media with effusion and tympanic retraction/atelectasis. This surgery appears to be safe and provides long-term efficient middle ear aeration. Strict postoperative follow-up is crucial for the success of the treatment.

Risk Factors for Multiple Tympanostomy Tube Placements in Children: Systematic Review and Meta-Analysis

OBJECTIVES/HYPOTHESIS

To determine the rate and predictors of receiving multiple tympanostomy tube (TT) placements in children.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for studies reporting the risk factors for receiving repeat TT (r-TT) placements in children with chronic otitis media with effusion or recurrent acute otitis media. These articles were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Data were pooled using a random-effects model.

RESULTS

Twenty-one studies involving a total of 290,897 children were included. Among all patients, 24.1% (95% confidence interval (CI), 18.2%-29.9%) underwent ≥2 TT placements and 7.5% (95% CI, 5.7%-9.4%) underwent ≥3 TT placements. Craniofacial disease (odds ratio (OR) 5.13, 95% CI, 1.57-16.74) was the strongest predictor of r-TT. Younger age at initial TT placement and shorter TT retention time were also significantly associated with r-TT. Receipt of primary adenoidectomy with initial TT placement was associated with decreased odds of r-TT (OR, 0.46; 95% CI, 0.39-0.55). Long-term tubes also significantly reduced the odds of r-TT (OR, 0.27; 95% CI, 0.17-0.44).

CONCLUSIONS

About 1 in 4 children receiving TT will receive at least one repeat set of TT and about 1 in 14 will receive multiple repeat sets. Concurrent adenoidectomy and long-term tubes reduced the incidence of r-TT. Younger patients and those with earlier extrusion of the initial set are at increased risk for repeat surgery. The identification of these risk factors may improve parental counseling and identify patients who might benefit from closer follow-up.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2363-E2370, 2021.

Ventilation tube non-function due to blockage in children: the frequency, course and effect on hearing. A prospective cohort study

OBJECTIVE

To assess the effect on hearing of non-functioning ventilation tubes due to blockage during the first six months post-operatively, using UK national guidelines.

METHOD

A prospective, observational study was conducted on 37 children who underwent bilateral ventilation tube insertion. Air and bone conduction thresholds were measured before and following surgery, and at one, three and six months post-operatively. Tube non-function was assessed by tympanometry supported by otoscopy.

RESULTS

Post-operatively, an average of 21 per cent of ventilation tubes were non-functioning. Ears with non-functioning tubes had significantly (p = 0.0001) poorer mean air conduction thresholds than functioning tubes, with a magnitude of 6 dB HL. Ears with otorrhoea were most affected (15 per cent). At any one visit, the air-bone gap was closed to 10 dB or less in 76 per cent of ears. Non-functioning tubes reduced this to 56 per cent. Compared with tympanometry, otoscopy underdiagnosed tube non-function due to blockage by 22 per cent.

CONCLUSION

Non-functioning of ventilation tubes occurs frequently and can be missed on otoscopy. Although it is associated with poorer air conduction thresholds, the magnitude of this difference is unlikely to warrant further intervention unless there is otorrhoea or recurrence of bilateral hearing impairment.

Long-term outcomes in children with and without cleft palate treated with tympanostomy for otitis media with effusion before the age of 2 years

BACKGROUND

Long-term outcomes of children with and without cleft palate receiving early treatment for otitis media with effusion (OME) are unclear.

OBJECTIVES

To compare long-term otological and audiological outcomes between children with and without cleft palate treated with tympanostomy for OME before the age of 2 years.

MATERIAL AND METHODS

Ninety-five children (180 ears) with cleft palate (study group) and 97 children (185 ears) without (control group) were followed-up to a maximum age of 7 years. We retrospectively analyzed the audiological outcomes at the age of 7 years, and the otological outcomes at the last examination.

RESULTS

The percentages of children with OME resolution before the age of 7 years were 47.4% and 60% in the study and control groups, respectively, and those of ears with healed tympanic membrane were 71.7% and 79.5% in the corresponding groups. Significantly more ears were subjected to retympanostomy in the study (31.1%) than in the control group (21.6%). Mean pure-tone average (0.5‒4 kHz) was 15.6 dB HL and 14.3 dB HL for the corresponding groups.

CONCLUSIONS/SIGNIFICANCE

Otological and audiological outcomes in both groups were similar. The audiological prognosis was favorable regardless of the cleft palate condition.

Postoperative controls of ventilation tubes in children by general practitioner or otolaryngologist? Study protocol for a multicenter randomized non-inferiority study (The ConVenTu study)

BACKGROUND

Otitis media with effusion is the major cause of acquired hearing problems in children. Some of the affected children need surgery with ventilation tubes in the tympanic membrane to reduce ear complaints and to improve hearing, middle ear function, and health-related quality of life. This is one of the most common ambulatory surgeries performed on children. Postoperative controls are needed to assess that the tubes are functional, to evaluate whether hearing loss has been improved, and to handle potential complications. The follow-up may continue for years and are usually done by otolaryngologists. Nevertheless, there exist no evidence-based guidelines concerning the level of expertise needed for postoperative controls of the ventilation tubes. The aim of this protocol is to describe the ConVenTu study that evaluates whether postoperative controls performed by general practitioners (GPs) represent a safe and sufficient alternative to controls performed by otolaryngologists.

METHODS/DESIGN

Multicenter randomized non-inferiority study conducted in clinical settings in seven hospitals located in Norway. Discharged children with ventilation tubes, aged 3-10 years, are allocated randomly to receive postoperative controls by either an otolaryngologist at the hospital where they had ventilation tube surgery or their regular GP. Study participants are enrolled consecutively until 200 patients are included in each group. Two years after surgery, we will compare the pure tone average of hearing thresholds (primary endpoint) and middle ear function, complication rate, health-related quality of life and the parents' evaluations of the postoperative care (secondary endpoints).

DISCUSSION

This protocol describes the first randomized non-inferiority study of GPs performing postoperative controls after surgery with ventilation tubes. Results from this study may be utilized for deriving evidence-based clinical practice guidelines of the level of postoperative controls after ventilation tube surgery which is safe and sufficient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02831985 . Registered on 13 July 2016.

