Current indications for tympanostomy tubes

Factors affecting persistent tympanic membrane perforation after tympanostomy tube removal in children

OBJECTIVES

Evaluate and compare the rates of persistent tympanic membrane (TM) perforations between short-term vs long-term tympanostomy tubes. In addition, to determine which demographic, anatomical, and physical factors affect ear drum healing after tympanostomy tube (TT) removal and simultaneous paper patch myringoplasty (PPM) in children.

STUDY DESIGN

Retrospective chart review.

METHODS

Charts were reviewed from the Women and Children's of Buffalo hospital and our pediatric otolaryngology practice electronic medical record. Data was retrieved from patients less than 18 years old who underwent surgical removal of a TT and concomitant PPM between January 2005 and January 2017.

RESULTS

343 ear drums were studied that underwent tympanostomy tube removal and paper patch myringoplasty. 45/343 (13%) of ears had a persistent perforation after PPM. The rate of persistent perforation with short-term tubes and long-term tubes was significantly different (6.6% and 20% respectively). Patient characteristics significantly associated with persistent perforations were: age at time of tube removal and number of tubes that patient received. Ear drum characteristics that significantly impacted persistent perforation included: size of ear drum perforation, and presence of tympanosclerosis. Length of intubation, ear drum atrophy, retraction, granulation tissue, middle ear effusion and thickened ear drum were not found to be significant factors.

CONCLUSION

Overall, we found an 87% perforation closure rate after surgical removal of the TT and PPM. Persistent perforations occurred significantly more often in patients with long-term tubes than short term tubes. Our data also suggests that several patient and ear drum characteristics may be important factors that contribute to persistent perforation after tympanostomy tube placement and removal.

Can lateral nasopharyngeal radiographs be used to predict eustachian tube dysfunction?

The objective of our case-control study was to determine whether craniofacial features on lateral nasopharyngeal radiographs (LNPRs) can predict eustachian tube dysfunction (ETD). The study included patients seen in the otolaryngology clinic from 2005 to 2011. Patients 0 to 10 years old with pressure equalization tube (PET) placement and LNPR within 6 months were included. Measurements were compared with age-matched controls selected at random to identify craniofacial features associated with ETD. Using receiver operating curve methodology, selected measurements were used to correlate age, craniofacial features, and ETD. The study population consisted of 32 patients and 34 controls. No significant differences were found between groups on any individual measurement: cranial base angle; lengths of anterior, middle, and total skull base; mandible; hard and soft palates; sella-soft-palate tip; sella-posterior nasal spine; and nasopharyngeal and palatal airway. Further statistical analysis demonstrated that patients who required PETs were more likely to have shortened anterior cranial base and maxilla relative to mandibular length. Contrary to the findings of previous studies, no single measurement was found to identify craniofacial features that may select for children with ETD requiring PETs. However, younger patients with a smaller cranial base and/or maxilla relative to mandibular length are more likely to require PETs, implying persistent ETD.

Audiometric Testing Guideline Adherence in Children Undergoing Tympanostomy Tubes: A Population-Based Study

Objective

Tympanostomy tube (TT) insertion is the most common ambulatory surgery performed on children. American Academy of Otolaryngology—Head and Neck Surgery Founda-tion (AAO-HNSF) Clinical Practice Guidelines (CPGs) recommend hearing testing for all pediatric TT candidates. The aim of this study was to assess audiometric testing in this population.

Study Design

Retrospective population-based cohort study.

Setting

All hospitals in the Canadian province of Ontario.

Subjects and Methods

All patients 12 years of age and younger who underwent at least 1 TT procedure between January 1993 and June 2016. The primary outcomes were the percentage of patients who underwent a hearing test within 1 year before and/or 1 year after surgery.

Results

A total of 316,599 bilateral TT procedures were performed during the study period (1993 to 2016). Presurgical hearing tests increased from 55.7% to 74.9%, and postsurgical hearing tests increased from 42.2% to 68.9%. Younger surgeons demonstrated a greater adherence to the CPGs (relative risk [RR], 1.22; 95% CI, 1.08-1.38; P = .001). Remarkably, there was not a spike in preoperative hearing tests following the introduction of the CPGs in 2013 (RR, 1.12; 95% CI, 0.85-1.47; P = .432). Presurgical hearing testing ranged from 26.1% to 83.5% across health regions.

Conclusion

In this cohort of children who underwent TT placement, the trends of preoperative and postoperative audiometric testing are increasing but are still lower than recommended by the CPGs, despite a tripling of practicing audiologists. This study describes the current state of testing in Ontario and highlights issues of access to audiology services, possible parent preferences, and the importance of ongoing continuing medical education for all health care practitioners.

