Predictive factors for the appearance of myringosclerosis after myringotomy with ventilation tube placement: randomized study

Analysis of Paparella Type 1 tympanostomy tubes in pediatric patients: A single-center retrospective review

OBJECTIVE

This study aims to evaluate the demographic characteristics, indications for surgery, clinical follow-up results and complication rates of pediatric patients who have received a Paparella Type 1 tympanostomy tube (TT) insertion.

METHODS

Retropective review of 816 ears of 442 pediatric patients who received Paparella type 1 tympanostomy tube insertions was performed. The patients' age, indication for surgery, middle ear effusion, time to extrusion and postoperative complications were analyzed retrospectively. Ears operated for chronic otitis media with effusion (COME) and recurrent acute otitis media (RAOM) were included in the study. Ears that underwent tympanostomy tube insertion for middle ear atelectasis and suppurative complications of acute otitis media were excluded from the study. Ears with middle ear effusion mucoid and serous were included. Ears without middle ear effusion or with purulent effusion were excluded from the study. Patients with a cleft palate, Down syndrome, craniofacial anomalies and those without regular follow-up until their tubes were extruded, were excluded from the study.

RESULTS

The mean age of surgery was 5.11 years. 54.3 % of the patients were male and 45.7 % were female. 734 (90 %) tube insertions were performed for patients with COME and 82 (10 %) for those with RAOM. Mucoid middle ear effusion was observed in 86.9 % and serous in 13.1 %. The mean extrusion time of the tubes was 7.16 months. 93.1 % of the tubes were extruded spontaneously within 1 year and 99.9 % within 2 years. Postoperative complications of patients that were included were 8.7 % with otorrhea, 7.7 % premature extrusion, 8.2 % tube occlusion, 0.2 % displacement into the middle ear, 8.2 % tympanic membrane changes (5.4 % sclerosis, 2.3 % retraction and 0.5 % atrophy), 1.2 % permanent perforation, 0.1 % cholesteatoma and 0.1 % retained their tube. Premature extrusion was found to be significantly higher in the RAOM group compared with the COME group (p = 0.042). Tube extrusion time did not affect tympanic membrane changes (p = 0.061).

CONCLUSIONS

Complication rates after Paparella Type 1 tube insertion are low. The incidence of complications such as otorrhea and tube occlusion were not significantly different between the indication and middle ear effusion groups. Compared to COME group, premature extrusion were found more frequently in the RAOM group. Complications of displacement into the middle ear, permanent perforation, cholesteatoma and retained tube were much rarer.

Laser, radiofrequency or tympanostomy knife? Comparison of surgical methods in tympanostomy treatment of young children and predictive value of tympanometry

OBJECTIVES

To investigate tympanostomy tube (TT) treatment in young children, with special interest in bloodless surgical methods (laser and radiofrequency), myringosclerosis formation and tympanometric testing.

METHODS

This prospective study includes 76 children whose 121 ears with middle ear effusion were treated with tympanostomy tubes. Myringotomy was performed with CO₂ laser in 37, radiofrequency in 40 and myringotomy knife in 44 ears. The ears were evaluated with otomicroscopy and tympanometry preoperatively and postoperatively every 3-4 months until spontaneous tube extrusion.

RESULTS

All tubes extruded spontaneously (mean 12.8 months, range 3-36 months), with no persistent perforations or cholesteatomas. CO₂ laser and radiofrequency inserted tympanostomy tubes extruded faster (mean 11 months) compared to incisional myringotomy (mean 15 months, p = 0.002). Myringosclerosis was noted in 25 (21%) ears after treatment. There was a tendency to less myringosclerosis with bloodless techniques, but the difference was not significant. Flat tympanograms on the day of procedure predicted continuation of ventilation problems also after TT treatment (p = 0.003). Ears with preoperative type B tympanogram had significantly more myringosclerosis 21/75 (28%) compared with type A and C tympanograms 4/41 (10%) (p = 0.032).

CONCLUSIONS

While all myringotomy methods were effective and safe, the traditional incisional myringotomy with a tympanostomy knife is still a good, feasible and cost-effective myringotomy method. No surgical removal of tympanostomy tubes is needed before 3 years of uncomplicated tympanostomy treatment. Tympanometry turned out to be a useful tool in prediction of post TT treatment ventilation problems of the middle ear.

