Effects of large-bore middle ear ventilation tubes

Preventive therapy for postoperative purulent otorrhea after ventilation tube insertion

OBJECTIVE

Treatment modalities which are intraoperative irrigation of the middle ear with isotonic saline, postoperative oral antibiotic treatment, and postoperative topical antibiotic use have been compared with each other and with control group regarding their efficiency in preventing postoperative purulent otorrhea after ventilation tube insertion. Moreover, the costs of the treatment modalities were analyzed.

STUDY DESIGN

Each group consisted of 70 patients, and a total of 280 patients were followed up for purulent otorrhea 2 weeks after the surgery. The study was a single-blind randomized clinical trial.

RESULTS

Ten (14.28%) patients in the oral antibiotic group, 11 (15.71%) patients in the isotonic saline irrigation group, 6 (8.57%) patients in the topical antibiotic drops group, and 21 (30%) patients in the control group had postoperative purulent otorrhea. Statistical analysis determined a significant difference between each treatment modalities and control group but did not show any significant difference between the treatment groups. When the treatment options were compared according to their cost, however, the cost per successfully treated patient was significantly lower in the saline irrigation group.

CONCLUSION

Intraoperative saline irrigation of the middle ear provides an effective, easy, and cheap treatment in preventing postoperative purulent otorrhea.

Synchronous fat plug myringoplasty and tympanostomy tube removal in the management of refractory otorrhoea in younger patients

OBJECTIVE

Tympanostomy tubes are associated with many complications, the most common being recurrent otorrhoea, in many cases resistant to medical treatment. With the associated vestibulo-cochlear toxicity of many topical antibiotics, their use is dose limited. Removal of the tympanostomy tube has been shown to cure the otorrhoea, however, it is associated with a high persistent perforation rate of 10-28%. A synchronous fat plug myringoplasty was performed with tube removal in an attempt to reduce the residual perforation rate.

METHODS

A retrospective study of 13 consecutive children, nine male and four female, mean age 9.1 years (median=9, range 2-15), with a total of 15 ears (left=6, right=9) had either Shah Tubes (n=5), Shepard Tubes (n=1) or Shah Long Term Tubes (n=9) in-situ for middle ear effusions. The tubes were removed for recurrent otorrhoea. The tubes had been in-situ for a mean of 38.8 months (median=31, range 9-84 months). All ears had recurrent infections, with a variable response to topical antibiotics. All were under the care of one specialist, who performed all the procedures. At the time of tube removal, a standard fat graft myringoplasty was done.

RESULTS

The procedure was successful in 15 of the 15 ears, and all perforations had closed by 3 weeks. Pure tone audiometry improved in 11 ears, remained the same in two and worsened in two (0-10 and 11-15 dBA, respectively). There were no complications arising from the procedure. Mean follow up was 13.7 months (median=9, range 3-31). None of the patients have re-perforated, but two have required re-ventilation of their middle ear for middle effusions, and one of these two has also undergone subsequent adeno-tonsillectomy.

CONCLUSIONS

Our experience in this small series shows that the removal of a tympanostomy tube for recurrent otorrhoea can be successfully managed with a fat plug myringoplasty, with the benefit of a reduction in the persistent perforation rate following tympanostomy tube removal. It is a simple technique that requires little extra operating time with no significant morbidity.

Otorrhea in young children after tympanostomy-tube placement for persistent middle-ear effusion: prevalence, incidence, and duration

OBJECTIVE

To characterize the occurrence of tube otorrhea after tympanostomy-tube placement (TTP) for persistent middle-ear effusion (MEE) in a group of otherwise healthy infants and young children.

METHODS

In a long-term, prospective study of child development in relation to early-life otitis media, we enrolled by 2 months of age healthy infants who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small-town/rural and 4 suburban private pediatric group practices. We monitored their middle-ear status closely. Children who developed persistent MEE of specified durations within the first 3 years of life became eligible for random assignment to undergo TTP either promptly or after an extended period if MEE persisted. The present report concerns 173 randomly assigned children who underwent bilateral TTP between ages 6 and 36 months and were followed for at least 6 months thereafter. Episodes of tube otorrhea were treated with oral antimicrobial drugs and, if persistent, with ototopical medication.

