Influence of COVID-19 pandemic on otitis media with effusion in children: A multicenter, retrospective survey in northern Japan

OBJECTIVE

The purpose of this study is to compare patient trends in otitis media with effusion (OME) symptoms and diagnoses before and after the COVID-19 pandemic in order to investigate the effects of the coronavirus disease of 2019 (COVID-19).

METHODS

A retrospective, multi-center, observational study was carried out between January 2018 and December 2022 at hospitals in the Iwate Prefecture with full-time doctors. All patients were initially separated into two groups, one for the pre-COVID-19 era (from January 2018 to June 2020), and the other for the COVID-19 era (from July 2020 to December 2022).

RESULTS

In the pre-COVID-19 era, 132 patients had tympanostomy tubes (TT) placed, while 64 patients had them placed in the COVID-19 era. Between the pre-COVID-19 and COVID-19 eras, there were no statistically significant differences in terms of age, sex, side, craniofacial deformity, or adenoidectomy. Children in elementary school showed a greater decline than those in preschool (42-11 patients in elementary school (74%) and 49 to 32 patients in preschool school (35%); p = 0.025).

CONCLUSIONS

The percentage of TT placements for OME dropped to roughly half during the COVID-19 epidemic. This was particularly obvious in elementary school students.

Adenoidectomy and Endoscopic Myringotomy with and without ventilation tube insertion for Treatment of Otitis Media with Effusion in 6-12 years old Children

BACKGROUND

Otitis Media with Effusion (OME) is frequently caused by adenoiditis in children. OME is arguably one of the most common disorders that impairs hearing, speech development, and causes learning issues as a result. However, treatment options are debatable.

AIM

This study aims to evaluate if inserting a ventilation tube in conjunction with adenoidectomy is significantly superior to adenoidectomy in conjunction with myringotomy alone in terms of hearing outcome in 6-12 years old children with OME. Patients and Methods: In this prospective controlled clinical study, 33 children; 66 ears, with ages ranging from 6-12 years (19 males and 14 females) diagnosed as cases of bilateral OME and varying degrees of adenoid hypertrophy were included. The patients were randomized into two groups; group I (17 patients; 34 ears) underwent adenoidectomy and endoscopic myringotomy alone, whereas the 16 patients;32 ears, in group II underwent adenoidectomy and endoscopic myringotomy together with ventilation tube insertion. Measurement of pure tone hearing threshold was achieved pre-operatively and at the end of 1st and 3rd postoperative months. The means of the pure tone hearing threshold averages of the patients in both groups were compared. Independent samples t-test was used to define the association between the two means.

RESULTS

Pre-operatively, the means of pure tone hearing threshold averages were 27.3 ± 2.670 dB in group I patients and 29.5 ± 2.865 dB in group II patients. At the end of 1st and 3rd post-operative months, the pure tone hearing threshold average means in group I patients were 18.2 ± 2.689dB and 14.8 ± 2.735 dB respectively, while the means in group II patients were 10.6 ± 1.742 dB and 3.5 ± 1.158 dB respectively. Independent samples t-test revealed a statistically significant difference between group I and group II patients regarding the means of pure tone hearing threshold averages at the end of the 1st and the 3rd post-operative months (P value=0.015 and 0.003 respectively).

CONCLUSION

In terms of hearing level, ventilation tube insertion in conjunction with adenoidectomy is statistically superior to adenoidectomy with myringotomy alone in the treatment of OME.