Otoacoustic Emissions in Children with Long-Term Middle Ear Disease

Introduction: Otoacoustic emissions (OAEs) evaluate the functional status of the cochlea. Repeated otitis media (OM) can cause changes in the peripheral structures of the auditory system, and, in this way, middle ear infection may irreversibly damage the middle ear, or even the cochlea. Objectives: To analyze the results of transiently evoked otoacoustic emissions (TEOAEs) and distortion product otoacoustic emissions (DPOAEs) in individuals with a history of OM. Method: Participants with 8 to 16 years of schooling were split into two groups: a control group (CG) of 50 subjects who had no history of otological disease and an experimental group (EG) of 50 subjects who had a history of recurrent otitis in childhood and had consequently undergone myringotomy to insert bilateral ventilation tubes. All children underwent basic audiological assessment (tonal audiometry, speech audiometry, and immittance testing) and otoacoustic emission testing (TEOAEs and DPOAEs). Results: There were no significant differences between the groups when audiometrically tested via air and bone conduction. OAEs were found in all CG subjects. For the EG, there were no TEOAE responses in 17 ears and no DPOAEs in nine ears; response amplitudes were lower at all frequencies. The emission level and the signal-to-noise ratio were statistically different between the two groups, and OAEs in the EG were statistically smaller compared to the GC. Conclusion: In the EG, responses were more likely to be absent and were of statistically smaller amplitude compared to the CG. A history of repeated OM apparently interferes with the generation and transmission of TEOAEs and DPOAEs.

A rare case of tympanostomy tube otorrhea: Pigmentiphaga

Tympanostomy tube otorrhea (TTO) is a common complication of tympanostomy tubes. The most common bacteria associated with TTO include Haemophalis influenza, Moraxella catarrhalis, Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa. We present the first case of a 9 year-old female with a history of 22q11 syndrome, hemifacial microsomia, Tetralogy of Fallot, and hearing aid dependence with left-sided profound sensorineural and right-sided moderate conductive hearing loss who presented with TTO caused by the bacteria Pigmentiphaga daeguenesis/kulla, a gram-negative bacteria often found in soil. This patient's otorrhea did not respond to typical otic antibiotic formulations, but was ultimately treated successfully with intramuscular ceftriaxone. We describe the natural history, presentation and management for a case of TTO caused by a rare bacteria from the genus Pigmentiphaga.

Cost of closure: Comparing success and spending of fat graft myringoplasties with and without hyaluronic acid

INTRODUCTION

Myringoplasties are common pediatric procedures used to surgically close a perforated tympanic membrane. While a wide variety of graft materials are available to surgeons, the cost effectiveness of these different techniques is not well studied.

OBJECTIVES

To compare the cost effectiveness of the fat graft myringoplasty (FGM) with the hyaluronic acid fat graft myringoplasty (HAFGM).

METHODS

Retrospective chart review of patients ages 31 days to 18 years who had undergone either FGM or HAFGM from 2006 to 2016.

RESULTS

We identified 85 patients who had undergone FGM and 51 patients who had undergone HAFGM. The two groups were statistically similar in age (CI -0.51, 1.9; p = 0.23), sex (CI 0.3, 1.4; p = 0.27), and history of prior tympanostomy tube placement (CI -0.07, 0.07; p = 0.69). Both groups had a similar number of total comorbidities (40.0% of patients in the FGM group and 27.5% of patients in the HAFGM; CI -0.04, 0.29; p = 0.19). The FGM and the HAFGM procedure did not have statistically significant differences in perforation closure rates, 82.4% and 92.2% respectively (CI 0.81, 7.3; p = 0.13). In comparing the total surgeons' cost of closing a tympanic membrane deficit, the FGM incurred a greater cost per perforation. The cost/tympanic membrane perforation closure for the FGM totaled $3011.88 per deficit, whereas the HAFGM totaled $2742.98.

CONCLUSION

As financial stewardship becomes more important for medical decision making, it is imperative that providers consider cost and outcomes data together when comparing similar treatment options. The FGM and the HAFGM have statistically similar rates of success in closing tympanic membrane perforations. In this study, the FGM cohort consumed more health care dollars per perforation secondary to the need for revision surgeries. As such, this study offers that the additional use of a hyaluronic disc does not increase overall cost to the healthcare system when performing a fat graft myringoplasty over a large cohort of patients.

Does Otitis Media Affect Later Language Ability? A Prospective Birth Cohort Study

Purpose The aim of the study was to examine whether otitis media (OM) in early childhood has an impact on language development in later childhood. Methods We analyzed data from 1,344 second-generation (Generation 2) participants in the Raine Study, a longitudinal pregnancy cohort established in Perth, Western Australia, between 1989 and 1991. OM was assessed clinically at 6 years of age. Language development was measured using the Peabody Picture Vocabulary Test-Revised (PPVT-R) at 6 and 10 years of age and the Clinical Evaluation of Language Fundamentals-Third Edition at 10 years of age. Logistic regression analysis accounted for a wide range of social and environmental covariates. Results There was no significant relationship between bilateral OM and language ability at 6 years of age (β = -0.56 [-3.78, 2.66], p = .732). However, while scores were within the normal range for the outcome measures at both time points, there was a significant reduction in the rate of receptive vocabulary growth at 10 years of age (PPVT-R) for children with bilateral OM at 6 years of age (β = -3.17 [-6.04, -0.31], p = .030), but not for the combined unilateral or bilateral OM group (β = -1.83 [-4.04, 0.39], p = .106). Conclusions Children with OM detected at 6 years of age in this cohort had average language development scores within the normal range at 6 and 10 years of age. However, there was a small but statistically significant reduction in the rate of receptive vocabulary growth at 10 years of age (on the PPVT-R measure only) in children who had bilateral OM at 6 years of age after adjusting for a range of sociodemographic factors.

Balloon Eustachian Tuboplasty (BET) in Children: A Retrospective Multicenter Analysis

OBJECTIVE

Generation of pilot data for planning of prospective BET-studies for treatment of dilatory Eustachian tube (ET) dysfunction in children.

