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Takai S, Nomura K, Oda K, Ozawa D, Irimada M, Ikeda R, Kakuta R, Katori Y, Ohyama K. Clinical Factors Associated With the Outcomes of Long-Term Middle Ear Ventilation Tube Insertion in Pediatric Patients. EAR, NOSE & THROAT JOURNAL 2023; 102:NP511-NP517. [PMID: 34130509 DOI: 10.1177/01455613211026437] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ventilation tube (VT) insertion is the most common treatment for otitis media with effusion (OME). However, OME recurrence and persistent tympanic membrane (TM) perforation after VT removal are encountered in a certain percentage of such children. METHODS This study was performed to determine the outcomes of children who underwent long-term VT insertion. A total of 326 ears from 192 patients were analyzed. The associations among the patient age, sex, history of OME, history of repeated acute otitis media, placement duration, whether the VT had been removed intentionally or spontaneously, and the outcome (persistent TM perforation or OME recurrence) were analyzed. The outcomes of multiple VT tube insertions were also reviewed. We also analyzed whether or not local or general anesthesia was associated with the early spontaneous extrusion of the VT. RESULT The OME recurrence and TM perforation rates were 29% (96/326 sides) and 17% (57/326 sides), respectively, for first insertions. In addition, 96 (29%) sides underwent ≥2 insertions. The shorter the duration for which the VT was retained in the middle ear, the more significant the rate of increase in OME recurrence. The OME recurrence was observed more often when VT was spontaneously removed than when intentionally removed. The rate of persistent TM perforation was significantly associated with male sex. Persistent TM perforation was not observed in patients who underwent 4 or 5 insertions. The anesthesia method did not significantly influence the timing of spontaneous extrusion of VT. CONCLUSION The retention period of VT should be at least 2 years, and VT removal at the age of 7 might be a viable strategy. Multiple VT insertions are recommended for patients with recurrent OME. Ventilation tube under local anesthesia is an effective option for tolerable children.
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Affiliation(s)
- Shunsuke Takai
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
| | - Kazuhiro Nomura
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
- Department of Otolaryngology, Tohoku Kosai Hospital, Kokubun-cho, Aoba-ku, Sendai-shi, Miyagi, Japan
| | - Kiyoshi Oda
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
| | - Daiki Ozawa
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
| | - Mihoko Irimada
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
| | - Ryoukichi Ikeda
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Risako Kakuta
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Yukio Katori
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Kenji Ohyama
- Department of Otolaryngology, Tohoku Rosai Hospital, Dainohara, Aoba-ku, Sendai, Miyagi, Japan
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Hearing Results in Patients With No Ossicular Chain Reconstruction and Factors Influencing the Outcome. Otol Neurotol 2022; 43:1041-1048. [PMID: 36047689 DOI: 10.1097/mao.0000000000003666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ossiculoplasty is aimed at improving or maintaining the conductive portion of hearing in patients subjected to otologic surgery. However, satisfying hearing is frequently observed after tympanoplasty even in the absence of ossicular chain reconstruction. Aims of this article would be to evaluate hearing outcomes, in terms of pure tone average air-bone gap (PTA-ABG), in patients subjected to tympanoplasty for middle ear disease whose ossicular chain has not been reconstructed, and then to investigate factors influencing those outcomes. MATERIALS AND METHODS Retrospective chart review of patients who underwent ear surgery from year 2003 to 2021 at the Otolaryngology-Head and Neck surgery department of the University Hospital of Modena was performed. Audiometric test results from patients who did not receive any ossicular chain reconstruction were collected and analyzed. SETTING Tertiary University referral center. RESULTS The mean patients' follow-up was 34.1 months. Overall, mean PTA-ABG in the study population was 23.5 dB. Integrity of stapes superstructure, malleus handle and malleus head, together with the use of tragal cartilage graft over autologous temporalis fascia to reconstruct the tympanic membrane were found to be significantly associated with better hearing outcomes, as demonstrated by lower PTA-ABG values. Stapes superstructure was found to be associated with more favorable outcomes in multivariate analysis, net of confounding factors. CONCLUSION Good hearing performance can be obtained in patients subjected to middle ear surgery, even if the ossicular chain is not reconstructed. Presence of ossicular chain remnants and the use of a rigid material for tympanic membrane reconstruction are the factors that seem to most favorably influence hearing outcomes after surgery for middle ear disease.