RESULTS

Socioeconomic status, as estimated from maternal education and type of health insurance, was lowest at the urban sites and highest at the suburban sites. The tenure of the 230 tubes that were extruded during the observation period ranged from 19 days to 38.5 months (mean = 13.8 months; median = 13.5 months). During the first 18 months after TTP, the proportion of children who had tubes in place and who developed 1 or more episodes of otorrhea increased progressively, reaching 74.8% after 12 months and 83.0% after 18 months. The mean number of episodes per child was 0.79 in the first 6 months, 1.50 in the first 12 months, 2.17 in the first 18 months, and 2.82 in the first 24 months. Overall, otorrhea occurred earliest and was most prevalent among urban children and occurred latest and was least prevalent among suburban children. The mean estimated duration of episodes of tube otorrhea was 16.0 days (standard deviation = 16.9 days), the median was 10 days, and the range was 3 to 131 days. The duration was >30 days in 13.2% of the episodes. Six of the 173 children (3.5%) developed on 1 or more occasions tube otorrhea that failed to improve satisfactorily with conventional outpatient management. Five of these children were hospitalized to receive parenteral antibiotic treatment, 1 child twice and 1 three times, and 1 also underwent tube removal. The sixth child underwent tube removal as an outpatient.

CONCLUSIONS

Tube otorrhea is a common and often recurrent and/or stubborn problem in young children who have undergone tube placement for persistent MEE. The extent of the problem seems to be related inversely to socioeconomic status. Tube otorrhea does not always respond satisfactorily to outpatient management and for resolution may require parenteral antimicrobial treatment and/or tube removal.

Ventilation tubes and persisting tympanic membrane perforations

Surgical management of otitis media with effusion and recurrent acute otitis media includes myringotomy and the use of ventilation tubes. Since this procedure was reintroduced by Armstrong in 1954, it has become one of the most commonly performed operations in otolaryngology. In most series perforation of the tympanic membrane in some patients has been reported after spontaneous extrusion or removal of the tympanostomy tubes. We present a retrospective review designed to examine the incidence of persisting perforations of the tympanic membrane in our series of 2604 operated ears. The study also identifies and analyzes the variables and the contributing risk factors. Perforations occurred in 3.06% of the ears: with a greater incidence in children younger than 5 years, when the indication was recurrent purulent otitis media, with the use of long-term Goode T tubes, in cases with repeated insertions of ventilation tubes, and in cases in which postoperative otorrhea was frequent.

Grommets, swimming and otorrhoea--a review

Ever since Armstrong reintroduced the concept of grommet insertion parents have been asking 'may my child swim?', yet there is still no consensus as to the correct answer. This paper reviews the work that has been done on this subject in the last 25 years. A review of the rates of otorrhoea following grommet insertion, irrespective of swimming, shows a variation from 12 to 64 per cent. Evidence suggests that pressures of 12-23 cm H2O are needed to push water through a grommet and that it is unlikely that water will enter the middle ear during surface swimming. Only bath water seems to cause significant inflammatory changes to middle ear mucosa. Not a single paper comparing swimmers with non-swimmers shows an increased rate of otorrhoea in those patients who swam; to the contrary, rates of otorrhoea were repeatedly higher in those patients who did not swim. The evidence suggests that swimming without ear protection can be safely permitted for children with grommets.

Long-term results of Goode's tympanostomy tubes in children

The results of a retrospective study of the complications of middle ear ventilation by Goode's T-tubes in children are presented. 248 T-tubes were inserted into 119 patients. 16.9% progressed to spontaneous extrusion with a mean period of ventilation approaching 20 months. 54.9% of patients experienced otorrhoea which was found to be significantly more common in those ears with a mucoid effusion at the time of T-tube insertion. 21.1% of ears developed a persistent perforation where spontaneous extrusion had occurred or the T-tubes had been removed. Perforation also occurred more frequently in those with otorrhoea.

