Relationship between tympanic membrane perforations and retained ventilation tubes

Risk Factors for Replacement of Tympanostomy Tubes After Surgical Removal for Pediatric Patients

OBJECTIVES

Ear tube removal and patch myringoplasty are frequently performed. The indication and timing for surgery varies among otolaryngologists. This study identifies risk factors associated with the need for the replacement of tympanostomy tubes after tube removal and myringoplasty.

STUDY DESIGN

Case series with chart review.

SETTING

Single institution academic otolaryngology practice.

METHODS

Patients younger than 12 years of age who underwent tympanostomy tube removal and myringoplasty at the University of Rochester Medical Center from March 2011 to September 2019. Patients with tympanostomy tube removal due to chronic otorrhea were excluded.

RESULTS

One hundred sixty-one patients (230 ears) met inclusion criteria and had sufficient follow-up. Myringoplasty success after tube removal was 94.8%. Successful myringoplasty was associated with shorter tube duration (32 months) versus unsuccessful myringoplasty (40 months) (P = .02). Replacement tympanostomy tubes after myringoplasty occurred in 9.6% of ears. There was no difference in average patient age (P = .96) or duration of tubes (P = .74) in patients who required replacement of tympanostomy tubes versus patients who did not require tube replacement. Patients with a cleft abnormality were more likely to require tympanostomy tube replacement (P < .001).

CONCLUSIONS

Most children do not need tubes replaced after removal. This study identified cleft abnormality as a factor that increased the need for replacement tubes. Longer tube durations of over 3 years negatively impacted myringoplasty success. Tympanostomy tube removal should be considered 2 to 3 years after placement in most patients with longer tube durations considered in children with a repaired cleft palate.

Elective Tympanostomy Tube Removal at 2.5 Years: Results of a Protocol for Retained Tubes

OBJECTIVES

In 2001, we instituted a protocol for the removal of retained tympanostomy tubes, delaying elective removal until 2.5 years after placement. It was hoped that this would decrease the number of surgeries without increasing the rate of permanent tympanic perforations compared to removal at 2 years.

METHODS

Protocol: Fluoroplastic Armstrong beveled grommet tympanostomy tubes were placed by a single surgeon supervising the residents. The children were seen at 6-month intervals after placement. Children with a retained tympanostomy tube(s) at 2 years were seen again at 2.5 years, and the retained tubes were removed under general anesthesia with patch application. All were evaluated 4 weeks after surgery by otoscopy, otomicroscopy, behavioral audiometry, and tympanometry.

STUDY

A computerized collection of patient letters and operative reports was queried to identify children treated according to the protocol between 2001 and 2022. Those with examinations at 2 years ± 1 month and 2.5 years ± 1 month and complete follow-up were included.

RESULTS

Of the 3552 children with tympanostomy tubes, 497 (14%) underwent tube removal. One-hundred and forty seven children fit the strict inclusion criteria. Among those with retained tubes at 2 years, 67/147 (46%) had lost any remaining tube or tubes at 2.5 years and did not need surgery, 80/147 (54%) required unilateral or bilateral tube removal, 9/147 (6%) had a persistent perforation at 1-year follow-up, and 4/147 children (3%) required tympanic re-intubation after either spontaneous extrusion or removal and patching at 2.5 years.

CONCLUSIONS

Delaying tympanostomy tube removal until 2.5 years can cut the need for surgery in half with, an acceptable (6%) incidence of persistent perforations.

LEVEL OF EVIDENCE

Four case series-historical control Laryngoscope, 134:439-442, 2024.

Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate

OBJECTIVE

Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing.

METHODS

We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results.

RESULTS

Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups.

CONCLUSIONS

Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.

Clinical Factors Associated With the Outcomes of Long-Term Middle Ear Ventilation Tube Insertion in Pediatric Patients

BACKGROUND

Ventilation tube (VT) insertion is the most common treatment for otitis media with effusion (OME). However, OME recurrence and persistent tympanic membrane (TM) perforation after VT removal are encountered in a certain percentage of such children.

METHODS

This study was performed to determine the outcomes of children who underwent long-term VT insertion. A total of 326 ears from 192 patients were analyzed. The associations among the patient age, sex, history of OME, history of repeated acute otitis media, placement duration, whether the VT had been removed intentionally or spontaneously, and the outcome (persistent TM perforation or OME recurrence) were analyzed. The outcomes of multiple VT tube insertions were also reviewed. We also analyzed whether or not local or general anesthesia was associated with the early spontaneous extrusion of the VT.