CHARACTERISTICS OF HEARING RECOVERY IN CHILDREN WITH CHRONIC OTITIS MEDIA WITH EFFUSION AFTER VENTILATION TUBE INSERTION

The objective was to determine the range of hearing improvement (in dB) post ventilation tube insertion in children with chronic otitis media with effusion (COME), and whether there was a difference in hearing improvement between age groups and genders. This study also investigated whether there was a difference in the mean hearing improvement between the left and right ear, how many months passed before recovery of eustachian tube function, and how long the aeration of the middle ear lasted. The children included in the study were between six and twelve years of age, diagnosed with COME by audiological processing (type B tympanometric recording and conductive hearing loss up to 40 dB on pure tone audiometry) and underwent surgical insertion of ventilation tubes in both ears. Patient data included preoperative tympanometric records, preoperative and postoperative tone audiometry findings, tubometry findings 6 and 10 months after insertion of ventilation tubes, age and gender data, and length of time during which the tubes were in place. The mean hearing improvement of the included patients was 24.2 dB on the right ear and 24.5 dB on the left ear. There was no statistically significant difference between the left and right ear or between the genders. Older age groups had a higher mean hearing improvement compared with the younger age group. Younger age groups had a longer expected period of eustachian tube function recovery, and were expected to have ventilation tubes inserted for a longer period of time. Treatment with ventilation tube insertion resulted in significant improvement in hearing in children where previous conservative therapy failed to recover eustachian tube function and improve hearing. Although children of older age groups had greater preoperative hearing impairment, the recovery of both eustachian tube function and hearing improvement was faster, and the mean length of time that the ventilation tubes had to be inserted was shorter.

Tympanomastoid cholesterol Granulomas presenting as a Blue Eardrum in children

OBJECTIVE(S)

This clinical study was performed to analyze the characteristics of cholesterol granuloma (CG) and evaluate our results in children.

METHODS

The clinical records of children diagnosed with CG were retrospectively reviewed.

RESULTS

The total of 17 children (20 ears) with CGs were included in this study. Endoscopy revealed pars flaccida retractions and lipoid tissue deposition behind the intact blue tympanic membrane (TM). CT scan revealed bony erosion and extensive soft tissue in the middle ear and mastoid. No ossicular chain destruction was found. All 20 ears underwent canal wall-up mastoidectomy and ventilation tube (VT) insertion, 3 sets of VT were performed in 5 ear and 2 sets in one. The residual perforation was seen in 2 ears following VT. The CT revealed well-pneumatized antra and tympanic cavities at postoperative 12-24 months.

CONCLUSION(S)

The CG should be suspected for the patients with yellow lipoid deposition behind the blue TM. CT of CG usually revealed bony erosion and extensive soft tissue in the middle ear and mastoid. Mastoidectomy combined with VT insertion and etiological treatment have a favorable prognosis for CG in children.

Is tympanic infrared thermometry valid in non-naive tympanic membranes?

OBJECTIVE

To investigate the impact of with tympanostomy tubes (TT) on infrared tympanic membrane thermometer (ITMT) results and to provide a systematic review of ITMT results in non-naïve tympanic membranes.

STUDY DESIGN

Original prospective blinded case series and systematic literature review.

SETTINGS

A single tertiary university-affiliated medical center.

METHODS

ITMT measurements of patients with unilateral TT and contralateral naïve control ear were randomly conducted by a single investigator blinded to the TT side before and after cerumen was removed from the external auditory canals. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Google Scholar" on comparable published cases was performed.

RESULTS

The mean paired differences (95% confidence interval [CI]) between ventilated and non-ventilated ears before and after cerumen removal were 0.08 ºC/0.14 ºF (-0.04 to 0.19 ºC/- 0.07º-0.34º) and 0.62 ºC/1.12 ºF (0.04-0.25 ºC/0.07-0.45 ºF), respectively (P < 0.001 and P = 0.01, respectively).

CONCLUSION

These findings support the validity and accuracy of ITMT in the setting of ventilated ears.

Predictors of Otitis Media with Effusion Recurrence Following Myringotomy

Otitis media with effusion (OME) is the most common cause of acquired pediatric hearing loss. The treatment of persistent OME includes myringotomy with or without tube insertion, with a reported recurrence rate of 19.9-40%. This study aims to investigate the recurrence rate of OME and its predictors following myringotomy. A retrospective study that included 345 ears that underwent myringotomy for persistent OME in 179 pediatric patients during 2016-2018. Patients were followed for 36-48 months post myringotomy procedure to detect the recurrence rate. The study sample was divided into two groups based on recurrence status, and the groups were compared using chi-square test and independent T-test. Significant variables (p-value ≤ 0.05) were included in the logistic regression model to determine the predictors of OME recurrence after myringotomy. OME recurrence was detected in 85 ears (24.64%). The OME recurrence rate is higher in patients who underwent myringotomy alone compared to myringotomy with tube insertion (44.1% vs. 22.8%). The insertion of a tympanostomy tube decreases the recurrence rate of OME by 59.9% (OR 0.401; 95% CI 0.162-0.933). The other socio-demographic and clinical characteristics such as age, siblings, daycare attendance, passive smoking, previous acute otitis media, atopy, and adenoidectomy did not significantly influence OME recurrence (p-value > 0.05). The recurrence rate of OME following myringotomy is high. Myringotomy with tube insertion significantly decreases the recurrence rate and the need for further surgeries compared to myringotomy alone. Adenoidectomy and the patient's age have no impact on the recurrence rate of OME.

