Intra-Tympanic Dexamethasone Therapy via Grommet Insertion for Improved Auditory Outcome in Sudden Sensorineural Hearing Loss

Idiopathic sudden-sensorineural hearing loss (ISSHL) is an emergent otological condition needing prompt treatment for better recovery. In our study we aimed to determine the efficacy of intra-tympanic dexamethasone therapy after inserting a grommet in postero-inferior quadrant of the tympanic membrane for dexamethasone instillation. This is a prospective cohort study of 31 patients of ISSHL, in whom grommet was inserted and dexamethasone drops were instilled for 5 days. Several factors such as time of initiation of therapy, age of patient was considered, and inferences were drawn. Auditory outcomes were divided into low, mid and high frequency and the results were tabulated. Paired t tested was applied for all frequencies for both pre-test and post-test. P-value was (< 0.05) in all the three ranges of frequencies. Also, statistical significance was found between early treatment from onset of disease and auditory outcome. The earlier the therapy was initiated, better were the results.

Endoscopic Treatment of Otitis Media with Effusion

Myringotomy with grommet insertion is considered the standard of care for patients with unresolved otitis media with effusion and is traditionally performed under the operating microscope. The introduction of endoscopic ear surgery has provided otologists a tool for minimally invasive ear surgery with a panoramic view. We have described the use of endoscope for myringotomy and grommet insertion. The technique was found to be safe and effective and has the added advantage of being an excellent tool for teaching. The advantages and disadvantages of this technique vis a vis the traditional otomicroscopic technique have been discussed.

The necessity and effect of prophylactic quinolone ear drops after ventilation tube insertion for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is a condition where non-infective fluid builds up in the middle ear. Long-term OME can cause damage to the middle ear and hearing impairment. Ventilation tube insertion (VTI) is an efficient procedure to drain persistent OME. However, the effect of prophylactic ear drops after VTI remains controversial because no infection is present. This study investigated the need for and effect of quinolone ear drops in patients with OME after VTI.

METHODS

Between July 2018 and July 2021, 272 patients (436 ears with OME) who underwent VTI were enrolled. Prophylactic quinolone ear drops (ofloxacin) were used in 271 OME ears and not used in 165. The clinical findings and effect of the ear drops were assessed.

RESULTS

The group with postoperative ofloxacin had less postoperative otorrhea (p < 0.001). In univariate analysis, age ≥ 13 years (odds ratio [OR] = 1.499, 95% confidence interval [CI]: 1.003-2.238, p = 0.046) was significantly associated with recovery to normal middle ear functioning (type A on postoperative tympanometry). No adenoid hypertrophy (OR = 1.692, 95% CI: 1.108-2.585, p = 0.014) and no postoperative otorrhea (OR = 2.816, 95% CI: 1.869-4.237, p < 0.001) were significant independent factors associated with middle ear recovery in both univariate and multivariate analysis. After VTI, 65% of tympanic membranes in the group with postoperative ofloxacin recovered to normal, while in 67% of tympanic membranes in the group without ofloxacin scarring remained.

CONCLUSIONS

Patients who received prophylactic postoperative ofloxacin had less postoperative otorrhea. No adenoid hypertrophy and no postoperative otorrhea were significant independent predictors of middle ear recovery to normal function in both univariate analysis and multivariate analysis. However, prophylactic ofloxacin was not an independent predictor of normal middle ear functioning after VTI. After VTI, most OME patients who had used ofloxacin postoperatively had eardrums that were in better condition than those of patients who had not used ofloxacin. In this study, we confirmed the advantages and limitations of OME after VTI with prophylactic ofloxacin, thus providing clinicians with some guidance regarding the decision to administer prophylactic ofloxacin.

Middle ear disease requiring myringotomy in the first two years after tracheotomy in the pediatric population

OBJECTIVES

Risk factors for middle ear disease necessitating myringotomy with tympanostomy tube placement after a tracheostomy have not been thoroughly explored. This study investigates the incidence and risk factors for ear tube placement in pediatric patients with a tracheostomy.

METHODS

Pediatric patients under age 18 who underwent tracheotomy between 2002 and 2010 at two institutions were identified. Patients were excluded if they had undergone myringotomy prior to, or at the same time as, the tracheotomy, or did not have at least two years of follow-up clinic visits. The presence of other comorbidities was recorded. Descriptive statistics and logistic regression models were used to assess the impact of clinical characteristics on outcomes.