RESULT

The OME recurrence and TM perforation rates were 29% (96/326 sides) and 17% (57/326 sides), respectively, for first insertions. In addition, 96 (29%) sides underwent ≥2 insertions. The shorter the duration for which the VT was retained in the middle ear, the more significant the rate of increase in OME recurrence. The OME recurrence was observed more often when VT was spontaneously removed than when intentionally removed. The rate of persistent TM perforation was significantly associated with male sex. Persistent TM perforation was not observed in patients who underwent 4 or 5 insertions. The anesthesia method did not significantly influence the timing of spontaneous extrusion of VT.

CONCLUSION

The retention period of VT should be at least 2 years, and VT removal at the age of 7 might be a viable strategy. Multiple VT insertions are recommended for patients with recurrent OME. Ventilation tube under local anesthesia is an effective option for tolerable children.

How long do tympanostomy ventilation tubes last in pediatric patients with otitis media with effusion or adhesion? A study using Kaplan-Meier survival analysis

OBJECTIVE

The purpose of this study was to evaluate the functional duration and survival rate of tympanostomy ventilation tubes and the complications associated with their use in pediatric patients who underwent tube insertion for otitis media with effusion (OME). Complications were analyzed including recurrence and tympanic membrane perforation after the tube removal or extrusion.

METHODS

Altogether, 447 ears from 234 pediatric patients younger than 15 years of age were studied retrospectively. All patients had undergone long-term tympanostomy ventilation tube: the Goode T-tube insertion for OME at the Osaka Women's and Children's Hospital, which is the pediatrics specialty hospital between April 2014 and March 2016. They were typically followed up every 3-4 months or more frequently if necessary due to otorrhea or tube infection. Subsequently, the tube duration, survival rates of the tube especially at 22 months after insertion defined as "full-term placement", and the rates of recurrence and perforation were calculated and statistically evaluated.

RESULTS

Of 447 ears, 335 ears from 184 patients underwent their first tube insertion, and 112 ears from 64 patients underwent their second or subsequent tube insertion within the targeted period. Two hundred ears from 106 patients were associated with a cleft palate. The survival rate at full-term placement was 51.7%. The recurrence rate was 56.3%, and the rate of the tympanic perforation was 8.5%.

CONCLUSIONS

Approximately half of the tubes survived for 22 months. The perforation rate was relatively low; however, recurrence of OME was seen in more than half the ears.

Outcome of the 'waiting until spontaneous extrusion' strategy for long-term tympanostomy tube placement in children with cleft palate

BACKGROUND

Otitis media with effusion (OME) in children with cleft palate (CP) is known to be refractory to treatment and most of these patients undergo surgery for ventilation tube (VT) placement.

OBJECTIVES

To identify the outcomes of children with CP using long-term VT with a 'waiting until spontaneous extrusion' strategy.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of all children with CP who visited our department from December 2016 to November 2017 and who received long-term VT placement in our department. Risk factors related to residual perforation and recurrence of OME were analyzed.

RESULTS

A total of 106 children were included in this study. Our statistical analysis of 94 ears followed for more than three months after VT loss revealed that longer VT placement was associated with residual perforation, and shorter VT placement was associated with OME recurrence. Although a longer duration of VT placement was associated with an increased rate, extremely long-term VT placement was not associated with residual perforation, as expected. Half of the VTs were spontaneously extruded at 40 months after insertion.

CONCLUSIONS AND SIGNIFICANCE

Long-term VT insertion using a waiting until spontaneous extrusion strategy is a potential option for children with CP.

A Systematic Review and Meta-Analysis: Timing of Elective Removal of Tympanostomy Tubes

OBJECTIVE(S)

Tympanostomy tube (TT) placement is the most common surgical procedure in children. Less than 10% of TT do not self-extrude. This study is a systematic review (SR) on elective TT removal in the pediatric population: timing, perforation rates, and role of simultaneous repair. A PICOTS (population, intervention, comparison, outcome, timing, setting) question was formulated: In pediatric patients who have retained TT, what is the preferred time to elective removal of such tubes, and what are the outcomes in terms of perforation rates? Does an intervention at the time of TT removal improve perforation rates?

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We searched four major electronic databases: EMBASE, MEDLINE, CDSR, CCRCT for articles published prior to 02/19/20. EndNote® was used to gather references, review abstracts, and obtain full text articles. Inclusion criteria were studies reporting patients aged 0 to 18 years undergoing elective TT removal with follow-up greater than 3 months. Exclusion criteria included patients >18 years, duplicate patient series, or case series with fewer than five patients. Articles that were not available in English, not available in full text, and those that only addressed long-acting TT were excluded. Data were pooled and meta-analysis was conducted to examine how timing of TT removal, patching of the tympanic membrane, or any TM intervention at TT removal affected outcomes.