Middle Ear Status in Cleft Lip and Palate Patients: A Five-Year Follow-Up

INTRODUCTION

The best strategy to treat otitis media with effusion in cleft lip/palate patients is still under debate. This research aimed to evaluate the otologic outcomes in children at least five years post-repair.

MATERIALS AND METHODS

A retrospective study was conducted on 40 children who underwent palatoplasty between January 1, 2012, and January 1, 2014, at Children's Medical Center (Tehran, Iran). Patients had intervelar veloplasty under magnification (Sommerlad's Technique). Based on patients' charts, their age, gender, cleft type, date of palatoplasty, as well as the date and the frequency of ventilation tube (VT) insertion, were recorded. Furthermore, otomicroscopy, middle ear status, and tympanometry were assessed five years postoperatively.

RESULTS

There was no significant difference in middle ear status between children with complete and incomplete cleft palates. The mean age at the time of study and the mean follow-up duration were significantly higher in the normal middle ear group, compared to the abnormal middle ear group (7.7±1.6 vs. 6.8±0.9, P=0.03 and 6±1.15 vs. 5.42±0.9, P=0.04, respectively). Middle ear status was not significantly different between early or late palatoplasty patients. In addition, the frequency and timing of VT insertion were not significantly different between the two groups.

CONCLUSIONS

Middle ear status improved as patients grew older; however, the age of palatoplasty and the frequency of VT insertion were not significant prognostic factors in patients who underwent intervelar veloplasty under magnification.

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.

The limits of pandemic precautions: Tympanostomy tube placement in children with cleft palate during COVID-19

PURPOSE

Coronavirus Disease-2019 (COVID-19) mitigation measures have led to a sustained reduction in tympanostomy tube (TT) placement in the general population. The present aim was to determine if TT placement has also decreased in children at risk for chronic otitis media with effusion (COME), such as those with cleft palate (CP).

MATERIALS AND METHODS

A cohort study with medical record review was performed including consecutive children, ages 0-17 years, undergoing primary palatoplasty at a tertiary children's hospital February 2019-January 2020 (pre-COVID) or May 2020-April 2021 (COVID). Revision palatoplasty (n = 29) was excluded. Patient characteristics and middle ear status pre-operatively and at palatoplasty were compared between groups using logistic regression or Wilcoxon rank-sum.

RESULTS

The pre-COVID and COVID cohorts included 73 and 87 patients, respectively. Seventy (44%) were female and median age at palatoplasty was 13.5 months for CP ± cleft lip (CP ± L) and 5.5 years for submucous cleft palate (SMCP). In patients with CP ± L, TT were placed or in place and patent at palatoplasty in 28/38 (74%) pre-COVID and 37/50 (74%) during COVID (P = 0.97). In patients with SMCP, these proportions were 5/35 (14%) and 6/37 (16%), respectively (P = 0.82). Examining only patients <2 years of age also revealed no difference in TT placement pre-COVID versus COVID (P = 0.99). Finally, the prevalence and type of effusion during COVID was similar to pre-COVID.

CONCLUSIONS

Reduced infectious exposure has not decreased TT placement or effusion at palatoplasty. Future work could focus on non-infectious immunologic factors underlying the maintenance of COME in these children.

The effect of intervelar veloplasty under magnification (Sommerlad's Technique) without tympanostomy on middle ear effusion in cleft palate patients

Objective

Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients.

Methods

non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty.

Results

Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold).

Conclusions

Intervelar veloplasty under magnification (Sommerlad’s technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion.

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.

Otological outcome in cleft lip and palate children with middle ear effusion

OBJECTIVE

To evaluate the factors contributing to middle ear pathology, hearing and speech development among cleft palate children treated for middle ear effusion.