RESULTS

A total of 214 patients met inclusion criteria. Median patient age at time of tracheotomy was 6 months (IQR 2-17), median patient age at time of myringotomy with tubes was 12 months (IQR8-17), and median time between tracheotomy and myringotomy with tube placement was 8 months (IQR 5-11). Sixty-seven (31%) patients required myringotomy with tympanostomy tube placement within the first two years after tracheotomy. Fifty-eight (87%) patients who underwent myringotomy with tympanostomy tubes were younger than 2 years at the time of the procedure. Logistical regression found younger age at time of tracheotomy to be a risk factor (OR: 0.71, 95% CI: 0.5-0.9, p < 0.006). The combination of tracheostomy with gastric tube increased the risk of requiring myringotomy with tubes 2.79 fold (p < 0.009). Craniofacial abnormalities (p < 0.001), known genetic syndrome (p = 0.009), cleft palate (p < 0.001), age at time of tracheotomy (p < 0.001) and gastric tubes (p = 0.002) were all independently found to increase risk of myringotomy with tubes. Patients' gestational age (p = 0.411), ventilator dependence (p = 0.33), and airway structural abnormalities (p = 0.632) did not increase this risk.

CONCLUSION

This study reports a high incidence of myringotomy with tubes in children with tracheostomy relative to the general pediatric population. Many comorbid conditions that often accompany the need for tracheotomy place these patients at a higher risk for ear disease requiring surgical intervention. Risk factors for operative middle ear disease in this population included age at time of tracheostomy, craniofacial abnormalities, and presence of a G-tube.

Multifrequency multicomponent tympanometry in children with a history of ventilation tube insertion

OBJECTIVES

To use multifrequency multicomponent tympanometry (MF-MCT) for evaluating the middle ear mechano-acoustics of children with a history of ventilation tube (VT) insertion and to determine the effects of tube insertion sequelae on middle ear function.

METHODS

A prospective case-control study in a tertiary referral center involving 26 children (51 ears) aged 3-15 years. The children had undergone VT insertion surgery at least one-year previously and had no other known ear diseases. In addition, 13 age-matched healthy controls (26 ears) with no prior history of ear disease were included. The patients and control subjects underwent an otoscopic examination, standard 226 Hz tympanometry, and MF-MCT.

RESULTS

In 13.7% of cases, the VT was still in place in the operated ears. Post-operative myringosclerosis and/or eardrum retraction were noticed in 30% of ears with intact tympanic membranes in the patient group. While patients exhibited a great variability of tympanometric types (with standard 226 Hz tympanometry and tympanometric patterns with 1000 Hz MF-MCT), all cases in the control group had type A tympanograms and 3B1G patterns.

CONCLUSION

The effects of VT treatment on the mechano-acoustics of the middle ear have been revealed in this study. It has also been determined that VT application may increase the mass effect on the middle ear functions, which can be detected in the tympanometric shape and pattern.

Predictors of postoperative complications in paediatric patients receiving grommets - A retrospective analysis

BACKGROUND

Insertion of middle ear ventilation tubes (MEVT), tympanostomy tubes or grommets is one of the most common paediatric surgical procedures performed by ENT surgeons worldwide. Outcomes may be complicated by postoperative otorrhoea and ventilation tube blockage.

OBJECTIVE

To identify risk factors associated with early postoperative complications of MEVT insertion.

METHOD

In a case-control study, set in a tertiary hospital in Melbourne, Australia, 590 paediatric patients undergoing grommet insertion between February 2017 and February 2018, 311 patients (205 males & 106 females; median age of 3.86 years) met the inclusion criteria and had identical middle ear status bilaterally.

INTERVENTION

Tympanostomy tube insertion and postoperative topical otic antibiotic drops.

MAIN OUTCOME AND MEASURES

Patient age, gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, season of surgery, diagnosis and time to first medical review were examined. The duration of topical otic antibiotic drops used and tube patency and presence of otorrhoea at 6-week postoperative review were also recorded.

RESULTS

At the first medical review, 8.7% of patients (n = 27) developed otorrhoea from one or both ears, 6.4% of patients (n = 20) had an obstructed MEVT in one or both ears. Exposure to intraoperative [IO] and postoperative [PO] antibiotic drops were significantly less associated with developing postoperative otorrhoea compared to non-exposure (IO: Odds Ratio [OR] = 0.15, 95%CI 0.04 to 0.57, p = 0.005; PO: OR = 0.21, 95%CI 0.58 to 0.76, p = 0.017). There were no statistically significant associations between antibiotic drop exposure and grommet blockage (p > 0.05). There was a significant association between developing postoperative otorrhoea and patients receiving surgery during the colder months of Winter/Autumn (OR = 3.17, 95%CI 1.14 to 8.84, p = 0.028), as well as patients aged less than 3 years (OR = 2.66, 95%CI 1.01 to 7.03, p = 0.049). There was a statistically significant association between serous effusions and grommet blockage compared to no effusion (OR = 4.03, 95%CI 1.03 to 15.7, p = 0.045). There were no statistically significant associations identified between otorrhoea and gender, weight/BMI percentile, intraoperative middle ear status, number of previous grommets, type of surgery, diagnosis and time to first medical review. There were no statistically significant associations between grommet blockage and age, gender, indication for surgery, concurrent surgery, season or number of previous grommets.

