Timing of tympanoplasty in children with chronic otitis media with effusion

Task force Guideline of Brazilian Society of Otology - hearing loss in children - Part II - Treatment

OBJECTIVES

To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0-18 years.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) treatment of sensorineural hearing loss: individual hearing aids, bilateral cochlear implants, cochlear implants in young children, unilateral hearing loss, and auditory neuropathy spectrum disorder; and (2) treatment of conductive/mixed hearing loss: external/middle ear malformations, ventilation tube insertion, and tympanoplasty in children.

CONCLUSIONS

In children with hearing loss, in addition to speech therapy, Hearing AIDS (HAs) or implantable systems may be indicated. Even in children with profound hearing loss, both the use of HAs and behavioral assessments while using the device are important.

Hydrodissection technique with t-tube placement in atelectatic ear

Hydrodissection technique is a safe way to establish a fully functional tympanic membrane in cases of early stages of atelectatic ears.

Comparison of adenoid size in lateral radiographic, pathologic, and endoscopic measurements

Background

Otitis media (OM) is a major health problem that usually results from adenoid hypertrophy. Diagnosis is based on symptoms like mouth breathing and imaging studies like lateral neck radiography (LNR). Adenoid-nasopharyngeal ratio (A/N ratio) is one of the most important and most widely used criteria in LNR study that could estimate the real size of adenoid gland measurements. However, there are huge controversies regarding LNR rules in the management of patients with OM.

Objective

This study aimed to determine Adenoid Nasopharyngeal Ratio (A/N ratio) in children with otitis media with effusion (OME) and its relation with different factors.

Methods

This was a cross-sectional study on OME suspected children who needed adenoidectomy. The study was conducted from the fall to winter of 2016 on patients referred to ENT clinics of Mashhad University of Medical Sciences. Before surgery, all children underwent standard LNRs and indirect laryngoscopy to assess adenoidal size, and nasopharyngeal length, and A/N ratio. After adenoidectomy, pathologic analysis was performed for assessment of pathologic size. SPSS 21 was used for data analyzing using Pearson’s correlation, independent t test and Mann-Whitney U test (p<0.05 was considered significant).

Results

A total of 27 children were enrolled. Most of the patients were male (70.4%, mean age=7.81±2.52 year). All patients in the study were symptomatic and the most frequent symptom was mouth breathing (100%). The mean A/N ratio, pathologic adenoid size, and laryngoscopic adenoid size were 0.825±0.099, 18.22±5.97, and 5.33±19.15 mm. There was a significant correlation between the A/N ratio laryngoscopic adenoid size (r=+0.46, p=0.01) and pathologic adenoid size (r=+0.44, p=0.02).

Conclusions

The results of this study showed that A/N ratio can be used to estimate the actual size of the adenoid gland and the necessity of adenoidectomy. Considering the reasonable costs and availability of this diagnostic method, researchers recommend using this procedure in assessment of patients with OME.

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.

Outcomes of tympanoplasty in children with down syndrome

INTRODUCTION

The prevalence of chronic otitis media with effusion (COME), and Eustachian tube dysfunction (ETD) is high in Down syndrome (DS) patients. This often necessitates multiple tympanostomy tube (TT) placements resulting in a higher rate of persistent tympanic membrane (TM) perforation requiring tympanoplasty for repair.

OBJECTIVES

To assess risk factors for persistent perforation and outcomes of tympanoplasty in DS patients.

METHODS

Retrospective case series of 91 ears in 69 DS patients with TM perforations, who were either observed or underwent tympanoplasty. Clinical features, surgical outcomes, and hearing outcomes were assessed.

RESULTS

91 ears were evaluated. Sixty perforations were observed, and 31 perforations were repaired. The closure rate was 54.8% for primary surgery, and 70.9% after secondary surgical interventions in the Tympanoplasty Group, compared to 33.0% spontaneous closure rate in the Observation Group (p < 0.001). The only risk factor for failed tympanoplasty repair was persistent COME/ETD (OR 27.2, p = 0.001). In the Observation Group perforations diagnosed at an older age, with >3 TT insertions, and with persistent COME/ETD were less likely to close spontaneously. Patients undergoing tympanoplasty had worse preoperative pure tone averages than those being observed, but significant improvement in air-bone gaps were noted in the Tympanoplasty Group (p = 0.02) post-operatively. Patients were often rehabilitated with hearing aids regardless of intervention (53.3% Observation Group, 48.4% Tympanoplasty Group).

CONCLUSIONS

Persistent TM perforation in children with Down syndrome was associated with a history of COME/ETD, and multiple prior TT insertions. Tympanoplasty was successful for repair in most patients who underwent surgical intervention, but residual hearing loss was common.

Retrospective analysis of tympanoplasty in children with cleft palate: a 24-year experience. II. Cholesteatomatous cases

BACKGROUND

Contradictory experience has been published on the outcomes of ear surgery in patients with cleft palate.