METHOD

A prospective cross-sectional otoscopic and audiological analysis was conducted on 102 cleft palate children (204 ears) aged 1-18 years old who were treated for middle ear effusion at our centre. Retrospective chart review was done to determine patient characteristics and prior patient management. The aim was to assess the effect of ventilation tube insertion (VTI) on hearing, speech and chronic otitis media; comparing the timing and number of ventilation tubes per ear and determining other factors affecting the short-term and long-term outcome.

RESULTS

68 children or 130 ears (63% of all cases) were selectively treated with ventilation tube insertion. Repeat procedures (more than 2) were performed in 41 ears. Among children with VTI performed, the incidence of chronic otitis media in children after the age of 4 was 17%. Overall, abnormal tympanic membrane findings and hearing loss were detected in nearly half the cases who were previously treated with VTI. Early ventilation tube insertion at less than 1 year of age, resulted in a better middle ear and hearing outcome in children less than 4 years old (p < 0.05), however there was no significant difference in children more than 4 years old. Early surgical repair of cleft palate prior to the age of one year resulted in favourable results in both age groups (p < 0.05). There was a higher prevalence of chronic otitis media with repeated grommet insertion (3 or more) (p < 0.05). Speech and language milestones were achieved in 94% of all children above the age of four.

CONCLUSION

Treatment with early ventilation tube insertion prior to the age of one year provides a hearing benefit in children less than 4 years of age, but no significant difference after 4 years of age. Factors significantly affecting the outcome after 4 years of age was the timing of palatal closure and total number of tube insertions. We recommend a conservative approach especially when considering repeated tube insertions. A long-term follow-up paired with interval hearing assessment is advocated until early adulthood.

Emergent and urgent otologic surgeries during the SARS-CoV-2 pandemic: a protocol and review of literature

Objective

To review guidelines for otologic procedures during the SARS-CoV-2 pandemic and to present a protocol for emergent or urgent mastoidectomy at our institution.

Data sources

Guidelines regarding emergent and urgent otologic procedures from otolaryngologic societies are reviewed. We described a protocol for emergent or urgent mastoidectomy at our institution.

Conclusion

Patients requiring urgent or emergent mastoidectomy during the COVID-19 pandemic require prompt treatment. We make the following recommendations: Emergent or urgent otologic procedures should be performed in a contained environment, such as a tent created by the microscope drape. The surgical team should practice using instruments in the tent setup to prepare for real cases. Otologic procedures should adhere to guidelines set for high-risk procedures.

Subannular ventilation tubes in the pediatric population: Clinical outcomes of over 1000 insertions

OBJECTIVES

Long-term transtympanic tube insertions for chronic middle ear disease are associated with high rates of complications. The objective of this study was to examine the clinical outcomes achieved with an alternate technique, the subannular tube insertion, by determining mean tube lifespan, cumulative incidence of post-operative events and complications, audiometric changes and risk factors associated with earlier tube extrusion in the pediatric population.

METHODS

A retrospective chart review of all patients operated for subannular tube insertion between January 2007 and 2013 was conducted in a single pediatric tertiary care center. Exploratory Cox regression analysis was performed to identify potential risk factors.

RESULTS

A total of 1014 tubes from 459 patients were included in the study. Mean subannular tube lifespan was 41.3 months with median time of 35.0 months. Cumulative incidence of post-operative events in decreasing frequency were otorrhea (21.7%), tube blockage (16.0%), tympanic membrane retraction (12.5%), otitis media with effusion (10.0%), acute otitis media (6.4%), perforation (4.6%) and cholesteatoma formation (1.1%). For patients with available pre- and post-operative audiograms, mean air-bone gap improved from 19.5 dB to 7.0 dB after subannular tube insertion (p < 0.01). Increasing age and previous subannular tube insertion carried hazard ratios of 1.029 (p < 0.01) and 1.749 (p < 0.01) for tube extrusion respectively, while craniofacial anomalies and concomitant tympanoplasty at the time of tube insertion had hazard ratios of 0.795 (p < 0.01) and 0.680 (p = 0.03).

CONCLUSIONS

Subannular tube insertion appears to be a safe and effective alternate technique for middle ear ventilation in cases of intractable disease.

Epidemiology of common otologic surgical procedures in pediatric patients: A population-based birth cohort study

OBJECTIVE

It is generally recognized the most common pediatric otologic surgical procedure is ventilation tube insertion (VTI). Tympanoplasty and mastoidectomy are more frequently performed on adults. In this study we examined the incidence and age distribution of these procedures by use of a population-based birth cohort design, in order to provide an overall view of the role of these procedures in the pediatric population.