CONCLUSIONS

8.7% of patients developed otorrhoea within 6 weeks post-operatively. Undergoing the procedure during winter/autumn, age <3 years were associated with developing otorrhoea. Topical antibiotic exposure was inversely associated with developing postoperative otorrhoea. 6.4% of patients had grommet blockage. Presence of serous middle ear effusion intraoperatively was a statistically significant indicator for developing grommet blockage.

Vestibular Dysfunction in Children Suffering from Otitis Media with Effusion: Does Grommet Help? An Observational Study Using Computerized Static Posturography

Otitis media with effusion (OME) has a detrimental effect on balance, which may not present as a clear symptom in children. This effect can be improved by the insertion of ventilation tubes. This study assesses balance in children suffering from OME pre and post operatively using computerized static posturography. 50 children of 3-6 years, suffering from OME were included in this observational descriptive study. These patients underwent myringotomy and grommet insertion. The balance was evaluated pre and post operatively after 3 months using computerized static posturography with Modified Clinical Test of Sensory Interaction on Balance under four conditions, namely eyes open/closed on firm surface/foam. Posturography mean sway velocity was deranged in these children preoperatively and it showed statistically significant improvement post operatively at 3 months. There is occult vestibular dysfunction in children with OME as assessed by static posturography which improves significantly 3 months after myringotomy and grommet insertion.

Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review

Otitis media with effusion (OME) is a frequent paediatric disorder. The condition is often asymptomatic, and so can easily be missed. However, OME can lead to hearing loss that impairs the child's language and behavioural development. The diagnosis is essentially clinical, and is based on otoscopy and (in some cases) tympanometry. Nasal endoscopy is only indicated in cases of unilateral OME or when obstructive adenoid hypertrophy is suspected. Otitis media with effusion is defined as the observation of middle-ear effusion at consultations three months apart. Hearing must be evaluated (using an age-appropriate audiometry technique) before and after treatment, so as not to miss another underlying cause of deafness (e.g. perception deafness). Craniofacial dysmorphism, respiratory allergy and gastro-oesophageal reflux all favour the development of OME. Although a certain number of medications (antibiotics, corticoids, antihistamines, mucokinetic agents, and nasal decongestants) can be used to treat OME, they are not reliably effective and rarely provide long-term relief. The benchmark treatment for OME is placement of tympanostomy tubes (TTs) and (in some cases) adjunct adenoidectomy. The TTs rapidly normalize hearing and effectively prevent the development of cholesteatoma in the middle ear. In contrast, TTs do not prevent progression towards tympanic atrophy or a retraction pocket. Adenoidectomy enhances the effectiveness of TTs. In children with adenoid hypertrophy, adenoidectomy is indicated before the age of 4 but can be performed later when OME is identified by nasal endoscopy. Children must be followed up until OME has disappeared completely, so that any complications are not missed.

Otitis Media with Effusion (OME) in Urban Pediatric Population in a Tertiary Care Centre: A Clinical Study

Otitis media with effusion (OME) is a common condition affecting children. It is one of the most common causes for reduced hearing in pediatric age group leading to various learning disabilities including delayed speech development. The aim of this study was to find out various epidemiological characteristics and risk factors for developing OME and various treatment modalities depending on the clinical features and their outcomes in urban pediatric population. A prospective comparative study was done in 100 children taken 50 as cases and 50 as controls for a period of 2 years. The risk factors, common presenting features and the examination and investigational findings (tympanometry) of the study condition were compared among the cases and controls. Among the 50 cases, 28 children were treated medically and 22 underwent surgical treatment in the form of Myringotomy and Grommet insertion. The patients were followed up-to 6 months in both groups.

Follow-up audiometry after bilateral myringotomy and tympanostomy tube insertion

OBJECTIVE

There are no evidence-based guidelines regarding timing of postoperative audiometric follow-up for children undergoing tympanostomy tube insertion. Given the variability of follow-up among physicians, we attempt to guide the timing of postoperative audiograms using objective data.

STUDY DESIGN

Retrospective chart review.

METHODS

All pediatric patients undergoing primary bilateral myringotomy and tympanostomy tube insertion for otitis media with effusion who had audiometric data available at two follow-up times were identified from 2014. Patients were classified according to the type of audiometry performed and were further categorized into those who had tympanostomy tube insertion only and those who had concurrent adenotonsillectomies.