OBJECTIVES

The authors of this study investigated whether there were differences in the short- and long-term outcomes of tympanoplasty performed due to cholesteatoma in children with or without cleft palate.

SETTING

Tertiary care medical centre.

METHODS

The authors retrospectively analyzed the first author's 24-year experience of paediatric tympanoplasty using the software programme developed by the fourth author. The outcomes of 268 tympanoplasties on 172 ears with cholesteatoma in 151 'NoCleft' patients were compared to the outcomes of 35 tympanoplasties on 20 ears of 19 'Cleft' patients. The average age of the patients was 10.7±3.6 years and 9.5±2.7 years respectively. The average follow-up time was 4 and 4.1 years.

RESULTS

Preoperative PTA-ABGs (31.22/34.88 dB; p=0.058), best postoperative PTA-ABGs (17.04/16.4 dB; p=0.499), last postoperative PTA-ABGs (19.93/20.98 dB; p=0.298), the final hearing improvement (11.29/13.9 dB; p=0.193) and postoperative PTA-ABG deterioration with time (2.89/4.58 dB; p=0.117) were statistically compared between the 'NoCleft' and 'Cleft' groups. The same parameters were analyzed separately in the case of tympanoplasty performed with intact ossicular chain and the different type of columella ossiculoplasty. No significant differences were found between the two groups in any of these parameters. However, significant difference was found in the necessity for grommet insertion (8-fold difference, p≈0), and conversion to open techniques (p≈0).

CONCLUSIONS

The authors conclude that the achievable audiological outcomes of tympanoplasty in children with cleft palate and cholesteatoma do not differ significantly from those of the general child population. However, this more frequently requires ventilation tube insertion and more frequent follow-up visits. The latter is ensured by patient care within the frameworks of the 'Cleft Palate Team'. We have to accept that in some cases Eustachian tube dysfunction caused by the underlying disease (cleft palate) 'takes over' and we have to resort to open techniques.

Management of acquired cholesteatoma in the pediatric population

PURPOSE OF REVIEW

This review focuses on the most recent literature pertaining to pediatric acquired cholesteatoma and aims to integrate findings into a comprehensive management approach.

RECENT FINDINGS

Pediatric acquired cholesteatoma has been shown to differ from the adult variety secondary to anatomy and physiologic factors. Whereas the goals of therapeutic management are ultimately similar in adult and pediatric patients, special considerations must be taken into account when deciding on a treatment plan for a child. Although avoidance of an unstable mastoid cavity is an important consideration in this population, successful management has been reported with canal wall-up, canal wall-down, and hybrid techniques. Second-look procedures are also important when concern of recurrence exists. Newer innovations include endoscopic ear surgery and diffusion-weighted imaging.

SUMMARY

The principal goal of pediatric cholesteatoma management is eradication of disease. An individualized approach is paramount in yielding superior results in these patients. Special consideration should be given to anatomical and social factors.

Retrospective analysis of tympanoplasty in children with cleft palate: a 22-year experience: I. Mesotympanic (non-cholesteatomatous) cases

BACKGROUND

Contradictory data have been published on the outcomes of ear surgeries in cleft patients.

OBJECTIVES

To investigate whether there are differences in the short and long term outcomes of tympanoplasty performed due to childhood chronic mesotympanic otitis media in patients without and with cleft palate.

SETTING

Tertiary care pediatric medical centre.

METHODS

The authors retrospectively analysed the first author's data on pediatric tympanoplasties of the past 22 years with the help of a computer programme developed by the third author. The outcomes of 159 'NoCleft' tympanoplasties (119 patients, 144 ears) were compared to the outcomes of 31 'Cleft' tympanoplasties (21 patients, 27 ears) with the average age of the patients being 10.8 and 10.7 years accordingly.

RESULTS

The preoperative ABG (28.76/28.94dB, p = 0.468), the best postoperative ABG (12.78/10.04dB, p = 0.096), the last postoperative ABG (15.59/13.19dB, p = 0.192), the final hearing gain (13.17/15.75dB, p = 0.253) and the postoperative ABG deterioration associated with time (2.81/3.15dB, p = 0.376) were statistically compared in the 'NoCleft'/'Cleft' groups. No significant difference was found between the outcomes of the two groups. The same parameters were examined separately after tympanoplasties performed with intact ossicular chain and after those requiring columella ossiculoplasty. The 'Cleft' group did not have worse outcomes in this respect, either. The average follow-up period of the patients was more than 3 years in both groups. The graft take rate was 100%, reperforation occurred in 3.5% of the cases in both groups. In their study, grommet insertion was more likely to be necessary in the 'Cleft' group.

CONCLUSION

The authors concluded that there was no significant difference between the expectable outcomes of pediatric tympanoplasties in patients with and without cleft palate regarding mesotympanic cases; therefore, the indications for tympanoplasty are the same in the two groups. They outline the importance of the therapeutic management of cleft patients in the frameworks of a "Cleft Palate Team" and the necessity for their lifelong otorhinolaryngological care due to their vulnerable Eustachian tube function. They are planning to publish the same comparative analysis of their patients with cholesteatoma in a following study.