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Tan GX, Hamilton A, MacArthur CJ. A Systematic Review and Meta-Analysis: Timing of Elective Removal of Tympanostomy Tubes. Laryngoscope 2021; 132:2063-2070. [PMID: 34964485 DOI: 10.1002/lary.30003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/01/2021] [Accepted: 12/19/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE(S) Tympanostomy tube (TT) placement is the most common surgical procedure in children. Less than 10% of TT do not self-extrude. This study is a systematic review (SR) on elective TT removal in the pediatric population: timing, perforation rates, and role of simultaneous repair. A PICOTS (population, intervention, comparison, outcome, timing, setting) question was formulated: In pediatric patients who have retained TT, what is the preferred time to elective removal of such tubes, and what are the outcomes in terms of perforation rates? Does an intervention at the time of TT removal improve perforation rates? STUDY DESIGN Systematic review and meta-analysis. METHODS We searched four major electronic databases: EMBASE, MEDLINE, CDSR, CCRCT for articles published prior to 02/19/20. EndNote® was used to gather references, review abstracts, and obtain full text articles. Inclusion criteria were studies reporting patients aged 0 to 18 years undergoing elective TT removal with follow-up greater than 3 months. Exclusion criteria included patients >18 years, duplicate patient series, or case series with fewer than five patients. Articles that were not available in English, not available in full text, and those that only addressed long-acting TT were excluded. Data were pooled and meta-analysis was conducted to examine how timing of TT removal, patching of the tympanic membrane, or any TM intervention at TT removal affected outcomes. RESULTS A total of 1,064 references were found. We identified 63 unique studies for full text review. Of these, 17 were selected for SR. MINORS (Methodological Index for Nonrandomized Studies) scores were low-revealing high bias among the studies. Reported perforation rates after elective TT removal ranged from 0% to 57%. Four studies had data suitable for comparative meta-analysis, which showed a significant increase in perforation rates after elective removal of TT after 3 years compared to removal prior to 3 years (OR 2.89; CI 1.78-4.69). No difference in perforation rates were identified when TM intervention vs. no intervention at time of TT removal was performed (six studies: OR 1.21; CI 0.71-2.07). No difference in perforation rates was identified when the type of TM intervention was compared, including freshening of TM edges, to patching with various materials (paper, fat, gelfoam®/gelfilm®, Trichloroacetic acid) (three studies: OR 1.07; CI 0.52-2.19). CONCLUSION From the data reviewed in this SR and meta-analysis, elective TT removal at or prior to 3 years' retention showed decreased perforation rates. However, TM intervention at the time of TT removal was not shown to lower perforation rates. In the absence of tube complications such as granuloma formation, nonfunctional tube, or chronic tube otorrhea, it may be reasonable to wait up to 3 years to electively remove a retained TT. Laryngoscope, 2021.