Clinical predictors of multiple tympanostomy tube placements in Ontario children

OBJECTIVES

To characterize risk factors that predict the need for multiple tympanostomy tube (TT) procedures.

STUDY DESIGN

Retrospective population-based cohort study of children aged 18 years and younger in Ontario, Canada, who underwent at least one TT placement between January 1, 1994, and October 31, 2013.

METHODS

The relative risk (RR) of need for multiple TT procedures was determined using log-binomial regression.

RESULTS

There were 193,880 children who underwent TT insertion included in this cohort. Of these, 28.58% underwent at least two separate TT procedures. Over time, the RR of undergoing multiple TT procedures is decreasing for all children. In general, the younger the child was at the first TT procedure, the more likely the child was to undergo multiple TT procedures. Significantly higher RR for multiple TT procedures also was associated with male sex, the second-highest neighborhood income quintile, asthma or reactive airways, gastrointestinal disease, prematurity, or cleft lip and/or palate. Significantly lower RR for multiple TT procedures was associated with adenoidectomy or tonsillectomy (with or without adenoidectomy) at first TT placement or within 3 years prior. Furthermore, the benefit of adjuvant adenoidectomy or tonsillectomy was present for children aged under 4 years, in addition to those aged 4 years and older.

CONCLUSION

Among Ontario children who have had TT placement, more than one in four will have multiple sets placed. These identified risk factors permit improved preoperative counseling and enable identification of children who need closer follow-up.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:991-997, 2018.

Effect of topical use of mitomycin C and 5-fluorouracil on the closure time of myringotomies created by radiofrequency unit

CONCLUSION

Both mitomycin C (MC) and 5-fluorouracil (5-FU) had a significant effect in prolonging the patency rate of radiofrequency myringotomy.

OBJECTIVE

To compare the effect of topical use of MC and 5-FU on the closure time of myringotomies created by a radiofrequency unit.

MATERIALS AND METHODS

Myringotomies were performed using a radiofrequency unit on 80 tympanic membranes of 40 rats. Rats were divided into two study groups and one control group. MC (0.4 mg/ml) and 5-FU (50 mg/ml) pledgets were applied topically in the right ears (study groups, 20 ears each) for 10 min and saline pledgets in the left ears (control group, 40 ears). Animals were monitored using otomicroscopy weekly and patency rates were recorded until myringotomy closure.

RESULTS

The mean patency times were 4.85 weeks for the MC group and 3.90 weeks for the 5-FU group. The mean patency rate for the control side was 1.30 weeks. The log-rank test revealed both study groups to have a significantly longer patency time than the control group (p<0.0001). Although the patency rate was found to be higher in the MC-treated group than the 5-FU-treated group, this difference was not statistically significant (p>0.05).

The Mechanical Reduction of Early Acquired Cholesteatomas in Children: Indications and Limitations

The standard treatment/or acquired cholesteatoma involves surgical removal of the lesion and reconstruction of the tympanic membrane. In some children, these lesions can be treated more conservatively. We conducted a retrospective study of 29 ears in 24 children who had been treated for early acquired cholesteatoma with mechanical reduction and a tympanostomy tube. Outcomes measures included hearing status, the postoperative appearance of the tympanic membrane, and the need for additional surgery. We found that anterior and inferior pars tensa lesions, with or without squamous debris, can be successfully reduced, but that posterosuperior retractions respond less well when the ossicular chain has been eroded. None of the children who responded to mechanical reduction required major reconstructive surgery later. We conclude that mechanical reduction of retraction pocket cholesteatomas with tympanostomy tube placement is sufficient to restore normal hearing and a normal tympanic membrane appearance in selected children with early lesions. We also identified several important prognostic features, including the patient's age, the specific location of the retraction pocket on the tympanic membrane, the extent of the pocket, ossicular chain involvement, and the patient's adenoid status.

The Effect of Radiofrequency and Mitomycin C on the Closure Rate of Human Tympanostomy

OBJECTIVES

To conduct a prospective, randomized, controlled trial determining the feasibility of radiofrequency with or without topical mitomycin C application in delaying the closure time of human tympanostomy and screening its efficacy in management of recurrent acute otitis media and otitis media with effusion.

METHODS

From November 2002 to January 2004, 96 patients (180 ears) who were to undergo surgical intervention for recurrent acute otitis media or otitis media with effusion were included in this study. Sixty ears with a diagnosis of recurrent acute otitis media were equally randomized to three procedures: cold knife myringotomy (Group A), radiofrequency tympanostomy (Group B), and radiofrequency tympanostomy with topical mitomycin C application (Group C). One hundred twenty ears diagnosed as having otitis media with effusion were equally randomized to the last two procedures only. Patients were followed-up every week in the first month, every 2 weeks in the second month, and monthly after that until closure of the tympanostomy. A special follow-up setting was designed 3 months after tympanostomy closure where tympanograms and pure-tone audiograms were obtained.