MATERIALS AND METHODS

We used the national health insurance research database in Taiwan. We retrieved data on all patients born in the years 2000 and 2001, subsequently underwent VTI, tympanoplasty or mastoidectomy from 2000 to 2013. The incidence and age distribution of these procedures were analyzed.

RESULTS

The cumulative incidence of VTI, tympanoplasty, and mastoidectomy was 0.41%, 0.02% and 0.025%, respectively. VTI were more often performed on children 4 or 5 years of age. Tympanoplasties are frequently done on children older than 5, and 30.7% of them had earlier VTI. The time interval from VTI to tympanoplasty was 5.18 ± 2.27 years (mean ± SD). Mastoidectomies are more often performed on children from 2 to 9 years of age.

CONCLUSIONS

VTI was the most frequent otologic surgery for the pediatric population, and was more often performed on children 4-5 years old. Also, tympanoplasty is more frequently performed on children older than 5, and a third of them had prior VTI. Overall, the time interval from VTI to tympanoplasty was 5.18 years. Furthermore, children with cleft palate and congenital metabolic disorder were more prone to otologic surgical procedures.

Menière's disease treated by grommet insertion

INTRODUCTION

Menière's disease (MD) is an uncommon cause of sudden profound vertigo. A variety of medical and surgical treatments have been used to manage this condition. This study reviewed the outcomes of patients treated with grommet insertion and transtympanic steroid injection.

METHODS

Patients diagnosed with MD between 2007 and 2017 were identified, and case notes and audiological data were retrieved for those managed by grommet (ventilation tube) insertion with and without transtympanic steroid injection.

RESULTS

Thirty-three patients were identified as being diagnosed with MD. Grommet insertion resulted in cessation or improvement of attacks in 91% of cases. The mean follow-up duration was 33.8 months (median: 29 months). The mean hearing threshold across the low frequencies improved from 57.2dBHL to 49.4dBHL (p=0.031). Following the intervention, improved tinnitus was reported in 80% of cases. Twelve patients (36%) reported aural fullness prior to grommet insertion; all reported improved symptoms following the procedure.

CONCLUSIONS

Early grommet insertion with transtympanic steroid injection, combined with customised vestibular physiotherapy, may provide an alternative first-line strategy for MD, preventing further true MD attacks. In some patients, it may significantly improve hearing thresholds.

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.

Hearing thresholds and ventilation tube treatment in children with unilateral cleft lip and palate

OBJECTIVE

Children with cleft lip and palate have a high prevalence of otitis media with effusion (OME) which is often associated with a fluctuating, conductive hearing loss in the low and mid-frequencies and a risk for permanent hearing loss in the higher frequencies. Although common, there is no consensus on the treatment of OME with ventilation tubes. The aim of this study is to document if the risk for permanent hearing loss and acquired cholesteatoma increases due to treatment with ventilation tubes (VT treatments) during childhood in a group of children with cleft lip and palate.

METHODS

A retrospective medical chart review of 33 children (25 boys and 8 girls) born with unilateral cleft lip and palate (UCLP) was completed. Audiological data (results of hearing sensitivity tests, the total number of hearing tests, and number of VT treatments) were extracted from medical records from when the children were 4-7 and >7-10 years of age.

RESULTS

The hearing thresholds in the speech frequencies improved with age (p < 0,05) but a minority of the children continued to present with elevated hearing thresholds in the higher frequencies at >7-10 years of age. There were no significant correlations between number of VT treatments and hearing thresholds at >7-10 years. Four of the 33 children presented with complications: two children exhibited perforations of the ear drum (6.1%) and two children developed unilateral cholesteatoma (6.1%).

CONCLUSION

In the current study, the hearing sensitivity of children with cleft lip and palate improved with age. However, this improvement was not seen in the higher frequencies. Twelve percent of the children experienced complications following VT treatments. Due to these complications, it is recommended that all children with cleft palate should have routine follow-ups by an ENT doctor and audiologist. As part of the routine follow-up care, hearing assessments should be performed before and after VT treatments.