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Affiliation(s)
- Grace X Tan
- Department of Otolaryngology, Head and Neck Surgery, OHSU, Portland, Oregon, U.S.A
| | | | - Carol J MacArthur
- Department of Otolaryngology, Head and Neck Surgery, OHSU, Portland, Oregon, U.S.A
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Diaz AR, Reina CO, Plaza G, Posadas ER, Arevalo FV, Iriarte MTG. Long-Term Follow-Up After Fat Graft Myringoplasty: Do Size and Location Matter? EAR, NOSE & THROAT JOURNAL 2020; 100:229S-234S. [PMID: 33314958 DOI: 10.1177/0145561320973555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess clinical and functional outcomes of a fat graft myringoplasty under local in an office setting. STUDY DESIGN Prospective case series. SETTING Tertiary care facility. PATIENTS Patients with a tympanic membrane (TM) perforation presenting between December 2005 and June 2019. Inclusion criteria included perforation size >25% of the surface of the pars tensa of the TM, entire perforation margins visualized through a transcanal view, and lack of spontaneous closure at the 6-month follow-up. The exclusion criteria were the presence of cholesteatoma, wet appearance of the mucosa in the tympanic cavity, ear discharge in the 3 months before surgery, or signs of ossicular inconsistency. INTERVENTION In-office fat graft myringoplasty technique under local anesthesia. MAIN OUTCOME MEASURES Complete perforation closure rate and audiometric outcomes. RESULTS A total of 121 patients underwent the procedure, of whom 21 had bilateral sequential procedures (total 142 ears). Average age was 51.1 ± 18.4 years (range, 3-78 years). The size of perforation was <25% of TM in 39 (27.5%) ears, 25% to 50% of TM in 49 (34.55%) ears, 50% to 75% of TM in 34 (23.91%) ears, and 75% to 100% of TM in 20 (14.10%) ears. Complete perforation closure was evident in 130 (91.55%) of the 142 ears. Preoperative mean air conduction threshold was 59.3 dB (17-95 dB) and significantly improved into 35.6 dB (10-85 dB; P < .0004) after surgery. Preoperative air-bone gap was 30.2 dB (5-70 dB) and also significantly improved into 10.2 dB (5-65 dB; P < .0001) after surgery. CONCLUSION In office fat graft myringoplasty, in adult and pediatric patients with variable perforation sizes, is a well-tolerated procedure with very satisfactory clinical results.
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Affiliation(s)
- Alfonso Rodriguez Diaz
- Hospital Naval de San Carlos, Otorhinolaryngology Department Hospital Naval de San Carlos, San Fernando Cadiz, Spain
| | - Carlos O'Connor Reina
- Othorhinolaryngology Department, 170643Hospital Quironsalud Marbella, Marbella, Spain
| | - Guillermo Plaza
- Otorhinolaryngology Department, Hospital Universitario de Fuenlabrada. Universidad Rey Juan Carlos. 207202Hospital Sanitas La Zarzuela. Madrid. Spain
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Michel M, Nahas G, Preciado D. Retained Tympanostomy Tubes: Who, What, When, Why, and How to Treat? EAR, NOSE & THROAT JOURNAL 2020:145561320950490. [PMID: 32865460 DOI: 10.1177/0145561320950490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Tympanostomy tube placement is one of the most common surgical procedures performed across the globe. Controversies exist regarding what to do when a tube is considered to be retained in the tympanic membrane for too long. MATERIALS AND METHODS Review of the PubMed medical literature starting in 1990, focusing on English language studies reporting on the definition, complications, and management of retained tympanostomy tubes. RESULTS The medical literature reporting on outcomes regarding retained tympanostomy tubes is relatively sparse. Most studies recommend prophylactic removal of tubes after a defined period of time, usually around 2 to 3 years after placement. A preferred method of myringoplasty after tympanostomy tube retrieval has not been established, but most studies recommend grafting the perforation at the time of tube removal. CONCLUSIONS Although a consensus as to the optimal management of retained tympanostomy tubes is not yet established in the medical literature, a preponderance of studies recommend prophylactic removal at defined period of time (>2-3 years) before the onset of complications such as otorrhea and granulation tissue formation. Due to a lack of best evidence, the surgeon's preference remains the guiding principle as to the best technique for myringoplasty at the time of removal.