RESULTS

Groups B and C showed a significantly slower rate of closure than Group A. At the same time, Group C demonstrated a slower rate when compared with Group B. The mean closure time of Group B was 3.5 weeks, with no difference between recurrent acute otitis media and otitis media with effusion. In contrast, the mean closure times for Group C were 5.3 and 7 weeks in cases of otitis media with effusion and recurrent acute otitis media, respectively, with the latter demonstrating a significantly slower closure rate. No recurrence of acute otitis media was reported in 10, 45, and 80% of Groups A, B, and C, respectively. Fifty-nine percent of Group C showed no clinical or tympanometric signs of otitis media with effusion 3 months after closure of tympanostomy. In contrast, Group B reported a lower cure rate (28%), with a statistically significant difference between both groups. Absence of recurrence and improvement in tympanometry signs correlated significantly with the duration of patency of tympanostomy (p < 0.01). The success rate was higher in patients who underwent adenoidectomy, but this did not reach statistical significance except in Group C (p < 0.01).

CONCLUSION

Radiofrequency and mitomycin C delay the closure rate of human tympanostomy. The efficacy of mitomycin C seems to be amplified in the presence of an inflamed tympanic membrane. Radiofrequency-assisted mitomycin-enhanced tympanostomy is a precise, safe, and cost-effective procedure that provides a viable approach in the management of recurrent acute otitis media and otitis media with effusion, especially when used in conjunction with adenoidectomy.

Tratamento cirúrgico da otite média com efusão: tubo de ventilação versus aplicação tópica de mitomicina C

O uso do tubo de ventilação (TV) da orelha média, tratamento cirúrgico eleito da otite média com efusão (OME), não é isento de complicações, promovendo ainda limitação social pela necessidade de abandono dos banhos de imersão. A mitomicina C (MMC) é um antineoblástico, cuja aplicação tópica retarda a fibrose e previne a estenose cicatricial. Em cobaias, retardou o fechamento de timpanotomias, permitindo maior tempo de aeração da orelha média, à semelhança dos tubos de ventilação. FORMA DE ESTUDO: Clínico prospectivo. OBJETIVO: Comparar a eficácia entre timpanotomia, aspirado da efusão e inserção de tubo de ventilação (grupo TV) versus timpanotomia, aspirado da efusão e aplicação tópica de mitomicina C (grupo MMC). Comparar o tempo de manutenção da timpanotomia e a incidência de complicações nos dois grupos. RESULTADOS: O grupo MMC apresentou eficácia significativamente menor (52% versus 80%) que o grupo TV (p= 0,34). A presença de timpanometria tipo "B" e a ausência de comprometimento do óstio faríngeo tubário pelo tecido adenóide no pré-operatório representaram fatores de mau prognóstico. A aplicação tópica de MMC nas bordas da timpanotomia proporcionou um tempo de abertura da membrana timpânica por duas a três semanas. No grupo TV, a otorréia foi observada em 13,3% dos pacientes. No grupo MMC, apesar da menor eficácia, nenhum paciente apresentou complicações nem sofreu prolongada proibição dos banhos de imersão. CONCLUSÃO: Apesar de concluirmos que o TV apresenta maior eficácia, novos estudos utilizando maior concentração, maior tempo de aplicação ou o uso seriado de MMC no tratamento da otite média com efusão devem ser realizados.

Long-term ventilation tubes: results of 726 insertions

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

Population-based, age-specific myringotomy with tympanostomy tube insertion rates in Calgary, Canada

Population-based rates of myringotomy with tympanostomy tube insertions in Calgary from 1997 to 2000 were determined with the use of administrative databases. Age-specific rates (procedures per 1,000 people per year) were 12.8, 54.2 and 11.1 for ages 0 to 11 months, 12 to 23 months and 0 to 15 years, respectively. Repeated procedures were performed on 7.1% of children <5 years of age.

Effect of topical 5-fluorouracil on closure time of myringotomies created by a radiofrequency surgical unit in guinea pigs

PURPOSE

To delay the closure time of myringotomy without inserting a ventilation tube by creating a myringotomies in guinea pigs by a radiofrequency surgical unit and using topical 5-fluorouracil (5-FU).

BACKGROUND

Topical 5-FU was used successfully in glaucoma surgery to depress the proliferation of fibroblasts, but the effects of 5-FU in the myringotomy site in delaying closure are not known. The availability of the use of a radiofrequency surgical unit in performing myringotomy and the effects of a radiofrequency surgical unit myringotomy in the patency period of the myringotomy opening are not known.

