Effectiveness of adenoidectomy and laser tympanic membrane fenestration

Flexible integration of laser myringotomy and ventilation tube for bilateral Otitis media with effusion: analysis of laser tympanostomy versus ventilation tube

BACKGROUND

The aim of this study was to evaluate the efficacy of laser myringotomy (LM) compared to ventilation tube (VT), and to assess the clinical success criteria of LM-assisted VT insertion as the flexible alternatives avoiding GA for the treatment of bilateral consistent otitis media with effusion (OME).

METHODS AND FINDINGS

LM under topical anesthesia was followed by VT insertion in cooperative children using Acuspot® 712 CO2 laser micromanipulator attached microscope. Sixty children failed VT and bilateral laser tympanostomy was done (group LL), and 130 children tolerated VT on one side but LM on the other side (group LV). The efficacy of LM was compared to VT regarding recurrent effusion and reoperation as the outcome measure; firstly, by ear-to-ear matched pair analysis in LV, and secondly between LL vs. LV. Long-term outcome was compared to control group who received both VT under GA (group GAVT) regarding the outcome of additional VT and GA.

RESULTS

The effectiveness of LM per ear was equivocal as 46.9% and 40.8% in LV and LL respectively; but the effectiveness per children was further lower in LL as 28.3%, which was a limitation of LM for bilateral OME. LL required reoperation in 71.7% mostly requiring impending GA in 51.7% within 4.7 months, thus was a controversial treatment. But LV required GA in 20.8% during the 27.2 months long-term follow-up, which was second set of VT and adenoidectomy that were also comparably required in GAVT control with multiple GA.

CONCLUSION

Standard GAVT was more recommended for bilateral OME than bilateral LM (LL) in our practice. But LM was selectively effective for some children, that combined approach with LM plus VT provided comparable period to outgrow OME as effectively as GAVT, when LM was supplemented with one VT side with recovered hearing.

Mitomycin C-associated radiofrequency microelectrocautery used in myringotomy in an animal model

This study aimed at describing an alternative surgical technique to the insertion of a ventilation tube in the tympanic membrane: myringotomy by radiofrequency alone and associated with mitomycin C.

AIM

to show a surgical approach that can be simple to execute, not subject to complications arising from the ventilation tube.

MATERIALS AND METHODS

we compared myringotomy by microknife and by radiofrequency microcautery (0.3 mm and 0.7 mm tips) alone and associated with mitomycin C, considering the time of tympanic closure in Wistar rats. Experimental study.

RESULTS

there was a statistically significant difference between radiofrequency myringotomy and knife myringotomy. As we analyze the radiofrequency approach with the 0.7 mm tip associated with mitomycin C (Wilcoxon test), the p value found was lower than 0.001, showing a statistical significance. The maximum tympanic membrane closure time was 44 days and the median found was 14 days.

CONCLUSION

the radiofrequency myringotomy (with the larger diameter tip) associated with mitomycin C enhances the tympanic membrane healing time.

Structural and Functional Properties of the Healed Tympanic Membrane

HYPOTHESIS

The short-term healing scar that forms after experimental laser myringotomy will revert to a normal lamina propria in the long run. The mechanical stiffness will stay normal.

BACKGROUND

Recent studies have shown severe structural changes in the fibrous layer in the early course after experimental laser myringotomy, whereas the scar quickly restored the strength of the tympanic membrane (TM). A reorganization of the fiber layer is expected to occur.

METHODS

Potassium titanyl phosphate laser myringotomy was made on one side of the TM in Sprague-Dawley rats. The ear of the other side was untouched and used for control. After half a year of observation, the stiffness and strength of the healed TMs were measured with moiré interferometry and examined with otomicroscopy and light and electron microscopy.

RESULTS

The interferometry readings showed a slightly reduced strength in the myringotomized and healed TMs. After half a year, still there were immense structural changes including increased thickness over a wide area of the pars tensa with increased amounts of fibers. An obvious reorganization of the fiber layer was lacking.

CONCLUSION

Laser myringotomy causes profound, long-standing, or permanent structural changes in the lamina propria of the pars tensa, whereas the strength of the TM may become slightly reduced.

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.