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Affiliation(s)
- Margaret Michel
- Division of Pediatric Otolaryngology, Head and Neck Surgery, 43989Children's National Health System, Washington, DC, USA
| | - Gabriel Nahas
- Division of Pediatric Otolaryngology, Head and Neck Surgery, 43989Children's National Health System, Washington, DC, USA
| | - Diego Preciado
- Division of Pediatric Otolaryngology, Head and Neck Surgery, 43989Children's National Health System, Washington, DC, USA
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Wang N, Isaacson G. Collagen matrix as a replacement for Gelfilm® for post-tympanostomy tube myringoplasty. Int J Pediatr Otorhinolaryngol 2020; 135:110136. [PMID: 32502915 DOI: 10.1016/j.ijporl.2020.110136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/13/2020] [Accepted: 05/21/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Gelfilm® is no longer available for use in myringoplasty. We have substituted a commercially available collagen matrix (Biodesign® Otologic Repair Graft) for Gelfilm® as on onlay patch after removal of retained tympanostomy tubes. We compare the effectiveness of these two materials for post-tympanostomy tube myringoplasty. METHODS Surgeries were performed in the same manner by residents supervised by the same surgeon during consecutive time periods. Tympanostomy tubes were removed under general anesthesia using a pick and cup forceps. Margins of the resultant perforation were rimmed and a patch placed on the lateral surface of the drum to cover the perforation. Children were seen at 4 weeks after surgery. Tympanic membrane closure was assessed by otoscopy and tympanometry. Patient age at time of myringoplasty, laterality (right/left/bilateral), and presence or absence of a persistent perforation at one month follow-up were tabulated. Total duration of tympanic intubation, tube design and material, reason for tube removal, and additional risk factors (trisomy 21, cleft palate, midfacial anomalies) were analyzed. RESULTS 55 children met inclusion criteria. 28 children (36 ears) were patched with Gelfilm®. 27 children (35 ears) were patched with collagen matrix. Median ages at surgery and duration of intubation were similar in the two groups. There were persistent perforations at 4 weeks in 5/28 children (5/36 ears, 14%) with Gelfilm®, and 3/27 children (3/35 ears, 9%) with collagen matrix. There was no significant difference in the rate of persistent perforation between the two materials by Fisher's exact test by patients (p = 0.7049) or by ears (p = 0.7101; OR: 1.72; 95% CI 0.38-7.82). CONCLUSION Gelfilm® and collagen matrix patches performed similarly in the operating room. Rates of tympanic membrane closure were comparable in this pilot study. Larger patient numbers will be needed to prove equivalence or superiority of collagen matrix for this application.
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Affiliation(s)
- Nigel Wang
- From the Departments of Otolaryngology, Head & Neck Surgery and Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Glenn Isaacson
- From the Departments of Otolaryngology, Head & Neck Surgery and Pediatrics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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Isaacson G. Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist. EAR, NOSE & THROAT JOURNAL 2020; 99:8S-14S. [PMID: 32551962 DOI: 10.1177/0145561320929885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Glenn Isaacson
- Departments of Otolaryngology, Head & Neck Surgery and Pediatrics, 12314Lewis Katz, School of Medicine at Temple University, Philadelphia, PA, USA
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Brown C, Behar P. Factors affecting persistent tympanic membrane perforation after tympanostomy tube removal in children. Int J Pediatr Otorhinolaryngol 2020; 130:109779. [PMID: 31786523 DOI: 10.1016/j.ijporl.2019.109779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Clarice Brown
- UTSW Medical Center, Department of Otolaryngology, F6.221, 2350 N. Stemmons Freeway, Dallas, 75207, Texas, USA.
| | - Philomena Behar
- Pediatric ENT Associates, PLLC 3580 Sheridan Drive Ste. 120, Amherst, 14226, NY, USA.