The effectiveness of myringotomy and ventilation tube insertion versus observation in post-radiation otitis media with effusion

To compare the effectiveness of myringotomy and ventilation tube insertion versus observation in post-radiation otitis media with effusion (OME) in nasopharyngeal carcinoma (NPC). NPC patients who finished radiotherapy and had persistent OME were randomized to myringotomy and ventilation tube insertion and observation groups. The resolution rate of OME and hearing outcomes were evaluated. Forty three patients (23 in control group and 20 in intervention group) were analyzed. One patient in the control group obtained a resolution of OME. The remaining patients in the control group had persistent middle ear fluid. Fourteen patients in the intervention group had retained ventilation tubes without otorrhea. Ventilation tubes had spontaneously extruded in the remaining six patients and all of these patients had recurrent OME. Mean air-pure tone average in the control group was 52.04 dB (SD 11.61), significantly different from the intervention group [38.15 dB (SD 19.10); p = 0.01]. Mean air-bone gap in the control and intervention groups were 27.30 dB (SD 9.11) and 9.30 dB (SD 9.59) respectively (p < 0.001). Mean air-pure tone average and mean air-bone gap improvement was significantly improved in the intervention group (p < 0.001). Two patients in the intervention group (10%) developed complications, one patient suffering suppurative otitis media whilst another had otorrhea, which resolved after 1-week course of antibiotic treatment. Post-radiation OME is common in patients with NPC and tends to persist long-term. Conservative management is safe, however, is plagued by frustrating effects of hearing impairment and aural fullness. Myringotomy with ventilation tube insertion leads to hearing improvement with few complications.

Rat model of chronic tympanic membrane perforation: A longitudinal histological evaluation of underlying mechanisms

OBJECTIVE

To evaluate histologically the progressive development and underlying mechanisms of chronic tympanic membrane perforation (TMP) in a rat model using a two-weeks ventilation tube (VT) treatment combined with topical application of mitomycin C/dexamethasone (VT-M/D), compared with normal tympanic membrane and acute TMPs.

METHODS

Fifty male Sprague-Dawley rats were divided into three experimental groups: a normal control group (n = 5), an acute TMP group (n = 5) (i.e. 3 days post-myringotomy) and a VT-M/D group (n = 40). The TMs were regularly assessed by otoscopy. The normal control animals were sacrificed on day 0 and the acute TMP group was sacrificed 3 days post-myringotomy for histological and immunohistochemical evaluations. The VT-M/D group was sacrificed at various time points - 14 and 17 days, 3, 4, 6, 8 and 10 weeks.

RESULTS

On longitudinal histological examination, compared with normal TM and acute TMP, the perforation edges at the later time points illustrated thickened stratified squamous epithelium rimming around the edges, significant increase in keratin and collagen deposition, increased macrophage infiltration as well as reduced cellular proliferation. Three phases of TMP healing process were identified - the acute healing phase (3-17 days), the transition phase (3-4 weeks) and the chronic phase (6-10 weeks).

CONCLUSION

Based on the histological results of this study, the progressive development of chronic TMPs appeared to be associated with increased epidermal thickening, collagen and keratin deposition, macrophage infiltration and reduced cellular proliferation. After the 3-4 weeks of transition phase, the TMPs seemed to have transformed into a non-healing chronic TMP between 6 and 10 weeks.

Variables associated with repeated ventilation tube insertion in healthy non-syndromic children

OBJECTIVES

The objectives of this study was to determine variables associated with rVT insertions for rAOM and/or OME in otherwise healthy children.

METHODS

This was designed as a retrospectively controlled cohort study. Patients were identified from a prospectively collected surgical database. Eligible subjects were those who had undergone rVT and a consecutive concurrent control group who received only one ventilation tube (VT). Exclusion criteria included craniofacial abnormalities and syndromes. Demographics, tympanic membrane characteristics, parental smoking, breast-feeding history, large day-care attendance, and soother use was collected.

RESULTS

Over a period of 10 years, 59 patients underwent rVT (5.6%). 180 children who underwent VT were included in the control group. There was no difference in gender distribution (p=1, 1.73:1 vs. 1.76:1), mean age (p=0.69, 4.7±3.33 vs. 4.4±3.17) or chronic rhinitis (p=0.36, OR 1.376, 95% CI: 0.69-2.74). The rVT group was associated significantly more with a smoking parent (p=0, OR 61.8, 95% CI 21.26-176.07), large day care attendance (p=0, OR 23.39, 95% CI: 8.637-57.54), breast feeding <3months (p=0, OR -0.074, 95% CI: 0.028-0.331), soother use (p=0, OR 21.49, 95% CI: 7.81-55.87), and tympanic membrane atelectasis (p<0.0005). The same factors were also found to be significant upon multiple regression analysis (p<0.05).