STUDY DESIGN

Retrospective multicenter analysis.

SETTING

Nine ENT departments at tertiary care teaching hospitals.

PATIENTS

4-12-year-old children with chronic otitis media with effusion (COME) for more than 3 months or more than 3 episodes of acute otitis media during the last year, having failed standard surgical therapy at least once.

INTERVENTION

BET with or without paracentesis, ventilation tube insertion, or tympanoplasty.

MAIN OUTCOME MEASURES

Tympanic membrane appearance, tympanometry, and hearing threshold.

RESULTS

Two hundred ninety-nine ETs of 167 children were treated. Mean age was 9.1 years (95% confidence interval [95% CI]: 8.7-9.4 yr). In 249 ears (83.3%), COME and/or retraction of the tympanic membrane were the indication for BET. Median hearing threshold was 20 dB HL (95% CI: 0-46 dB). One hundred fifty-five ears (51.8%, 95% CI: 46.1-57.4%) showed a tympanogram type B. Treatment consisted of BET without other interventions ("BET-only") in 70 children, 128 ears. Median length of follow-up for 158 (94.6%) children was 2.6 months (95% CI: 0.3-16.1 mo). After treatment, the tympanic membrane appeared normal in 196 ears (65.6%, 95% CI: 60.0-70.8%, p < 0.001). Median hearing threshold improved to 10 dB HL (95% CI: 0-45 dB, p < 0.001). Tympanograms shifted toward type A and C (type A: 39.1%, 95% CI: 33.7-44.7, p < 0.001). These improvements were also observed in subgroup analyses of "BET-only" treatment and the indication of "COME" respectively.

CONCLUSION

BET is improving a variety of dilatory ET dysfunction-related ear diseases in children. This study provides detailed data for design and planning of prospective studies on BET in children.

Dexamethasone eardrop with grommet placement vs intratympanic steroid injection for sudden sensorineural hearing loss: A randomized prospective clinical trial

OBJECTIVES

The purpose of this study was to compare different means of intratympanic steroid delivery in the treatment of idiopathic sudden sensorineural hearing loss.

DESIGN

Prospective, multicentered, randomized controlled trial.

SETTING AND PARTICIPANTS

Fifty-six patients who fulfilled the inclusion criteria for idiopathic sudden sensorineural hearing loss who failed or were contraindicated for oral steroids were included in this study. Patients were randomly divided into 2 groups according to delivery methods: group A received 4 sections of intratympanic dexamethasone injection and group B received grommet placement with dexamethasone delivery followed by 3 sections of dexamethasone ear drop application. Self-administered paper-based questionnaires were filled out to measure subjective pain scores, vertigo, anxiety, and overall satisfaction immediately after each procedure. Hearing threshold was measured with pure tone audiogram in the follow-up.

RESULTS

There was no statistical significance detected in hearing threshold improvement between both groups (P = 0.30). Grommet placement followed by dexamethasone eardrop application demonstrated a significant difference in shorter waiting time (24 min in grommet group vs 52 min in injection group; P < 0.01); and better overall satisfaction (1.6 in grommet group vs 2.5 in injection group; P < 0.05).

CONCLUSIONS

Grommet placement followed by dexamethasone eardrop application is a good alternative for a patient indicated for intratympanic steroid, with less administrative cost, shorter waiting time, and more satisfaction.

Clinical practice guidelines for the diagnosis and management of acute otitis media in children-2018 update

OBJECTIVE

"Clinical Practice Guidelines for the Diagnosis and Management of Acute Otitis Media in Children-2018 update (2018 Guidelines)" aim to provide appropriate recommendations about the diagnosis and management of children with acute otitis media (AOM), including recurrent acute otitis media (recurrent AOM), in children under 15 years of age. These evidence-based recommendations were created with the consensus of the subcommittee members, taking into consideration unique characteristics of bacteriology and antimicrobial susceptibilities of AOM pathogens in Japan, as well as global advances in vaccines.

METHODS

The subcommittee re-evaluated key clinical issues based on SCOPE (a master plan of the guidelines) and created clinical questions (CQ) about the diagnosis and management of AOM patients. A literature search of the publications from 2013 to 2016 were added to the Guidelines 2013, not only to assess the evidence on the effectiveness of vaccines, but also to provide up to date information of the bacteriology and antimicrobial susceptibilities of AOM causative pathogens in Japan.

RESULTS

We have proposed guidelines for disease severity-based management of AOM patients, after classifying AOM severity into mild, moderate, and severe, based on age, clinical manifestations, and otoscopic findings.

CONCLUSIONS

Precise otoscopic findings are essential for judging AOM severity, which can lead to appropriate management of AOM patients.

Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist

OBJECTIVES

To illustrate some of the common dilemmas in tympanostomy tube care and describe time-tested ways to address them.

METHODS

Computerized literature review.

RESULTS

Issues including the correct diagnosis of recurrent acute otitis media, tympanostomy tube types and techniques for tube placement, management of tube clogging and otorrhea, and methods for tube removal and patching are illustrated.

CONCLUSIONS

Tympanostomy tube placement is the most common surgery performed in children requiring general anesthesia. While some elements of tympanostomy tube care have been addressed in clinical studies, much of clinical practice is guided by shared experience.

Utilization of Invasive Procedures for Adult Eustachian Tube Dysfunction

OBJECTIVE

Eustachian tube dysfunction (ETD) is a common diagnosis among adults presenting for outpatient care. We sought to determine national utilization and the associated cost of invasive procedures for adult ETD.

STUDY DESIGN

Cross-sectional study.

SETTING

National health care database.

SUBJECTS AND METHODS

The Truven Health MarketScan Databases (2010-2014) analytic cohort included health care encounters of patients ≥18 years of age with a diagnosis of ETD or related conditions of otitis media with effusion (OME) or tympanic membrane retraction (TMR). Visits associated with recent diagnoses of acute upper respiratory infection, head and neck cancer, or radiation therapy were excluded. Invasive procedure usage was subdivided into nasal and otologic procedures.