The effects of povidone-iodine preparation on the incidence of post-tympanostomy otorrhea

Persistent otorrhea after tympanostomy tube placement in children is a common complication. Previous reports have suggested that bacteria present within the ear canal may be the cause of postoperative drainage. Preparation of the ear canal with povidone-iodine solutions has been recommended to decrease these infections. A prospective study evaluating the efficacy of povidone-iodine ear canal preparation before myringotomy and tube placement was performed in 111 children (220 ears) with documented chronic otitis media with effusion. One ear in each patient was prepared with povidone-iodine. The contralateral ear in each child was used as control. Postoperative otorrhea developed in seven (6.3%) of the treated ears within 14 days, compared to eleven (10%) of the ears in the control group. The difference was not statistically significant (p greater than 0.05). Purulent or mucoid middle ear effusions and edematous or granular middle ear mucosa were associated with a significantly higher incidence of postoperative otorrhea (p less than 0.05). This study suggests that postoperative otorrhea is generally a consequence of preoperative middle ear condition rather than contamination from the external canal. Antimicrobial therapy should be considered when purulent effusion or granulation tissue is seen.

Tympanic membrane perforation following the removal of ventilation tubes in the presence of persistent aural discharge

This study considers the effect of the removal of a ventilation tube from the tympanic membrane of an ear which has been affected with persistent mucopurulent discharge for at least 3 months. The records of 332 patients were reviewed. Thirty-three patients with 34 ears satisfied the entry criteria. Tube removal cured 27 out of 34 ears (79%) of aural discharge within 1 month. The tympanic membrane healing rates were: at 1 month, 14 (41%); at 3 months, 23 (68%); at 6 months, 24 (71%); and at 1 year, 28 (82%). A table is presented comparing perforation rates from different ventilation tube studies.

Results of middle ear ventilation with Goode's tubes

The results of a retrospective study of the effect and outcome of middle ear ventilation by Goode's tubes are presented. 83 ears from 50 patients were analyzed both as a group and in age-related sub-groups over a mean follow-up period of 1.83 years. The mean period of ventilation by Goode's tubes before removal or extrusion was 18.4 months. The tubes became infected in 70.4% and were spontaneously extruded in 44.9% of patients. Permanent perforation of the tympanic membrane ensued in 47.5% of patients and significantly more often in those aged between 10 and 20 years (P less than 0.002). Patients aged less than 10 years were significantly less likely to develop a retraction of their tympanic membranes after removal of the Goode's tube than those older (P less than 0.02). No significant relationship was found between the development of these complications and the period of ventilation, past experience of otitis media, consistency of effusion, degree of tympanosclerosis or the preoperative presence of tympanic retraction.

The use of Per-Lee ventilation tubes in the management of refractory secretory otitis media

Per-Lee ventilation tubes have been used successfully for long-term ventilation in 35 ears, and none have been extruded although the maximum follow-up period is now in excess of 56 months. It is suggested that the benefits of this type of tube outweight any technical difficulty in insertion and that, if possible, the flange should be left untrimmed and the tube itself placed anterior to the malleus.

Predictive value of tympanometry in middle ear effusion

The presence of middle ear effusion may be inferred from a tympanogram by the configuration of the pressure compliance curve. Not infrequently, however, effusion is absent at the time of surgery when strongly indicated by preoperative tympanometry. We evaluated this discrepancy by contrasting preoperative tympanograms with the findings at surgery in 462 children, aged 4 to 8 years, with clinical evidence of persistent effusion in 909 ears. Based on these results we can classify tympanograms as to high risk for effusion, intermediate, and low risk. The proportion of ears with effusion was 83%, 47%, and 34%, respectively. The proportion of ears with fluid in the high risk tympanogram group did not change appreciably over a 1- to 8-week period, ie, no trend toward spontaneous resolution occurred. The high incidence of effusion at surgery in our low risk group is far higher than expected and is presumably due to reinfection of these ears during the time between examination and operation.