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Can Fat-plug Myringoplasty Be a Good Alternative to Formal Myringoplasty? A Systematic Review and Meta-analysis. Otol Neurotol 2019. [PMID: 29533328 DOI: 10.1097/mao.0000000000001732] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study reviewed available literature to evaluate the success rate of fat myringoplasty compared with methods using other graft materials and suggests proper indications for this procedure. DATA SOURCES Studies reporting the success rate of fat myringoplasty were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases for studies published from database inception to 2017. STUDY SELECTION The following terms were used for the literature search: ("Fat" OR "Adipose") and ("Myringoplasty" OR "Tympanoplasty"). DATA EXTRACTION Eight case series reported the data of perforation size and audiologic results. The success rate varied according to the perforation size with a cutoff value of 3 to 5 mm in length or 30% of the total tympanic membrane area. The success rate in anterior perforation was lower than that in other sites, ranging from 76.7 and 85.2% to 84.5 and 91.7%, respectively. The meta-analysis was performed on 10 articles. The overall success rate in fat myringoplasty and paper patch technique was not significantly different, while the success rate of fat myringoplasty was lower than that for the conventional myringoplasty technique using fascia or perichondrium (OR 0.63, 95% CI 0.49-0.80). Hyaluronic acid showed a significantly higher success rate than fat myringoplasty (90.1% versus 69.9%) (OR 0.20, 95% CI 0.09-0.46). CONCLUSIONS The success rate of fat myringoplasty may be associated with the perforation site and size. The success rate of fat myringoplasty was equivalent to that of the paper patch but inferior to a conventional method using perichondrium or fascia.
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Song JS, Corsten G, Johnson LB. Evaluating short and long term outcomes following pediatric Myringoplasty with Gelfoam graft for tympanic membrane perforation following ventilation tube insertion. J Otolaryngol Head Neck Surg 2019; 48:39. [PMID: 31462319 PMCID: PMC6714377 DOI: 10.1186/s40463-019-0363-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background Myringotomy with ventilation tube (VT) insertion to treat recurrent acute otitis media and chronic secretory otitis media has become one of the most common surgical procedures performed in children. Although contemporary literature has detailed the various patient and perioperative factors that affect successful pediatric myringoplasty, there is still limited evidence surrounding the increasing number of graft material options. In particular, gelfoam patching has arisen as a simple and efficient modality for perforation closure, but has a paucity of evidence particularly in pediatric cohorts. Our study aims to evaluate the clinical and audiometric outcomes following gelfoam myringoplasty for TMP following prolonged VT insertion in an urban pediatric population. Methods A retrospective review of pediatric patients who underwent myringoplasty between 2013 and 2018 following ventilation tube insertion. Patient demographics, comorbidities, and graft material were correlated with audiometric and clinical outcomes on follow up examination. Results One hundred twenty patients underwent myringoplasty, with 61 (50.8%) males with a mean age of 8.9 years old. 101 (84.2%) of patients eventually underwent successful tympanic membrane (TM) closure, with 93 (77.5%) demonstrating closure at initial follow up. In the gelfoam cohort, 77 (90.6%) of patients demonstrated successful TM closure at initial follow up. Overall mean time to closure was 5.6 (standard error (SE) 0.9) months. A multivariate Cox proportional hazards model demonstrated none of the covariates including graft material significantly affected TM closure. Mean change in air conduction threshold were comparable between graft materials. Conclusions Pediatric myringoplasty with gelfoam graft material is a safe and viable alternative with favorable short and long term clinical and audiometric outcomes.
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Affiliation(s)
- Jin Soo Song
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Dalhousie Medical School, Dalhousie University, 5850 College St, Halifax, Nova Scotia, B3H 1X5, Canada.