RESULTS

ETD, OME, or TMR was diagnosed in 1,298,987 patients, 11.1% of which were chronic. The most common procedure was diagnostic endoscopy (including nasal endoscopy and laryngopharyngoscopy), which was used most frequently in the first 3 months after diagnosis, during which it was performed in 120,971 (9.3%) patients. The most frequent therapeutic nasal procedure was eustachian tube inflation without catheterization, performed in 11,412 patients over 5 years at a total cost of $1,210,939 ($106 per person annually). The most common therapeutic otologic procedure was myringotomy with tympanostomy, performed on 56,137 patients over 5 years at a total cost of $47,713,708 ($810 per person annually).

CONCLUSION

Several nasal and otologic procedures are associated with a diagnosis of adult ETD at substantial cost. Development of therapeutic alternatives should be sought to mitigate the need for invasive procedures to treat this condition.

Tympanostomy Tube Controversies and Issues: State-of-the-Art Review

OBJECTIVE

To review current pragmatic issues and controversies related to tympanostomy tubes in children, in the context of current best research evidence plus expert opinion to provide nuance, address uncertainties, and fill evidence gaps.

METHODS

Each issue or controversy is followed by the relevant current best evidence, expert insight and opinion, and recommendations for action. The role of expert opinion and experience in forming conclusions is inversely related to the quality, consistency, and adequacy of published evidence. Conclusions are combined with opportunities for shared decision-making with caregivers to recommend pragmatic actions for clinicians in everyday settings.

RESULTS

The issues and controversies discussed include (1) appropriate tube indications, (2) rationale for not recommending tubes for recurrent acute otitis media without persistent middle ear effusion, (3) role of tubes in at-risk children with otitis media with effusion, (4) role of new, automated tube insertion devices, (5) appropriateness and feasibility of in-office tube insertion in awake children, (6) managing methicillin-resistant Staphylococcus aureus acute tube otorrhea, and (7) managing recurrent or persistent tube otorrhea.

CONCLUSIONS

Despite a substantial, and constantly growing, volume of high-level evidence on managing children with tympanostomy tubes, there will always be gaps, uncertainties, and controversies that benefit from clinician experience and expert opinion. In that regard, the issues discussed in this review article will hopefully aid clinicians in everyday, pragmatic management decisions.

Eradication of biofilms on tympanostomy tubes with acetic acid treatment: an in vitro study

The purpose was to evaluate the eradicative effect of acetic acid on bacterial biofilm grown on tympanostomy tubes by an in vitro experiment. Biofilms of Pseudomonas aeruginosa and Staphylococcus aureus were grown on sterile tympanostomy tubes for 24 h. The tubes were treated with acetic acid solutions at various concentrations for 24 h. Main outcome was viability of bacteria after treatment. The presence of consistently attached biofilm was examined on selected tympanostomy tubes with confocal laser scanning microscopy. Both pH-adjusted and non-pH-adjusted media solutions were applied as control groups. Results showed complete eradication of P. aeruginosa biofilm with 0.50% v/v acetic acid. Biofilm of S. aureus was eradicated with 1.25% v/v acetic acid. Low pH value alone led to decreased growth of already established biofilm, but not eradication. In conlusion, acetic acid showed an eradicating effect on biofilm established on sterile tympanostomy tubes in vitro.

Diseño, modelado 3D y optimización del comportamiento mecanoacústico de un nuevo tubo de ventilación transtimpánico

Introducción y Objetivos: En este trabajo mostramos un nuevo tubo de ventilación transtimpánico cuyo diseño pretende solventar los efectos indeseables aparecidos durante la inserción de tubos de ventilación actualmente comercializados; analizamos su comportamiento mecánico en un modelo 3D del oído a fin de optimizar su comportamiento acústico. Métodos: Para el diseño del tubo se empleó un software autoCAD; El comportamiento mecánico se analizó en un modelo computadorizado dinámico 3D del oído humano basado en el método de los elementos finitos (FEM). Resultados: El nuevo tubo de ventilación posee un tamaño y una masa significativamente menores a los actualmente disponibles en el mercado lo que provoca un menor interferencia en la vibración del sistema tímpano-osicular; su diseño facilita que permanezca insertado mientras las condiciones del paciente así lo aconsejen evitando su caída hacia la caja o su precoz extrusión. Conclusiones: Las ventajas teóricas biológicas y acústicas del nuevo tubo desarrollado (con menor masa y cuyo diseño evita las complicaciones de los actuales) puede abrir una nueva posibilidad de tratamiento de la otitis media seromucosa crónica.

Analysis of Risk Factors for Myringosclerosis Formation after Ventilation Tube Insertion

BACKGROUND

This study examined possible risk factors for myringosclerosis formation after ventilation tube insertion (VTI).

METHODS

A retrospective study was performed in a single tertiary referral center. A total of 582 patients who underwent VTI were enrolled in this study. Patients were divided into two groups based on the presence or absence of myringosclerosis: MS+ and MS-. Characteristics of patients were collected through medical chart review; these included age, gender, nature and duration of effusion, type of ventilation tube (VT), duration and frequency of VTI, incidence of post-VTI infection, incidence of intraoperative bleeding, and presence of postoperative perforation. Incidences of risk factors for myringosclerosis and the severity of myringosclerosis in association with possible risk factors were analyzed.

RESULTS

Myringosclerosis developed in 168 of 582 patients (28.9%) after VTI. Patients in the MS+ group had an older mean age than those in the MS- group. The rates of myringosclerosis were higher in patients with older age, serous otitis media, type 2 VT, post-VTI perforation, and frequent VTI. However, there were no differences in occurrence of myringosclerosis based on gender, duration of effusion, duration of VT placement, incidence of post-VTI infection, or incidence of intraoperative bleeding. The severity of myringosclerosis was associated with the duration of effusion and frequency of VTI.

CONCLUSION

Older age, serous effusion, type 2 VT, presence of post-VTI perforation, and frequent VTI may be risk factors for myringosclerosis after VTI; the severity of myringosclerosis may vary based on the duration of effusion and frequency of VTI.