CONCLUSIONS

Otherwise healthy children with rAOM and/or OME are at a greater risk of rVT if they attend large day cares, were not breast fed for ≥3 months, if their tympanic membranes were atelectatic and most significantly if their parents smoke.

Rat model of chronic tympanic membrane perforation: Ventilation tube with mitomycin C and dexamethasone

OBJECTIVE

Chronic tympanic membrane perforation (TMP) in a clinical setting may attract surgical intervention. With the advent of modern biomaterials, new options are available for myringoplasty but safety and efficacy need evaluation in a chronic TMP animal model. The aim of this study was to evaluate the efficacy of ventilation tube (VT) insertion in conjunction with topical application of mitomycin C/dexamethasone (M/D) for the creation of chronic TMP in rats.

METHODS

Thirty male Sprague-Dawley rats underwent myringotomy of the right tympanic membrane (TM) and were divided into three experimental groups: spontaneous healing (myringotomy control), VT insertion for 2 weeks and VT insertion for 2 weeks in conjunction with topical application of M/D (VT-M/D). All TMs were regularly assessed by otoscopy for 10 weeks and then animals were sacrificed for histological evaluation.

RESULTS

In the VT-M/D group, seven out of ten (70%) perforations were patent at 10 weeks (mean patency, 57.9 days; P<0.01). The VT group had two out of ten (20%) perforations patent at 10 weeks (mean patency, 26.5 days; P<0.01), while all TMPs from the myringotomy control group were closed by day 9 (mean patency, 7.2 days). Histologically, the TMPs patent at week 10 had a stratified squamous epithelialized rim, keratinocyte layer thickening around the perforation edge as well as increased collagen deposition and macrophage infiltration.

CONCLUSION

Chronic TMP in a rat model was successfully created by VT insertion and the efficacy was increased in combination with topical application of M/D.

The association of cleft severity and cleft palate repair technique on hearing outcomes in children in northern Finland

BACKGROUND

The consequences of cleft lip and palate include scaring, dental malformations, tooth misalignment, speech problems, and hearing loss. Otitis media with effusion causing hearing loss is a problem for many cleft palate patients.

METHODS

This study examines the association among cleft severity, palate repair technique, and hearing outcomes in children from northern Finland with clefts, aged 3-9 years. The study included 90 cleft patients who were treated at the Oulu University Hospital Cleft Lip and Palate Center between 1998 and 2011. The severity of the cleft, the surgical technique used to repair the palate, audiogram configuration data, and the need for ventilation tube placement were determined retrospectively from patient records.

RESULTS

Only 3.3% of cleft patients had an abnormal pure tone average hearing threshold representing abnormal hearing. Neither the surgical technique used to repair the cleft palate nor the severity of the cleft was a significant factor related to hearing loss or to the number of ventilation tubes required. Hearing improved significantly with increasing age over a span of 6 years.

CONCLUSIONS

Continuous follow-up with proactive placement of ventilation tubes before or at the time of palatoplasty results in hearing outcomes in cleft children that are similar to those reported in non-cleft children.