| | - Gerard Corsten
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Dalhousie Medical School, Dalhousie University, 5850 College St, Halifax, Nova Scotia, B3H 1X5, Canada
| | - Liane B Johnson
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Dalhousie Medical School, Dalhousie University, 5850 College St, Halifax, Nova Scotia, B3H 1X5, Canada
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Baik G, Brietzke S. How Much Does the Type of Tympanostomy Tube Matter? A Utility-Based Markov Decision Analysis. Otolaryngol Head Neck Surg 2015; 152:1000-6. [DOI: 10.1177/0194599814566594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/11/2014] [Indexed: 11/15/2022]
Abstract
Objectives To use a utility-based Markov decision analysis model to compare outcomes of short-term grommet tympanostomy tubes (TTs), intermediate-type tubes, and permanent T-Tubes and to use a detailed sensitivity analysis to determine the most important factors influencing outcomes with one type of TT versus another. Study Design Markov decision analysis. Setting Hypothetical cohort. Subjects and Methods A Markov cohort decision analysis model was created using computer software (TreeAge Software, Inc, Williamstown, Massachusetts) comparing the 3 types of TT. Published data were used to determine key baseline model parameters. The model featured potential complications including eardrum perforation, early TT extrusion/blockage, and the need for possible repeat TT placement after extrusion. Outcomes were quantified using a 0.95 (1 procedure, full recovery) to 0.6 (failed myringoplasty) utility scale. Utility values were discounted over time to incorporate real-life inconvenience. Results The intermediate TT accumulated superior total utility in 2-, 4-, and 6-year models (2.48, 3.96, and 5.27 total utility) compared with grommets (2.32, 3.82, 5.18) and T-Tubes (2.42, 3.86, 5.18). Examining a hypothetically otherwise healthy 3000-child cohort, T-Tubes resulted in an increased overall persistent perforation rate (7.9% vs 0.2%, P < .001, χ2). Sensitivity analysis indicated that the rate of repeat TT placement, the utility assigned to having a functional tube in place, and the inconvenience utility discount factor over time were the driving factors of the model. Conclusion The intermediate TT may produce optimal outcomes as it combines a balance of a lower perforation rate than T-Tubes and a longer period of ventilation than grommet tubes.
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Affiliation(s)
- Grace Baik
- Uniformed Services of the University Health Sciences, Bethesda, Maryland, USA
| | - Scott Brietzke
- Uniformed Services of the University Health Sciences, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Comparison of temporal muscle fascia and cartilage grafts in pediatric tympanoplasties. Am J Otolaryngol 2014; 35:796-9. [PMID: 25115537 DOI: 10.1016/j.amjoto.2014.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 07/15/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare anatomic and functional outcomes of the different graft materials used in pediatric tympanoplasty. MATERIALS AND METHODS The patients younger than 18 years of age and who had tympanoplasty between 2010 and 2012 were included in the study. Temporal muscle fascia or cartilage was used as the graft material. The age, gender, the side of the operated ear, the operation technique, pre- and postoperative audiological results, and the status of the graft were noted. An intact graft and an air-bone gap (ABG) ≤ 20 were regarded as surgical success in the postoperative period. Audiograms obtained before surgery and 1 year after surgery were used for the comparison. RESULTS Sixty pediatric cases were included in the study. Fascia graft was used as the graft material in 35 of them, and cartilage was used in 25 patients. The graft success rate was 82.9% in the fascia group while it was 92% in the cartilage group. In the fascia group preoperative ABG was 28.2 ± 10.1 dB, postoperative ABG was 15.1 ± 10.2dB, and postoperative gain was 13.1 ± 9.6 dB. In the cartilage group, preoperative ABG was 28.9 ± 10.2dB, and postoperative ABG was 16.8 ± 10.3 dB with a postoperative gain of 12.1 ± 6.8 dB. The differences between the fascia and the cartilage groups were not statistically significant either for hearing gain or graft success rate. CONCLUSION Cartilage and fascia grafts yield similar results for hearing gain and graft success rate in pediatric tympanoplasty.