Endoscopic ear surgery in children with down syndrome

INTRODUCTION

Children with Down syndrome (DS) have a high incidence of chronic middle ear disease. Surgery to manage this disease is challenging due to the severity of illness and narrow ear canal dimensions. Endoscopic ear surgery is used to manage tympanic membrane and middle ear disease with the advantages of improved visualization and avoidance of post-auricular incisions. However, its application in children with DS has not been reported. We aim to compare the outcomes of endoscopic versus microscopic ear surgery in children with DS.

METHODS

All patients with DS who underwent tympanoplasty without mastoidectomy between 2012 and 2018 were identified, and their charts retrospectively reviewed. Rate of residual perforation, hearing, surgical time, and surgical details were recorded.

RESULTS

37 surgeries in 26 patients were identified that met inclusion criteria. Two subgroups were analyzed. The first included 14 cases that were done using traditional microscopic visualization (MV). The second included 17 cases that had substantial or exclusive use of endoscopic visualization (EES). Due to a learning curve, the number of cases done endoscopically increased over time. The average age in MV was 13.9 years vs 11.0 in EES. The MV cases included 2 with cholesteatoma vs 4 in EES. In cases with adequate follow up, residual perforations were found in 1/13 MV, and 4/17 EES. All of the residual perforation cases in EES used acellular porcine submucosa grafts. None of the cases in MV used this material. Average air bone gap reduction was seen in both groups; 4.2 dB in MV, 9.8 dB in EES. Average surgical time was similar between groups; 124 min in MV, 115 min in EES. All cases in MV required a post-auricular incision and approach to the middle ear. Only four cases in EES required this approach. Six cases in EES did not require any incision outside of the ear canal for either graft harvest or middle ear approach.

CONCLUSION

Endoscopic and microscopic ear surgery in children with DS have similar outcomes. There were no statistical differences in hearing results, surgical times, or residual tympanic membrane perforations, although the rate of perforations in the endoscopic group trended higher. Most endoscopic cases did not require conversion to a post-auricular approach. Endoscopic surgery allows some DS patients to avoid any incision outside of the ear canal.

Subannular ventilation tubes in the pediatric population: Clinical outcomes of over 1000 insertions

OBJECTIVES

Long-term transtympanic tube insertions for chronic middle ear disease are associated with high rates of complications. The objective of this study was to examine the clinical outcomes achieved with an alternate technique, the subannular tube insertion, by determining mean tube lifespan, cumulative incidence of post-operative events and complications, audiometric changes and risk factors associated with earlier tube extrusion in the pediatric population.

METHODS

A retrospective chart review of all patients operated for subannular tube insertion between January 2007 and 2013 was conducted in a single pediatric tertiary care center. Exploratory Cox regression analysis was performed to identify potential risk factors.

RESULTS

A total of 1014 tubes from 459 patients were included in the study. Mean subannular tube lifespan was 41.3 months with median time of 35.0 months. Cumulative incidence of post-operative events in decreasing frequency were otorrhea (21.7%), tube blockage (16.0%), tympanic membrane retraction (12.5%), otitis media with effusion (10.0%), acute otitis media (6.4%), perforation (4.6%) and cholesteatoma formation (1.1%). For patients with available pre- and post-operative audiograms, mean air-bone gap improved from 19.5 dB to 7.0 dB after subannular tube insertion (p < 0.01). Increasing age and previous subannular tube insertion carried hazard ratios of 1.029 (p < 0.01) and 1.749 (p < 0.01) for tube extrusion respectively, while craniofacial anomalies and concomitant tympanoplasty at the time of tube insertion had hazard ratios of 0.795 (p < 0.01) and 0.680 (p = 0.03).

CONCLUSIONS

Subannular tube insertion appears to be a safe and effective alternate technique for middle ear ventilation in cases of intractable disease.

The Role of Mastoidectomy in Draining Ventilation Tubes

OBJECTIVES

To discuss the indication for performing a mastoidectomy with catheter placement in patients with chronic tympanostomy tube otorrhea.

METHODS

The Medical Literature Analysis and Retrieval System Online was searched via PubMed for relevant articles using serous mastoiditis, mastoidectomy, chronic otorrhea, tube otorrhea, tympanostomy tubes, and biofilm as keywords.

RESULTS

Further understanding of the pathophysiology of otorrhea and the development of ototopical fluoroquinolones have made a draining tympanostomy tube more manageable. Nevertheless, chronic otorrhea refractory to an otolaryngologist's traditional treatment algorithm still occurs and may benefit from a mastoidectomy with antibiotic irrigation using a catheter in certain cases. We theorize that resolution of otorrhea results from this technique by decreasing the burden of diseased mucosa and providing a larger concentration or dose of antibiotic to the middle ear cleft through the antrum. High-resolution images of the technique and catheter placement are included in this review.

CONCLUSIONS

Despite being an uncommon management strategy, the literature suggests an indication for performing a mastoidectomy in a small percentage of patients with a chronically draining tympanostomy tube.

Medial migration of the tympanostomy tube: what is the optimal management option?

The tympanostomy tube insertion is the gold standard of treatment for secretory otitis media. Complications are associated with this surgery in 17% of cases. One of the rare but real complications is the medial migration of the tympanostomy tube. To our knowledge, this is the 14^th case reported in childhood. Considering this rarity, there is no consensus for the management of this phenomenon. Some authors propose a surgical removal, while others prefer to observe whether the patient is asymptomatic. We reported a case of migration of the tympanostomy tube and described the detailed clinical features and management options. This case report and mini-review will broaden readers the knowledge of medial migration of the tympanostomy tube and may guide the relative treatment of this complication in the future.

Oxymetazoline, Mupirocin, Clotrimazole-Safe, Effective, Off-Label Agents for Tympanostomy Tube Care

OBJECTIVES

Only a few medications have a United States Food and Drug Administration indications for prevention and/or treatment of infections in patients with tympanic perforations or tympanostomy tubes. We examined 3 off-label agents that have become important in tympanostomy tube care hoping to demonstrate the effectiveness and safety of each in experimental assays and human application.

METHODS

Computerized literature review.