Timing for Removal of Asymptomatic Long-Term Ventilation Tube in Children

Otitis media with effusion (OME) is the most frequent illness in children. Surgical treatment options include ventilation tube insertion, adenoidectomy or both. Opinions regarding the risks, benefits and intubation period of ventilation tube insertion vary greatly. To determine the appropriate time for when to remove asymptomatic longterm ventilation T-tubes in children. In this prospective study, we analyzed the results of 120 pediatric patients (6-12 years) (240 ears) with persistent OME; we employed the Goode T-silicone tubes. We intentionally planned to remove the tubes at different time points of the study and divided our patients randomly into four subgroups with 30 patents (60 ears in each) according to the intubation period; group I: intubation for 6 months, group II: intubation for 12 months, group III: intubation for 18 months and group IV: intubation for 24 months. The relationship between intubation period and OME recurrence, the rate of persistent tympanic membrane (TM) perforation, granulation tissue or discharge near the tympanostomy tubes, normalization of Eustachian tube function and change of hearing level was analyzed in each patient group. The χ² analysis showed that the rate of normalization of ET function was significantly higher when tubes were removed after 12-months of intubation (P = 0.002), the rate of OME recurrence was significantly higher when tubes were removed before 12-months of intubation (P = 0.004), The rate of otorrhea significantly increased after 12-months of intubation, development of granulation around tubes was significantly higher after 18-months of tube insertion. The rate of appearance of permanent TM perforation significantly increased after 18-months from tube insertion (P = 0.008). Adenoidectomy did not significantly influence the recurrence rate of OME or the rate of persistent TM peroration after tube removal. Our present results suggest that the appropriate intubation period for healing OME in children would be at 12-18 months. Also, we can conclude that longterm ventilation tubes are recommended to avoid repeated intubation and to obtain sufficient results, although their performance is not always satisfactory; mainly because of accompanying complications.

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.

Long-term follow-up of otitis media with effusion in children: comparisons between a ventilation tube group and a non-ventilation tube group

OBJECTIVE

The objective of this study was to investigate the long-term outcomes in children with otitis media with effusion who received either medical treatment or ventilation tubes.

METHODS

We retrospectively analyzed the medical records of 89 bilateral cases of otitis media with effusion in children who were recommended to receive ventilation tube insertion and were followed up for more than 5 years. Tympanic membrane was inspected by otoscopic examination. Hearing was evaluated with pure tone audiometry. The mean duration of follow-up was 8.4 years (range, 5.2-15.7 years). Twenty-three children were treated without surgery, while 22 were treated once by ventilation tube insertion and 44 were treated more than once by ventilation tube insertion.

RESULTS

At the fifth year of follow-up, both groups of children who underwent ventilation tube insertion had more frequent tympanic membrane abnormalities than the medication group (8.7% in those treated without surgery, 72.7% in those treated once by ventilation tube insertion, and 88.6% in those treated more than once by ventilation tube insertion). Common tympanic membrane abnormalities were retraction (27.0%) and tympanosclerotic plaque (23.6%), regardless of the treatment modality. At the fifth year follow-up, the average air-conduction threshold was 10.0 dB (± 6.5 dB) in patients treated without surgery, 15.9 dB (± 11.2dB) in patients treated once by ventilation tube insertion, and 17.8 dB (± 7.6 dB) in those treated more than once by ventilation tube insertion. The audiological difference was significant when we compared the hearing level of children treated by medication without surgery to the two ventilation tube groups.

CONCLUSION

Though ventilation tube insertion can resolve hearing loss quickly, there were more tympanic membrane abnormalities and a decline in hearing levels in our ventilation tube insertion group vs. the observation group measured 5 years later. Physicians should therefore be cautious when applying a ventilation tube in patients with otitis media with effusion and should explain the risks to patients who are a candidate for repeated ventilation tube insertion.

Factors affecting the extrusion rate of ventilation tubes

Objectives

The objective of this study was to determine the various factors that affect the extrusion rate of ventilation tubes (VTs), including the nature of the middle ear effusion.

Methods

A retrospective chart review of 82 pediatric patients (177 ears) who received VT insertion surgery under general anesthesia was carried out to evaluate the relationship between various factors and the VT extrusion rate. The factors we analyzed included age, gender, the adenoid size, the amount and content of the middle ear effusion after myringotomy, bleeding events, associated adenoidectomy and the findings of the tympanic membrane status, the tympanometry and the audiometry of the air bone gap.

Results

The mean extrusion time was 254 days (range, 11 to 809 days). The patients with no history of previous VT insertion had a longer extrusion time (mean, 279 days) than did the patients who had undergone previous VT insertion (mean, 203 days). The patients with serous effusion had the shortest extrusion time (mean, 190 days) as compared to those patients with glue (273 days) and pus (295 days) effusions. Other factors had no statistical significant relationship with the extrusion time.

Conclusion

The mean VT extrusion time was 254 days. The VT extrusion time was significantly related to the characteristics of the middle ear effusion and a history of previous VT insertion. Thus, the nature of middle ear effusion can provide a clinical clue to predict the VT extrusion time.