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Kwong KM, Smith MM, Coticchia JM. Fat graft myringoplasty using umbilical fat. Int J Pediatr Otorhinolaryngol 2012; 76:1098-101. [PMID: 22560767 DOI: 10.1016/j.ijporl.2012.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/03/2012] [Accepted: 04/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Myringoplasty is a common procedure performed by otolaryngologists, particularly in the pediatric population. Tympanic membrane (TM) perforations can be caused by a variety of factors including retained tympanostomy tubes, infection and trauma. First described in 1878, myringoplasty has evolved to include many different materials for repair. Current materials used for myringoplasties include fascia, perichondrium, gelfoam, fat and paper. Multiple studies have looked at the success rates for these different materials. Fat graft myringoplasties in particular offer the advantage of a high success rate commonly reported in the range between 80% and 90%. Fat graft is classically harvested from ear lobe or post-auricular subcutaneous tissue. PURPOSE In this study, we described the techniques and results of harvesting umbilical fat for the use in pediatric myringoplasty. METHOD Twenty-eight cases of umbilical fat-graft myringoplasty performed between June 2008 and January 2011 was retrospectively reviewed and studied for rate of successful TM closure. RESULTS Average length of follow up was 8 months ranging from 3 months to 26 months. Overall rate for successful TM closure of 100% was achieved. Literature review was performed to compare our results with those of studies using auricular fat graft. Furthermore, a review of existing literature on various properties of fat graft was done to explain the potential advantages of using umbilical fat for myringoplasty. CONCLUSION Fat patch myringoplasty using umbilical fat is a safe and successful procedure for TM repair.
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Affiliation(s)
- Kelvin M Kwong
- Department of Otolaryngology-Head & Neck Surgery, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Silverstein H, Wycherly BJ, Darley DS, Alameda YA. Mixed Hearing Loss in Iatrogenic Tympanic Membrane Perforations over the Round Window Niche and the Immediate Effect of Paper Patch Myringoplasty. ACTA ACUST UNITED AC 2012; 17:155-60. [DOI: 10.1159/000333792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 09/15/2011] [Indexed: 11/19/2022]
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[CO2-laser-assisted de-epithelialization of perforation margins of persistent tympanic membrane perforations. An alternative to conventional surgical procedures]. HNO 2009; 57:1185-92. [PMID: 19763523 DOI: 10.1007/s00106-009-1963-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The standard treatment of persistent eardrum perforation is conventional surgical closure using myringoplasty or a tympanoplasty type I. In this study the valence of a modified, CO(2)-laser-assisted de-epithelialization of perforation margins was investigated. MATERIAL AND METHODS A total of 44 patients with mesotympanal eardrum perforation (diameter 1-5 mm) were included in a partially retrospective and partially prospective study. The genesis of the eardrum perforations was partially traumatic or the eardrum did not heal after spontaneous perforation caused by an acute otitis media or after surgery. The procedure was performed under topical anaesthesia. Focussed, adjacent, single CO(2) laser pulses (1 watt, 0.05 s) were applied with the laser otoscope Otoscan (Lumenis, Yokneam, Israel) along the edge of the perforation until complete de-epithelialization. This was done to stimulate growth. Closure of eardrum perforation was monitored using an ear microscope and if this treatment was not successful after three attempts conventional surgical therapy was suggested. RESULTS Complete eardrum closure occurred in 27 cases (61%), 17 patients (39%) had a residual perforation, of which 9 experienced a significant reduction of the perforation. There were no complications during and after the treatment. CONCLUSION A closure rate of at least 61% (27/44) can be expected with a CO(2)-laser-assisted de-epithelialization of the perforation margins. This procedure can be performed under topical anaesthesia and is an economic, painless and facile alternative to conventional surgical treatment.
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Sarkar S, Roychoudhury A, Roychaudhuri BK. Tympanoplasty in children. Eur Arch Otorhinolaryngol 2009; 266:627-33. [DOI: 10.1007/s00405-008-0908-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 12/24/2008] [Indexed: 05/25/2023]
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Abstract
OBJECTIVE To evaluate the impact of patient and graft variables on the successful closure of tympanic membrane perforations treated with myringoplasty at the Children's Hospital of Pittsburgh from 2000 to 2005. STUDY DESIGN Retrospective chart review at an academic tertiary-care children's hospital. METHODS Charts were reviewed for 604 children, ages 1 to 18 years old, with complete records who underwent myringoplasty by the pediatric otolaryngology practice at Children's Hospital of Pittsburgh of UPMC from 2000 to 2005, totaling 777 procedures. RESULTS Significant variables include patient age, number of prior tubes, perforation etiology (P < .000), presence of a retained tube (P < .000) as well as tube type (P = .016), graft material (P = .001), and history of Down syndrome (P = .035). Nonsignificant variables include season of procedure (P = .599), status of adenoid tissue (P = .910), prior otorrhea (P = .175), as well as perforation location (P = .318) and duration (P = .150). CONCLUSIONS Proper patient and graft material selection can affect the outcome of myringoplasty procedures. Practical implications from these data suggest that Gelfoam myringoplasty is more successful than either paper patch or fat graft closures, with a 90.8% success rate (P = .001). Myringoplasty should not be deferred during the winter months as the season of procedure does appear to not affect the success of closure (P = .60). Similarly, the presence or absence of adenoid tissue did not affect the success of closure (P = .91).