The extrusion rate of grommets

A prospective study was performed to determine the factors influencing the extrusion rate of tympanostomy tubes. Nine hundred thirty-nine tubes were inserted in 589 patients and the extrusion of these tubes was reviewed up to a period of 27 months. The eight tubes used in the survey were the Shepard, Exmoor, Bobbin, Armstrong, Paparella, Shah, Arrow, and collar button. These tubes were inserted in strict rotation, the operator using the designated tube. The position, type of incision, presence of fluid, quality of tympanic membrane, and degree of difficulty of insertion were all recorded at operation. The sex, age, side of operation, and any simultaneous operative procedures were also recorded. The patients were reviewed the day after operation and then every 3 months thereafter until the tube was extruded. A definite pattern was identified for the extrusion of each type of tube. At one end of the spectrum, Exmoor and Shepard tubes were, for the most part, extruded between 6 and 9 months after insertion, while at the other end, most of the collar button tubes were still functioning at 18 months. The design of the tube was the only factor found to be a significant determinant of the extrusion of the tube, although the experience of the surgeon affected the extrusion rate of the Arrow tube. The different dimensions of the Exmoor and collar button tubes are examined and compared.

A comparison of retention and complication rates of large-bore (Paparella II) and small-bore middle ear ventilating tubes

Large-bore myringotomy tubes are usually reserved for the treatment of refractory middle ear effusion. Theoretically, they have an extended intubation time and a higher complication rate. There is, however, scant support of this in the literature. The duration of intubation, efficacy, and complication rates of the large-bore Paparella type II tube were compared with Paparella type I, Shepard, and Armstrong tubes. The study included 242 patients with 600 intubations. In addition, a subpopulation of patients receiving their initial intubation during this study was reviewed. Findings were similar for both groups. Paparella type II tubes had a prolonged period of intubation and a decreased reintubation rate when compared with the smaller bore tubes. Larger bore tubes had an increased complication rate when compared with the smaller bore tubes. Complications included occasional or frequent otorrhea and an increased rate of permanent perforation of the tympanic membrane. There was no instance of cholesteatoma formation secondary to intubation. Guidelines are presented for the use of the Paparella type II tube.

Middle ear irrigation during insertion of ventilation tubes

Tympanostomy and insertion of ventilation tubes has become one of the most commonly performed operations in the United States. Most authors reporting complications of this procedure describe a postoperative rate of otorrhea in the range of 10-20% with some reports much higher. This rate of presumed suppuration would generally be considered high by surgeons operating in other areas of the body. It is a commonly accepted surgical practice to follow incision and drainage of a relatively closed space infection with irrigation of that space. This is true in the surgery for the paranasal sinuses, deep space infections of the neck, joint spaces and abscesses in general. However, this practice is not routinely performed when incising and draining the middle ear. We have completed a prospective controlled double blind study on post tympanostomy tube otorrhea utilizing irrigation of the middle ear. In 220 consecutive cases, the use of middle ear irrigation reduced postoperative infections in the first 6 months from 16 to 4%. Irrigation was also found to be useful in removing very thick effusions from the middle ear by displacement, including those effusions localized in the hypo or epitympanum which were not initially identified at the time of incision and suction. A soft plastic, angled irrigation catheter with radial ports was developed for this purpose.

Factors affecting the extrusion rates of ventilation tubes

A survey in which 939 ventilation tubes of 8 different patterns were inserted and reviewed (up to a maximum of 2 1/4 years) is analysed. Various factors determining the rate of extrusion are discussed. The Sheehy Collar Button tube remained functional for a longer period than any of the other tubes included in the survey.