RESULTS

A total of 1,064 references were found. We identified 63 unique studies for full text review. Of these, 17 were selected for SR. MINORS (Methodological Index for Nonrandomized Studies) scores were low-revealing high bias among the studies. Reported perforation rates after elective TT removal ranged from 0% to 57%. Four studies had data suitable for comparative meta-analysis, which showed a significant increase in perforation rates after elective removal of TT after 3 years compared to removal prior to 3 years (OR 2.89; CI 1.78-4.69). No difference in perforation rates were identified when TM intervention vs. no intervention at time of TT removal was performed (six studies: OR 1.21; CI 0.71-2.07). No difference in perforation rates was identified when the type of TM intervention was compared, including freshening of TM edges, to patching with various materials (paper, fat, gelfoam®/gelfilm®, Trichloroacetic acid) (three studies: OR 1.07; CI 0.52-2.19).

CONCLUSION

From the data reviewed in this SR and meta-analysis, elective TT removal at or prior to 3 years' retention showed decreased perforation rates. However, TM intervention at the time of TT removal was not shown to lower perforation rates. In the absence of tube complications such as granuloma formation, nonfunctional tube, or chronic tube otorrhea, it may be reasonable to wait up to 3 years to electively remove a retained TT. Laryngoscope, 2021.

Subannular Tubes in Children With Cleft Palate

OBJECTIVE

To investigate subannular tube (SAT) placement as an alternative treatment of chronic middle ear disease in children with cleft palate.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All children with cleft palate with intractable otitis media with effusion and/or with tympanic membrane retraction, operated for insertion of 1 or more sets of transtympanic tubes followed by SAT in a tertiary center.

MAIN OUTCOME MEASURES

Audiological outcomes, average duration of tubes, and postoperative complications were analyzed.

RESULTS

This study included 21 children with cleft palate, aged 3 to 14 years. A total of 38 ears was evaluated. The median time of follow-up was 42 months. During follow-up, 69.2% of the patients had no complications. Observed complications were otorrhea (13.5%) and tube obstruction (7.7%). In 7.9% of the cases, otitis media with effusion relapsed after tube extrusion. By the end of the study, 76.3% of the tubes remained in situ and 68.4% of the tympanic membranes had the SAT in place and had no significant alterations. The mean duration of SATs was 16 months, which was significantly superior to transtympanic tube duration. A significant sustained improvement in the hearing of children with SATs was observed.

CONCLUSION

Subannular tube insertion results in hearing improvement to normal range and tympanic retraction pockets reversion in children with cleft palate with persistent otitis media with effusion and tympanic retraction/atelectasis. This surgery appears to be safe and provides long-term efficient middle ear aeration. Strict postoperative follow-up is crucial for the success of the treatment.

Retained Tympanostomy Tubes: Who, What, When, Why, and How to Treat?

BACKGROUND

Tympanostomy tube placement is one of the most common surgical procedures performed across the globe. Controversies exist regarding what to do when a tube is considered to be retained in the tympanic membrane for too long.

MATERIALS AND METHODS

Review of the PubMed medical literature starting in 1990, focusing on English language studies reporting on the definition, complications, and management of retained tympanostomy tubes.

RESULTS

The medical literature reporting on outcomes regarding retained tympanostomy tubes is relatively sparse. Most studies recommend prophylactic removal of tubes after a defined period of time, usually around 2 to 3 years after placement. A preferred method of myringoplasty after tympanostomy tube retrieval has not been established, but most studies recommend grafting the perforation at the time of tube removal.

CONCLUSIONS

Although a consensus as to the optimal management of retained tympanostomy tubes is not yet established in the medical literature, a preponderance of studies recommend prophylactic removal at defined period of time (>2-3 years) before the onset of complications such as otorrhea and granulation tissue formation. Due to a lack of best evidence, the surgeon's preference remains the guiding principle as to the best technique for myringoplasty at the time of removal.

Collagen matrix as a replacement for Gelfilm® for post-tympanostomy tube myringoplasty

OBJECTIVE

Gelfilm® is no longer available for use in myringoplasty. We have substituted a commercially available collagen matrix (Biodesign® Otologic Repair Graft) for Gelfilm® as on onlay patch after removal of retained tympanostomy tubes. We compare the effectiveness of these two materials for post-tympanostomy tube myringoplasty.