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Abstract
OBJECTIVES/HYPOTHESIS It has been assumed that prolonged retention of tympanostomy tubes was random, with an incidence of 4% to 12% per tube. We have noticed patterns of tube retention that suggested a genetic predilection. We undertook this study to validate or disprove this impression. Such information may shed light on the physiology of tube extrusion and may help better define the risks of tympanostomy tube placement. STUDY DESIGN Retrospective, single-surgeon, statistical analysis. METHODS A computerized database of approximately 10,000 pediatric otolaryngology patients was queried. We identified all children treated by the senior author during a 6-year period who underwent tube removal for failed extrusion 24 or more months after placement. Siblings with retained tubes and individuals requiring bilateral tube removal were further analyzed: 1) using the law of multiplication of independent factors, the chance of retaining tubes in both ears of an individual was compared with the observed rate of bilateral retention by calculating the difference in Poisson rates; 2) the rate of siblings who retained one or both tubes was compared with nonsiblings who retained one or both tubes using the Z test for independent proportions. RESULTS The observed rate of bilateral retention (228/6,000 = 0.038) far exceeded the theoretical rate (0.068 = 0.0046; P < .001). Siblings were more likely to retain tubes than nonsiblings (difference = 0.042; P = .085). This difference was more pronounced in unilateral (difference = 0.048; P = .014) than in bilateral retention (difference = 0.005; P = .856). CONCLUSIONS Tympanostomy tube retention is not a random occurrence. Patterns of nonextrusion in individuals and siblings suggest a genetic mechanism. Implications for patient counseling and research are discussed.
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Yum JH, Park YS, Jeon EJ, Kim DH, Jung MK, Lee DH. Factors affecting the persistence of tympanic membrane perforation developed with the extubation of ventilation tube. Int J Pediatr Otorhinolaryngol 2008; 72:49-55. [PMID: 18045701 DOI: 10.1016/j.ijporl.2007.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 09/14/2007] [Accepted: 09/14/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine which factors are associated with persistence of the tympanic membrane (TM) perforation detected after a spontaneous extrusion or surgical removal of a ventilation tube (VT). METHODS We conducted a retrospective chart review of all patients who underwent ventilation tube insertion from 1995 to 2003 at our institution. We identified 909 ears in which we could see the final state of TM and found 89 ears that fitted the inclusion/exclusion criteria. Various factors were analyzed to determine the factors associated with persistence of a TM perforation after VT extrusion or removal in 89 ears, including age at the time of tube extrusion or removal, sex, extubation pattern, intubation period, reason for VT insertion, history of previous VT insertions, condition of the TM when a perforation was detected, and previous adenoidectomy. RESULTS Three factors were found to be statistically significant predictors of permanent perforation including age, extubation pattern and intubation period on univariate analysis. However, on multivariate analysis, extubation pattern, intubation period remained as statistically significant predictors. CONCLUSIONS Our data shows that factors affecting the permanent TM perforation after the spontaneous extrusion or surgical removal of VT include extubation pattern and intubation period.
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Affiliation(s)
- Jin-Ho Yum
- Department of Otolaryngology-Head and Neck Surgery, Our Lady of Mercy Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
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