RESULTS

(1) Oxymetazoline nasal spray applied at the time of surgery is equivalent to fluoroquinolone ear drops in the prevention of early postsurgical otorrhea and tympanostomy tube occlusion at the first postoperative visit. (2) Topical mupirocin 2% ointment is effective alone or in combination with culture-directed systemic therapy for the treatment of tympanostomy tube otorrhea caused by community-acquired, methicillin-resistant Staphylococcus aureus. (3) Topical clotrimazole 1% cream is highly active against the common yeast and fungi that cause otomycosis. A single application after microscopic debridement will cure fungal tympanostomy tube otorrhea in most cases. None of these 3 agents is ototoxic in animal histological or physiological studies, and each has proved safe in long-term clinical use.

CONCLUSIONS

Oxymetazoline nasal spray, mupirocin ointment, and clotrimazole cream are safe and effective as off-label medications for tympanostomy tube care in children.

Association of tympanostomy tubes with future assistive hearing devices-a population based study

Background

Ear (tympanostomy) tube (TT) placement is a common ambulatory surgery in children. Despite the commonality of this treatment, the long-term effects are unknown. The objective of this study was to determine the rate of permanent hearing loss, as measured by use of a rehabilitative hearing device.

Methods

A retrospective comprehensive population-based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario. Three cohorts of children were constructed: TT – at least one ear tube procedure (n = 193,880), No-TT –recurrent visits to a physician for middle ear disease, did not undergo ear tubes (n = 203,283), and Control – an age/sex matched group who had not undergone ear tubes and who didn’t have repeat physician visits for middle ear disease (n = 961,168). The main outcome measures were risk and odds ratio (OR) of rehabilitative hearing devices.

Results

The TT cohort had a higher risk of obtaining a hearing aid (OR 4.53 vs. No-TT, p < 0.001; OR 10.81 vs. Control, p < 0.001), an FM system (OR 3.84 vs. No-TT, p < 0.001; OR 15.13 vs. Control, p < 0.001), and an implanted bone conduction device (OR 5.08 vs. No-TT, p < 0.001; OR 15.67 vs. Control, p < 0.001).

Conclusions

An association between ear tube placement and long-term need for a rehabilitative hearing device was found. This association warrants future prospective research in this area.

Bacterial Biofilm and its Role in the Pathogenesis of Disease

Recognition of the fact that bacterial biofilm may play a role in the pathogenesis of disease has led to an increased focus on identifying diseases that may be biofilm-related. Biofilm infections are typically chronic in nature, as biofilm-residing bacteria can be resilient to both the immune system, antibiotics, and other treatments. This is a comprehensive review describing biofilm diseases in the auditory, the cardiovascular, the digestive, the integumentary, the reproductive, the respiratory, and the urinary system. In most cases reviewed, the biofilms were identified through various imaging technics, in addition to other study approaches. The current knowledge on how biofilm may contribute to the pathogenesis of disease indicates a number of different mechanisms. This spans from biofilm being a mere reservoir of pathogenic bacteria, to playing a more active role, e.g., by contributing to inflammation. Observations also indicate that biofilm does not exclusively occur extracellularly, but may also be formed inside living cells. Furthermore, the presence of biofilm may contribute to development of cancer. In conclusion, this review shows that biofilm is part of many, probably most chronic infections. This is important knowledge for development of effective treatment strategies for such infections.

In-Office Tympanostomy Tube Placement Using Iontophoresis and Automated Tube Delivery Systems

OBJECTIVES

(1) To evaluate safety, tolerability, and technical success of lidocaine iontophoresis and a tympanostomy tube placement system for adults in an office setting and (2) to meet regulatory evidence requirements for new drugs and devices.

STUDY DESIGN

Prospective, multicenter, single arm.

SETTING

Patients were recruited in 8 community-based practices in the United States between June and September 2017.

SUBJECTS AND METHODS

This study evaluated tympanic membrane anesthesia and tube placement in 30 adults. Anesthesia was achieved via iontophoresis of a lidocaine/epinephrine solution. Tube placement was conducted using an integrated myringotomy and tube delivery system. Tolerability of tube placement was measured using a patient-reported visual analog scale from 0 mm (no pain) to 100 mm (worst possible pain). Mean pain score was compared to a performance goal of 45 mm, where statistical superiority represents mild pain or less. Technical success and safety through 3 weeks postprocedure were evaluated.

RESULTS

Twenty-nine (29/30, 96.7%) patients had tube(s) successfully placed in all indicated ears. One patient demonstrated inadequate tympanic membrane anesthesia, and no tube placement was attempted. The mean (SD) pain score of 9.4 (15.7) mm was statistically superior to the performance goal. There were no serious adverse events. Seven nonserious events were related to device, procedure, or drug: inadequate anesthesia (1), vertigo (1), and dizziness (1) at the time of procedure and ear discomfort (1), tube occlusion (2), and medial tube migration (1) postprocedure.

CONCLUSION

Lidocaine iontophoresis provides acceptable tympanic membrane anesthesia for safe, tolerable, and successful in-office tube placement using an integrated myringotomy and tube delivery system.

Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention

BACKGROUND

In recent years, new information has been acquired regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society, therefore, decided to issue an update to the Italian Pediatric Society guidelines published in 2010.

METHODS

The search was conducted on Pubmed, and only those studies regarding the pediatric age alone, in English or Italian, published between January 1, 2010 and December 31, 2018, were included. Each study included in the review was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The quality of the systematic reviews was evaluated using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts.

RESULTS

The importance of eliminating risk factors (passive smoking, environmental pollution, use of pacifier, obesity, limitation of day-care center attendance) and the promotion of breastfeeding and hygiene practices (nasal lavages) was confirmed. The importance of pneumococcal vaccination in the prevention of AOM was reiterated with regard to the prevention of both the first episode of AOM and recurrences. Grommets can be inserted in selected cases of recurrent AOM that did not respond to all other prevention strategies. Antibiotic prophylaxis is not recommended for the prevention of recurrent AOM, except in certain carefully selected cases. The use of complementary therapies, probiotics, xylitol and vitamin D is not recommended.

CONCLUSIONS

The prevention of episodes of AOM requires the elimination of risk factors and pneumococcal and influenza vaccination. The use of other products such as probiotics and vitamin D is not supported by adequate evidence.

