A systematic review of concomitant interventions to prevent persistent perforations following the removal of long-term ventilation tubes

Clinical Factors Associated With the Outcomes of Long-Term Middle Ear Ventilation Tube Insertion in Pediatric Patients

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.

A Systematic Review and Meta-Analysis: Timing of Elective Removal of Tympanostomy Tubes

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.

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.