Chronic otitis media in children: an evidence-based guide for diagnosis and management

AIM

To provide an easy-to-follow evidence-based diagnostic and therapeutic algorithm for the management of chronic otitis media (COM) in children.

MATERIALS/METHODS

Literature review and critical analysis of the available evidence in Medline and other scientific database sources.

DATA SYNTHESIS

Otorrhea and hearing loss are the cardinal symptoms of COM, while oto-microscopy and imaging techniques can confirm the diagnosis. Conservative treatment is acceptable to some extent (i.e. mild cases of COM without cholesteatoma). It involves topical drops (quinolones as first choice drugs- strength of recommendation B), as well as performing aural toilet (strength of recommendation B), and avoiding water ingress. Tympanoplasty without mastoidectomy is expected to improve hearing in cases of non-cholesteatomatous COM (strength of recommendation C), and positively affect the children's quality of life (strength of recommendation B). Less experienced surgeons and inflamed, wet middle ear mucosa represent the two most important factors, which could lead to reperforations (strength of recommendation C). The surgical management of COM with cholesteatoma tends to employ the least invasive surgical technique, in order to obtain a small self-cleaning mastoid cavity, as well as good hearing results (strength of recommendation C).

CONCLUSION

The treatment of choice in most cases of pediatric COM is surgery. Figure 1 proposes a detailed and easy-to-follow evidence-based algorithm with regard to the diagnosis and management of COM in children.

Otitis media with effusion in children with cleft lip and palate: a narrative review

OBJECTIVE

Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP.

METHODS

All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles.

RESULTS

Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference.

CONCLUSIONS

The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.

Outcomes of cartilage tympanoplasty in the pediatric population

OBJECTIVE

To justify the successful use of a patient selection algorithm based on age for primary cartilage tympanoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

We performed a retrospective chart review of patients between ages 4 and 13 years who underwent cartilage tympanoplasty for tympanic membrane perforations from August 2005 to November 2011. Demographics, complication data, and auditory outcomes were collected.

RESULTS

Patients were subdivided into 3 age groups. Group 1 consisted of patients younger than 7 years (n = 43); group 2, ages 7 to 10 years (n = 40); and group 3, ages 10 to 13 years (n = 36). Mean follow-up was 595 days (range, 48-1742). Complication rates respective to the 3 groups were as follows: remnant perforation (6.97%, 5.00%, 2.78%), revision tympanoplasty (2.33%, 2.50%, 0%), and need for tympanostomy tubes (4.65%, 2.50%, 0%). Logistic regression models were used to evaluate complication rates between groups. No significant differences were found (remnant perforation, P = .710; repeat tympanoplasty, P = .998; tympanostomy tubes, P = .875). No significance was found among audiological outcomes between the 3 groups.

CONCLUSION

These data suggest cartilage tympanoplasty can be performed effectively in young children when appropriate conditions exist.

Ten top considerations in pediatric tympanoplasty

Tympanoplasty in children poses some different challenges from the same procedure in adults. The aim of the current article is to review 10 important considerations in pediatric tympanoplasty that focus on these differences and help to optimize the chance of successful outcome.

Myringoplasty in children with cleft palate and craniofacial anomaly

OBJECTIVES

Analyze the anatomical and audiological success rates of myringoplasty in children with craniofacial anomaly, cleft palate and compare them to a control group.

METHODS

Retrospective review of medical records for all children who underwent myringoplasty between 1997 and 2007. The following data was recorded: sex, age, perforation side, size, location and etiology, surgical approach, type of myringoplasty, graft material, season of surgery, preoperative status of the operated and contralateral ear, history of previous otologic surgery, and adenoidectomy or tonsillectomy.

RESULTS

Myringoplasty outcomes of 22 craniofacial anomaly patients (15/22 were cleft palate patients) were compared to 144 controls. Children in the craniofacial anomaly group demonstrated a tendency towards surgery at an older age. Children in the craniofacial anomaly and cleft palate groups had a significant positive history of previous otologic procedures to both operated and contralateral ears. Peroperative subannular ventilation T-tubes were more frequently recorded in patients with craniofacial anomaly than patients in the control group. The craniofacial anomaly, cleft palate and control group had comparable mean preoperative and postoperative ABG and their ABG improvement was statistically significant. Children with craniofacial anomaly, cleft palate and control group shared similar anatomical and audiological success rates (ABG<20 dB) at 6, 12 and 24 months.

CONCLUSIONS

Although children in the craniofacial anomaly and cleft palate groups are predisposed to middle ear disease, their disease responds well to surgical intervention. Their audiological and anatomical success rates were equivalent to the ones observed in the control group. In light of our results, we recommend that myringoplasty in children with craniofacial anomaly and cleft palate be performed after the age of 12.