What's New with Tubes, Tonsils, and Adenoids?

Evidence-based recommendations are constantly being updated for various pediatric surgical procedures, including the role for tympanostomy tubes, as well as indications for adenoidectomy and tonsillectomy. With a growing body of research available on some of the most prevalent pediatric conditions, an update on the current concepts surrounding management is warranted.

Preventing unnecessary tympanostomy tube placement in children

OBJECTIVE

In 2013 the American Academy of Otolaryngology published tympanostomy tube guidelines for children; Action Statement 6 recommends against tube placement without middle ear effusion (MEE) at time of assessment. To date, little research has directly evaluated this recommendation in reducing the need for ear tubes. We evaluated the effectiveness of this recommendation and potential risk factors that influence the success of watchful waiting.

METHODS

Retrospective chart review collecting demographics, daycare status, smoking exposure, and time of year of visit. Children aged 6 months to 12 years without MEE on presentation, but with 3 or more episodes of acute otitis media (AOM) in 6 months or 4 or more episodes in 12 months, were assigned to watchful waiting (WW) treatment. These patients were followed every 4 months or returned sooner with additional infections. Any continued AOM, or MEE on follow up leading to tube placement, defined WW failure.

RESULTS

123 patients met criteria, with 81 still in WW to date (66% success rate). 42 children failed WW and received tympanostomy tubes (34% failure rate). There were no statistically significant associations between age, race, gender, smoking exposure, daycare, or month of presentation between children who failed WW compared to children receiving tubes.

CONCLUSIONS

Tympanostomy tube guidelines mitigate unnecessary tube placement in a majority of children with recurrent AOM without MEE. To our knowledge, this is the first study supporting the 2013 recommendations, with a 66% success rate. Additionally, no significant associations between modifying risk factors in those who failed watchful waiting were identified.

Management of otitis media with effusion in children. Société française d'ORL et de chirurgie cervico-faciale clinical practice guidelines

The Société française d'ORL et de chirurgie cervico-faciale clinical practice guidelines concern the management of otitis media with effusion (OME) in children under the age of 12 years. They are based on extensive review of MEDLINE and Cochrane Library publications in English or French from 1996 to 2016 concerning the methods of diagnosis and assessment of otitis media with effusion, as well as the efficacy of tympanostomy tubes and medical and surgical treatments of OME.

Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study

The "Clinical Practice Guideline: Tympanostomy Tubes in Children" published in 2013 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation encourages that an "educational video, or other teaching aid, should be developed to illustrate how parents/caregivers" may manage postoperative complications such as tube otorrhea; however, the current literature is devoid of such patient safety and quality improvement measures. Our objective was to develop an effective educational model to assist parents and caregivers in understanding the signs and symptoms of tympanostomy tube (TT) otorrhea and how to independently institute the appropriate otologic treatment. A 3.5 × 2-inch instructional card was designed to illustrate TT otorrhea and describe the subsequent steps necessary to obtain and institute the appropriate medical therapy. This was distributed to caregivers of all patients undergoing TT placement in September 2016; patients undergoing TT placement in May 2016 served as the preintervention control cohort. Group comparisons were made before and after implementation of the educational model by number of telephone calls our clinic triaged regarding untreated TT otorrhea, as documented within the electronic medical record. A total of 30 sets of TT were placed in September 2016, compared to 27 sets of TT in May 2016. Postoperatively, a run chart revealed a significant shift (ie, 7 consecutive points) in the number of telephone calls received (16-5 calls) after establishment of the proposed educational model. This clinical experience demonstrates the utility of patient-driven management of TT otorrhea through ancillary educational material. Given the superiority of topical otic therapy, continued translation efforts are needed for continued focus on practice implementation and dissemination.

Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review

Otitis media with effusion (OME) is a frequent paediatric disorder. The condition is often asymptomatic, and so can easily be missed. However, OME can lead to hearing loss that impairs the child's language and behavioural development. The diagnosis is essentially clinical, and is based on otoscopy and (in some cases) tympanometry. Nasal endoscopy is only indicated in cases of unilateral OME or when obstructive adenoid hypertrophy is suspected. Otitis media with effusion is defined as the observation of middle-ear effusion at consultations three months apart. Hearing must be evaluated (using an age-appropriate audiometry technique) before and after treatment, so as not to miss another underlying cause of deafness (e.g. perception deafness). Craniofacial dysmorphism, respiratory allergy and gastro-oesophageal reflux all favour the development of OME. Although a certain number of medications (antibiotics, corticoids, antihistamines, mucokinetic agents, and nasal decongestants) can be used to treat OME, they are not reliably effective and rarely provide long-term relief. The benchmark treatment for OME is placement of tympanostomy tubes (TTs) and (in some cases) adjunct adenoidectomy. The TTs rapidly normalize hearing and effectively prevent the development of cholesteatoma in the middle ear. In contrast, TTs do not prevent progression towards tympanic atrophy or a retraction pocket. Adenoidectomy enhances the effectiveness of TTs. In children with adenoid hypertrophy, adenoidectomy is indicated before the age of 4 but can be performed later when OME is identified by nasal endoscopy. Children must be followed up until OME has disappeared completely, so that any complications are not missed.

Otologic, audiometric and speech findings in patients undergoing surgery for cleft palate

BACKGROUND

Although considerable progress has been made in the last 30 years in the treatment of cleft palate (CP), a multidisciplinary approach combining examinations by a paediatrician, maxillofacial surgeon, otolaryngologist and speech and language pathologist followed by surgical operation is still required. In this work, we performed an observational cross-sectional study to determine whether the CP grade or number of ventilation tubes received was associated with tympanic membrane abnormalities, hearing loss or speech outcomes.

METHODS

Otologic, audiometric, tympanometric and speech evaluations were performed in a cohort of 121 patients (children > 6 years) who underwent an operation for CP at the Vall d'Hebron Hospital, Barcelona from 2000 to 2014.