RESULTS

34 patients were included in the study. Among patients assessed by sound field audiometry, the mean sound field threshold value was 29.2dB preoperatively and improved to 21dB 2 weeks postoperatively and 17.9dB 6 to 10 weeks postoperatively. The difference between the two postoperative means was significant (p<0.0001). For patients evaluated by pure-tone audiometry, the mean preoperative air-bone gap was 20.1dB; this improved to 10dB at the first postoperative visit and 7.3dB at the second visit. The difference between the two means was significant (p<0.0001). For the subgroups in which adjunct adenotonsillectomy was performed, the greater improvement at the later follow-up was still statistically significant.

CONCLUSIONS

Progressive hearing improvement was demonstrated from 2 weeks to 6 to 10 weeks postoperatively. We recommend testing no fewer than 6 weeks after tympanostomy tube insertion. Earlier audiometry underestimates the degree of hearing improvement.

The impact of ventilation tubes in otitis media on the risk of cholesteatoma on a national level

OBJECTIVE

To estimate the impact of treatment with middle ear ventilation tube insertion (VTI) in children with otitis media (OM) on the risk of cholesteatoma on a national level.

METHODS

Data were obtained from the Danish National Patient Register, the National Health Service Register and Statistics Denmark. Cumulative incidence proportions were estimated by the Kaplan-Meier method and hazard ratios with Cox regression analysis. The first surgically treated middle ear cholesteatoma in a child (STMEC1) was considered an event.

RESULTS

A total of 217,206 children, born after December 31, 1996, who had VTI from January 1, 1997 to August 31, 2011 were identified. Of these, 374 subsequently had a STMEC1. A corresponding 36,981 children without any VTI were identified for comparison using a random 5% sample of the Danish population. Of these, 5 had a STMEC1. The cumulative incidence proportion with STMEC1 at 12 years of age for children with 0, 1, 2, 3, and ≥4 VTI's was 0.04% (95% confidence interval 0.02-0.12%), 0.21% (0.18-0.26%), 0.35% (0.28-0.43%), 0.40% (0.30-0.54%), and 0.55% (0.44-0.70%), respectively. In the regression model each additional year of age before the first VTI increased the risk of STMEC1 by 54% (47-63%), while each additional year between two successive tube insertions increased the risk by 28% (15-43%).

CONCLUSION

We found that prolonged OM requiring multiple VTIs was associated with an increased risk of STMEC1. Early age at first VTI and short time between two VTIs was associated with a lower risk of STMEC1. This may be the result of reduced time with negative middle ear pressure and OM. However, these findings may be susceptible to selection bias, as age at first VTI and time between VTIs, as well as the outcome variable, STMEC1, may all depend on the underlying indication for VTI. In short the present study suggests that treatment with VTI in children with OM reduces the risk of STMEC1 on a population level. However, for the individual child the absolute risk reduction is very small, and the decision of treatment with VTI must always rely on the symptoms and clinical findings in the individual child.

Increasing rate of middle ear ventilation tube insertion in children in Denmark

OBJECTIVE

To study the incidence rates of middle ear ventilation tube insertion in children aged 0 to 15 years in Denmark from 1997 to 2010.

METHODS

Using two national registers, the Danish National Health Service Register and the Danish National Patient Register, practically all cases of middle ear ventilation tube insertion performed in Denmark in the period were identified. A possible change in incidence rate over time was examined using Poisson regression analysis, while the cumulative incidence proportion was estimated using life-tables.

RESULTS

A total of 502,569 uni- or bilateral ventilation tube insertions distributed among 269,459 different children were identified. From 1997 to 2010 the age standardized incidence rate in 0-15-year-olds increased from 26 to 40 per 1000 person years with an estimated annual increase of 2.0% (95% confidence interval 1.9-2.1%). The largest increase in incidence rate was found in 1-year-olds with an annual increase of 4.5% (95% confidence interval 4.4-4.6%). Age-specific incidence rates remained at maximum around the age of 14 months throughout the period. The cumulative incidence proportion for the 2010 birth cohort by the time they reach the age of 5 years was estimated to 29% (95% confidence interval 28-29%).

CONCLUSION

The rate for middle ear ventilation tube insertion in Denmark was high compared to other developed countries, and an estimated 3 in 10 children born in 2010 will undergo at least one ventilation tube insertion before their fifth birthday.

Role of grommet in otitis media with effusion: A necessity or nuisance? A comparative study

Otitis media with effusion is one of the commonest otological problems in paediatric age group. The condition occurs in childhood as overt or covert hearing loss presenting as an educational or behavioural problem. As there is widespread controversy regarding its precise aetiology, natural history and pathogenesis a treatment dilemma still persists. The main goal of this study is to compare the efficacy of different modalities of medical and surgical treatment designed for this condition and analysis of the results statistical.