Laser myringotomy versus ventilation tubes in children with otitis media with effusion: a randomized trial

OBJECTIVES

Insertion of ventilation tubes in children with otitis media with effusion (OME) is an accepted and common treatment procedure. The majority of patients require general anesthesia. Although laser myringotomy can be performed in local anesthesia, evidence is lacking that this treatment modality is an alternative for tubes, and outcome predictors for laser myringotomy are not available.

STUDY DESIGN

Prospective randomized trial.

METHODS

We screened 1,403 children with chronic OME that were indicated for placement of ventilation tubes. In the eligible patients, we performed laser myringotomy in one ear and placed a tube in the other ear, both within the same patient. Follow-up was scheduled each month for 6 months. Success was defined as absence of effusion or aural discharge. A logistic regression model was used with success of the therapy as binary outcome. This model was based on base-line variables, asked for in a parent's questionnaire.

RESULTS

Two hundred eight children received the allocated intervention, and no complications occurred. The mean closure time of the laser perforation was 2.4 weeks, and the mean patency time of the ventilation tube was 4.0 months. The mean success rate was 40% for laser and 78% for tubes. Ten known variables were found to predict middle ear status after therapy.

CONCLUSION

Laser myringotomy is a safe but less-effective procedure than insertion of a ventilation tube in the treatment of chronic OME. The prognostic model enables the otolaryngologist to choose the surgical treatment for the child that benefits most: laser myringotomy or ventilation tube.

The effects of incisional myringotomy and CO2 laser myringotomy on rat tympanic membranes

OBJECTIVE

The purpose of this study was to compare closure rates and histopathological findings of carbon dioxide (CO(2)) laser myringotomies to those of incisional myringotomy.

STUDY DESIGN

We performed CO(2) laser round myringotomy on left ears and incisional round myringotomy on the right ears of 34 rats on the same day. The incisions were 2mm in size on both ears. Examination was made with otoendoscope on days 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 25, 30, 35, 40, 45, 50 with videorecording. Two rats were sacrificed every 2 days for 25 days and every 5 days thereafter, randomly. The tympanic membranes (TM) were excised and hyalinization, fibrosis and inflammation were assessed with light microscope.

RESULTS

Most of the CO(2) laser myringotomies healed after day 15, and all of them healed by day 50. Three of the incisional myringotomy perforations were closed at day 3, and the rest by day 15. Patency of CO(2) laser myringotomies was significantly longer than that of incisional myringotomies. Hyalinization, fibrosis and inflammation of the incisional myringotomy group were significantly less than those of the laser myringotomy group.

CONCLUSIONS

CO(2) laser myringotomies remain patent for a longer period of time than the incisional procedure, however, they cause more tissue inflammation. We believe that CO(2) laser myringotomy is an effective method, however, additional studies are needed to identify its complications.

Laser myringotomy in otitis media with effusion: long-term follow-up

Otitis media with effusion is a leading cause of conductive hearing loss in children. Myringotomy and insertion of tympanostomy tubes is the accepted form of treatment. Recently, several studies utilizing laser myringotomy have been published, but few of them present late results. The objective of this study was to compare late results of the treatment with laser and classical myringotomy. A clinical effectiveness trial was conducted in three groups of children: (1) 37 children treated with laser myringotomy (ML), (2) 29 children treated with laser myringotomy and the insertion of tympanostomy tubes (ML+V) and (3) 43 children treated with classical myringotomy and the insertion of tympanostomy tubes (MC+V). All types of surgery were performed under general anesthesia because adenoidectomy and/or tonsillectomy was done at the same time. The results of treatment were assessed on the basis of the otoscopic examination (recurrences of effusion, condition of the tympanic membrane, and audiological examination (pure-tone audiometry, tympanometry and DPOAE). The minimum follow-up period was 1 year. The recurrence rate was lowest in the ML+V (11%) group, and highest in the ML group (36%). The difference between ML+V and MC+V was not significant. Permanent changes in the tympanic membrane were observed in 8% of the ears after ML, 19% after ML+V and 31% after MC+V. The difference was significant between the ML and MC+V groups. PTA was significantly higher in the MC+V group than in the control group of otologically healthy children. Mean amplitudes of DPOAE, measured in treated children with normal tympanometry results, were significantly lower than in the control group, but within the normal range. The use of CO(2) laser during myringotomy has no negative effect on the function of the cochlea. Healing of the tympanic membrane after laser myringotomy was uneventful with a low percentage of permanent sequelae.