METHODS

A myringotomy in the tympanic membranes of 30 guinea pigs was created by using a radiofrequency surgical unit. Right ears of these guinea pigs were identified as the study group and sponges with 50 mg/ml 5-FU were applied topically. Saline-soaked sponges were applied to the left myringotomy site, which served as the control side for 15 minutes. Guinea pigs were separated into 2 groups. In Group 2, an additional 20 mg/ml 5-FU and saline solution were dropped into the right and left external ear on the fourth and on the 11th day, respectively.

RESULTS

In all guinea pigs, it was found that all the left-ear myringotomy sites were closed at the end of the first week. In the right ears, the myringotomy sites were closed in 75% of Group 1 and in 80% of Group 2 at the end of the second week. In the histopathologic examination of tympanic membranes, there was no apparent difference between study and control sides, but a slight increase in inflammatory findings were encountered in the study sides.

CONCLUSION

The closure time of the myringotomy site was delayed twice as much as in the control group in the site where topical 5-FU was applied, and the drop form of 5-FU did not create any additional delay in the closure time.

Evaluation of the effect of passive smoking on otitis media in children by an objective method: urinary cotinine analysis

OBJECTIVES

We aimed to determine objectively the effect of the passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM) by using the method of cotinine urinalysis.

STUDY DESIGN

We designed a prospective case-control study with follow-up of the case group for 1 year after insertion of tympanostomy tubes to evaluate postoperative complications such as otorrhea and early extrusion (<6 months), in case a significant risk factor was found.

METHODS

One hundred fourteen children between 3 and 8 years of age requiring tympanostomy tubes because of OME and ROM were chosen and compared with 40 age-matched children. Exposure to environmental tobacco smoke was assessed by cotinine urinalysis, which was performed by means of the radioimmunoassay method.

RESULTS

In this study, 73.7% (84 of 114) of the children in the case group and 55.0% (22 of 40) of the children in the control group were found to be "exposed" (P = .0461). This difference was statistically significant. Comparing the cotinine urinalysis results with parental smoking histories, 23.1% (9 of 39) of the children without parental smoking histories were "exposed" to tobacco smoke versus 84.3% (97 of 115) of the children with parental smoking histories (at least one person smoking).

CONCLUSIONS

Our results indicate that sidestream smoking increases the risk of OME and ROM. Legal regulations and guidelines must be established to protect children from passive smoking. Because cotinine urinalysis is a noninvasive and reliable method for the determination of passive smoking, it can be used for that purpose.

[Controversies concerning acute otitis media]

Acute otitis media is the subject of many unresolved points of controversy: 1) correct diagnosis; 2) whether or not bacteria are present in each case of acute otitis media; 3) spontaneous course; 4) indication of antibiotherapy; 5) treatment of recurrent acute otitis media; and 6) the place of alternative medicine, such as homeopathy. There is no ideal response. It is important, however, to take into account the knowledge of the different otoscopic stages of acute otitis media and the fact that the course of the disease is spontaneously favorable in the majority of cases. Selective prescription of an antibiotic in cases of purulent otitis only, and attention directed towards early recognition of complications, appear to be the most appropriate attitudes in the management of the disease, helping to reduce the alarmingly increasing numbers of resistant bacteria.

Effect of otitis media with effusion on gross motor ability in preschool-aged children: preliminary findings

OBJECTIVE

To investigate whether gross motor skills in preschool-aged children 24 to 60 months old with otitis media with effusion (OME) are different from those of preschool children without OME.

CHILDREN AND METHODS

The gross motor portion of the Peabody Developmental Motor Scales (PDMS-GM) was used to compare 13 children with OME before and after tympanostomy tube placement to 12 children without OME.

RESULTS

The children with OME had significantly reduced scores preoperatively compared to those without OME on the PDMS-GM. After surgery, the children with OME had higher scores than those without OME, indicating an accelerated rate of development.

CONCLUSIONS

Balance and motor development are additional factors to be considered in the medical and surgical management of the young child with chronic OME. Chronic OME may represent an additional problem for young children with existing motor deficits or other disabilities.

Tympanostomies with tubes: the parent perspective

Successful physician-patient encounters satisfy patient and family member needs beyond the effect on the disease process itself. To evaluate that aspect of care in children with chronic and recurrent acute otitis media with effusion, surveys regarding perceptions of health, socioeconomic issues, and other aspects of postoperative status were sent to the parents of 637 children who underwent tympanostomies with tubes in 1994. Three hundred one (47.3%) were returned. Responses included perceptions of improved health (87%), improvement in socioeconomic factors (75%), overall satisfaction with the results of the operation (93%), and willingness to consent to the operation given similar problems in another child (87%). There were no significant differences in responses with regard to patient gender, length of follow-up, or multiple operations. These results suggest that patient and family needs are satisfied by tympanostomies with tubes.