Clinical practice guidelines for the diagnosis and management of otitis media with effusion (OME) in children in Japan - 2022 update

This is an update of the 2015 Guidelines developed by the Japan Otological Society and Oto-Rhino-Laryngeal Society of Japan defining otitis media with effusion (OME) in children (younger than 12 years old) and describing the disease rate, diagnosis, and method of examination. Recommended therapies that received consensus from the guideline committee were updated in consideration of current therapies used in Japan and based on available evidence.

METHOD

Regarding the treatment of OME in children, we developed Clinical Questions (CQs) and retrieved documents on each theme, including the definition, disease state, method of diagnosis, and medical treatment. In the previous guidelines, no retrieval expression was used to designate a period of time for literature retrieval. Conversely, a literature search of publications from March 2014 to May 2019 has been added to the JOS 2015 Guidelines. For publication of the CQs, we developed and assigned strengths to recommendations based on the collected evidence.

RESULTS

OME in children was classified into one group lacking the risk of developing chronic or intractable disease and another group at higher risk (e.g., children with Down syndrome, cleft palate), and recommendations for clinical management, including follow-up, is provided. Information regarding management of children with unilateral OME and intractable cases complicated by adhesive otitis media is also provided.

CONCLUSION

In clinical management of OME in children, the Japanese Clinical Practice Guidelines recommends management not only of complications of OME itself, such as effusion in the middle ear and pathologic changes in the tympanic membrane, but also pathologic changes in surrounding organs associated with infectious or inflammatory diseases.

Role of TGF-β1-mediated epithelial-mesenchymal transition in the pathogenesis of tympanosclerosis

The present study aimed to explore the role of TGF-β1-mediated epithelial-mesenchymal transition (EMT) in the pathogenesis of tympanosclerosis. Sprague Dawley rats were injected with inactivated Streptococcus pneumoniae suspension to establish a rat model of tympanosclerosis. The rats were sacrificed 8 weeks after the model was established. H&E and von Kossa staining was used to observe the morphological changes of middle ear mucosa. Western blotting was used to detect the expression of TGF-β1 and EMT-associated proteins in the mucosa samples. Middle ear mucosal epithelial cells of rats were collected to establish a primary culture. The cultured cells were stimulated with TGF-β1 and the expression of EMT-associated proteins was detected by western blotting and immunofluorescence. In addition, the cells were treated with TGF-β receptor type I/II inhibitor and the expression level of EMT-associated proteins was detected by western blotting. Sclerotic lesions appeared on 72.4% of tympanic membranes, and marked inflammation, inflammatory cell infiltration and fibrosis were found in the middle ear mucosa of rat models of tympanosclerosis. In middle ear mucosa of rats with tympanosclerosis, the expression of mesenchymal cell markers increased and that of epithelial cell markers decreased compared with the control group. TGF-β1 stimulated the activation of the EMT pathway in middle ear mucosal epithelial cells, resulting in an increased expression of fibronectin and N-cadherin. In addition, a decreased expression level of EMT-associated proteins was observed when TGF-β1 was inhibited. In conclusion, the present study indicated that TGF-β1-mediated EMT may play an important role in the pathogenesis of tympanosclerosis.

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.

The effect of rosmarinic acid on the prevention of myringosclerosis

OBJECTIVES

Myringosclerosis commonly occurs as a long-term complication of ventilation during the treatment of otitis media. We aimed to determine the effects of rosmarinic acid as an antioxidant on experimentally induced myringosclerosis.

METHODS

Twenty-four male Sprague-Dawley rats, weighing 250-300 g, were unilaterally myringotomized and randomly separated into three groups. Group 1 received no treatment (control group) (n = 8); Group 2 received topical rosmarinic acid (n = 8); Group 3 received oral rosmarinic acid (n = 8). On the twenty-first day, the right ears were examined by otomicroscope and findings of myringosclerosis were recorded. Finally, all of the rats were euthanized and the tympanic membrane (TM) thickness and the severity of middle ear mucosal inflammation were evaluated histopathologically.

RESULTS

The myringosclerosis severity, TM thickness, and inflammation scores were found to be significantly higher in the control group than in the topical and systemic treatment groups (p < 0.05). There were no statistically significant differences in terms of TM thickness and inflammation scores between the topical and systemic treatment groups (p > 0.05). While moderate and severe myringosclerosis were higher in the control group, mild myringosclerosis was found to be higher in both treatment groups.

CONCLUSION

The local and oral administration of rosmarinic acid suppressed inflammation, reduced TM thickness, and prevented the development of myringosclerosis in myringotomized rats.