METHODS

Surgeries were performed in the same manner by residents supervised by the same surgeon during consecutive time periods. Tympanostomy tubes were removed under general anesthesia using a pick and cup forceps. Margins of the resultant perforation were rimmed and a patch placed on the lateral surface of the drum to cover the perforation. Children were seen at 4 weeks after surgery. Tympanic membrane closure was assessed by otoscopy and tympanometry. Patient age at time of myringoplasty, laterality (right/left/bilateral), and presence or absence of a persistent perforation at one month follow-up were tabulated. Total duration of tympanic intubation, tube design and material, reason for tube removal, and additional risk factors (trisomy 21, cleft palate, midfacial anomalies) were analyzed.

RESULTS

55 children met inclusion criteria. 28 children (36 ears) were patched with Gelfilm®. 27 children (35 ears) were patched with collagen matrix. Median ages at surgery and duration of intubation were similar in the two groups. There were persistent perforations at 4 weeks in 5/28 children (5/36 ears, 14%) with Gelfilm®, and 3/27 children (3/35 ears, 9%) with collagen matrix. There was no significant difference in the rate of persistent perforation between the two materials by Fisher's exact test by patients (p = 0.7049) or by ears (p = 0.7101; OR: 1.72; 95% CI 0.38-7.82).

CONCLUSION

Gelfilm® and collagen matrix patches performed similarly in the operating room. Rates of tympanic membrane closure were comparable in this pilot study. Larger patient numbers will be needed to prove equivalence or superiority of collagen matrix for this application.

A retrospective review of Paparella Type 1 tympanostomy tubes

OBJECTIVE

This study aims to provide data on ear tube extrusion and complication rates for patients who have Paparella Type 1 tympanostomy tube (TT) placement.

METHODS

Retrospective chart review of patients 6 months to 12 years old who underwent insertion of Paparella Type 1 TT by a single surgeon.

RESULTS

Of 197 tubes evaluated, 3% were plugged between 1 and 3 months after surgery. Of the 144 tubes evaluated long-term, all tubes extruded within 4 years. There were no tympanic membrane perforations.

CONCLUSIONS

This chart review showed expected rate of initial ear tube plugging. The rate of tympanic membrane perforation was lower than expected.

Impact of perforation size and predictive factors for successful pediatric gelfoam myringoplasty

OBJECTIVES

Rates of success with pediatric myringoplasty range from 35 to 95%. The objective of this study is to evaluate the impact of perforation size on successful closure of the tympanic membrane (TM) after gelfoam myringoplasty. We also aim to identify variables that affect perforation closure rates and define predictive factors for successful TM closure.

METHODS

A retrospective chart review of all patients that underwent gelfoam myringoplasty by a single surgeon from August 2008 through January 2015 was performed.

RESULTS

One hundred fifty-nine patients met inclusion criteria and underwent a total of 219 procedures. Overall, gelfoam myringoplasty had an 83.1% rate of successful closure. Average perforation size was 15.31%. Classification tree analysis separated our cohort into three groups based on perforation size: Group 1 (<16.25%) had a 91% closure rate, group 2 (16.25% to <31.25%) had a 66.0% closure rate and group 3 (≥31.25%) had a 30.0% closure rate. Smaller perforations (P ≤0.001) were associated with increased success rates. Other factors associated with successful closure of the TM included younger age at the time of myringoplasty (P ≤0.001), fewer number of prior tympanostomy tubes (P = 0.016), and lesser duration of tube retention (P = 0.003).

CONCLUSION

Gelfoam myringoplasty provides good overall TM closure rates and may be considered as a potential first-line option for repair of perforations, including those involving up to 40% of the TM. Younger patients with smaller perforations, fewer sets of tubes, shorter length of tube retention are more likely to have successful closure of the tympanic membrane.

Evaluating short and long term outcomes following pediatric Myringoplasty with Gelfoam graft for tympanic membrane perforation following ventilation tube insertion

Background

Myringotomy with ventilation tube (VT) insertion to treat recurrent acute otitis media and chronic secretory otitis media has become one of the most common surgical procedures performed in children. Although contemporary literature has detailed the various patient and perioperative factors that affect successful pediatric myringoplasty, there is still limited evidence surrounding the increasing number of graft material options. In particular, gelfoam patching has arisen as a simple and efficient modality for perforation closure, but has a paucity of evidence particularly in pediatric cohorts. Our study aims to evaluate the clinical and audiometric outcomes following gelfoam myringoplasty for TMP following prolonged VT insertion in an urban pediatric population.

Methods

A retrospective review of pediatric patients who underwent myringoplasty between 2013 and 2018 following ventilation tube insertion. Patient demographics, comorbidities, and graft material were correlated with audiometric and clinical outcomes on follow up examination.