RESULTS

The most and least frequent CP types evaluated according to the Veau grade were type III (55.37%) and I (8.26%), respectively. A normal appearance of the membrane was observed in 58% individuals, of whom 55% never underwent ventilation ear tube insertion. No statistically significant associations were identified between the CP type and number of surgeries for insertion of tubes (p = 0.820). The degree of hearing loss (p = 0.616), maximum impedance (p = 0.800) and tympanic membrane abnormalities indicative of chronic otitis media (COM) (p = 0.505) among examined patients revealed no statistically significant association with the grade of CP. However, an association was identified between hypernasality and the grade of CP (p = 0.053), COM (p = 0.000), hearing loss (p = 0.000) and number of inserted ventilation tubes.

CONCLUSION

Although the placement of tympanic ventilation tubes has been accompanied by an increased rate of COM, it is still important to assess whether this is a result of the number of ventilation tubes inserted or it is intrinsic to the natural history of middle ear inflammatory disease of such patients. Our results do not support improvements in speech, hearing, or tympanic membrane abnormalities with more aggressive management of COM with tympanostomy tubes.

Is there any effect of montelukast on prevention of myringosclerosis after myringotomy in a rat model?

OBJECTIVES

In this study, our aim was to identify the possible effects of montelukast sodium (ML) on the prevention of experimentally induced myringosclerosis.

MATERIALS AND METHODS

Twenty-eight female Wistar albino rats were used and they were divided into four groups randomly. Tympanic membranes (TM) of all animals were perforated and then group 1 received no treatment (control group), group 2 was treated with a topical saline solution, group 3 received topically ML and group 4 received orally ML. On the 15th day, all animals were euthanized. Tympanic membranes were evaluated otomicroscopically and histopathologically.

RESULTS

The histopathological findings, compared against a control and saline groups, showed the topically and orally ML groups had statistically significant differences of degree of myringosclerosis (p < 0.002) and median thickness of the TMs (p < 0.001). Suppression of inflammation was statistically significant only in the oral ML treatment group (p < 0.002).

CONCLUSION

Oral and topically administration of ML reduced myringosclerosis formation in myringotomies rats.

A newly designed tympanostomy stent with TiO2 coating to reduce Pseudomonas aeruginosa biofilm formation

Biofilm formation has been implicated as a cause of post-tympanostomy tube otorrhea in patients suffering from otitis media with effusion, and biofilms have been found to adhere to all available types of tympanostomy tubes (TT) made from silicone. In this study, we present a novel stent designed with a reduced surface area and a titanium dioxide (TiO2) coating to prevent biofilm formation. Using a radio frequency power supply, tympanostomy stents (TS) made from Nitinol (Nikel-titanium) were coated with TiO2 to form an oxide layer on the metallic target. We successfully reproduced biofilms with carbenicillin-resistant Pseudomonas aeruginosa strain, PAO1-GFP (green fluorescent protein) on the tubes in vitro. We then compared the levels of biofilm formation by this strain on the two types of implants using several methods, including bacterial quantification, electron microscopy, and confocal laser fluorescent microscopy. Our results provide definitive evidence that the combination of the TiO2 coating and minimized surface area of the Nitinol stent inhibited the P. aeruginosa biofilm formation. The ability of the TS to prevent viable bacteria colonization (over 10 folds, compared to silicone TT) was verified by anti-biofilm test. Future studies will reveal more useful in reducing otorrhea and plugging complications as a novel tympanostomy tube.

Internationally adopted children with cleft lip and/or cleft palate: Middle ear findings and hearing during childhood

OBJECTIVE

Adopted children with cleft lip and/or cleft palate form a diverse group of patients. Due to increased age at palatal repair, adopted children have a higher risk of velopharyngeal insuffiency and poor speech outcome. Delayed palate repair may also lead to longer lasting Eustachian tube dysfunction. Decreased function of the Eustachian tube causes otitis media with effusion and recurrent acute otitis media, which can lead to other middle ear problems and hearing loss.

METHODS

One-hundred-and-thirty-two adopted children treated by the Cleft palate team in Wilhelmina Children's Hospital during January 1994 and December 2014 were included. Retrospectively, middle ear findings, the need for ventilation tube insertion and hearing during childhood were assessed. Findings were compared with 132 locally born children with cleft lip and/or cleft palate.

RESULTS

Adopted children had a mean age of 26.5 months old when they arrived in our country. After the age of two the total number of otitis media with effusion episodes and the need for ventilation tube placement did not significantly differ among adopted and non-adopted children. Adopted children had significantly more tympanic membrane perforations. Hearing threshold levels normalized with increasing age. Although within normal range, adopted children showed significantly higher pure tone averages than locally born children when they were eight to ten years old.

CONCLUSION

In general, adopted patients with cleft lip and/or cleft palate did not have more middle ear problems or ventilation tubes during childhood. However, theyhave more tympanic membrane perforations.

Tube patency: Is there a difference following otic drop administration?

PURPOSE

Many surgeons instill peri-operative otic drops to maintain tube patency. A post-hoc analysis of three randomized, controlled studies involving a one-time administration of ciprofloxacin (OTO-201) given instead of otic drops perioperatively was conducted to evaluate tube patency in patients who did and did not receive otic drops as defined within the study protocol.

MATERIALS AND METHODS

Post-hoc, retrospective analysis from three prospective, randomized, double-blind trials, (Phase 1b study [n = 83] and two Phase 3 studies [n = 532]) which enrolled children with confirmed middle ear effusion on the day of tympanostomy tube surgery and then randomized to placebo/sham (tubes alone) or OTO-201 and studied over a 28-day observation period. Patients with observed otorrhea post-tube were provided otic drops in the studies. An analysis was performed on the combined studies to evaluate tube patency, determined by pneumatic otoscopy and tympanometry, at four defined study visits over 28 days after the initial tube placement.

RESULTS

The analysis included 591 total patients with similar baseline demographics across groups. Tube patency ranged from 87 to 95% for patients who received otic drops, and from 96 to 99% for patients who did not receive otic drops.

CONCLUSION

Based on a retrospective post-hoc analysis from three randomized controlled trials in nearly 600 patients, tympanostomy tube occlusion rates was not increased in patients who did not receive otic drops. From this analysis, occlusion is likely caused primarily by peri-operative otorrhea since patency rates approached 99% in the absence of this complication.