Results

One hundred twenty patients underwent myringoplasty, with 61 (50.8%) males with a mean age of 8.9 years old. 101 (84.2%) of patients eventually underwent successful tympanic membrane (TM) closure, with 93 (77.5%) demonstrating closure at initial follow up. In the gelfoam cohort, 77 (90.6%) of patients demonstrated successful TM closure at initial follow up. Overall mean time to closure was 5.6 (standard error (SE) 0.9) months. A multivariate Cox proportional hazards model demonstrated none of the covariates including graft material significantly affected TM closure. Mean change in air conduction threshold were comparable between graft materials.

Conclusions

Pediatric myringoplasty with gelfoam graft material is a safe and viable alternative with favorable short and long term clinical and audiometric outcomes.

Can lateral nasopharyngeal radiographs be used to predict eustachian tube dysfunction?

The objective of our case-control study was to determine whether craniofacial features on lateral nasopharyngeal radiographs (LNPRs) can predict eustachian tube dysfunction (ETD). The study included patients seen in the otolaryngology clinic from 2005 to 2011. Patients 0 to 10 years old with pressure equalization tube (PET) placement and LNPR within 6 months were included. Measurements were compared with age-matched controls selected at random to identify craniofacial features associated with ETD. Using receiver operating curve methodology, selected measurements were used to correlate age, craniofacial features, and ETD. The study population consisted of 32 patients and 34 controls. No significant differences were found between groups on any individual measurement: cranial base angle; lengths of anterior, middle, and total skull base; mandible; hard and soft palates; sella-soft-palate tip; sella-posterior nasal spine; and nasopharyngeal and palatal airway. Further statistical analysis demonstrated that patients who required PETs were more likely to have shortened anterior cranial base and maxilla relative to mandibular length. Contrary to the findings of previous studies, no single measurement was found to identify craniofacial features that may select for children with ETD requiring PETs. However, younger patients with a smaller cranial base and/or maxilla relative to mandibular length are more likely to require PETs, implying persistent ETD.

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.

Animal models of chronic tympanic membrane perforation: a 'time-out' to review evidence and standardize design

OBJECTIVE

To review the literature on techniques for creation of chronic tympanic membrane perforations (TMP) in animal models. Establishing such models in a laboratory setting will have value if they replicate many of the properties of the human clinical condition and can thus be used for investigation of novel grafting materials or other interventions.

METHODS

A literature search of the PubMed database (1950-August 2014) was performed. The search included all English-language literature published attempts on chronic or delayed TMP in animal models. Studies of non English-language or acute TMP were excluded.

RESULTS

Thirty-seven studies were identified. Various methods to create TMP in animals have been used including infolding technique, thermal injury, re-myringotomy, and topical agents including chemicals and growth factor receptor inhibitors. The most common type of animal utilized was chinchilla, followed by rat and guinea pig. Twenty three of the 37 studies reported success in achieving chronic TMP animal model while 14 studies solely delayed the healing of TMP. Numerous experimental limitations were identified including TMP patency duration of <8 weeks, lack of documentation of total number of animals attempted and absence of proof for chronicity with otoscopic and histologic evidence.

CONCLUSION

The existing literature demonstrates the need for an ideal chronic TMP animal model to allow the development of new treatments and evaluate the risk of their clinical application. Various identified techniques seem promising, however, a need was identified for standardization of experimental design and evidence to address multiple limitations.

A systematic review of concomitant interventions to prevent persistent perforations following the removal of long-term ventilation tubes

OBJECTIVE

To review the current evidence for the use of concomitant interventions to reduce the persistent perforation rate following the removal of long-term ventilation tubes.

TYPE OF REVIEW

A systematic review of the literature and meta-analysis of randomised controlled trials on this topic.

SEARCH STRATEGY

Medline (1952-2008), EMBASE (1974-2008) and the Cochrane Central Register of Controlled Trials. A combination of search terms were used in a search strategy derived from guidance from the Cochrane collaboration.

EVALUATION METHOD

A review of all trials by two authors with grading of the level of evidence.

RESULTS

Fifteen studies using a variety of interventions were identified.

CONCLUSION

A multi-centre randomised controlled trial is indicated to validate findings of previous studies and elucidate any optimum intervention to reduce the persistent perforation rate.

Contemporary indications for ventilation tube placement

PURPOSE OF REVIEW

To discuss the current indications for ventilation tube placement

RECENT FINDINGS

In the past year, several studies have challenged the current guidelines for ventilation tube placement and antibiotic use for otitis media in children. Critics argue that some of these studies have poor scientific validity, yet these studies are being referenced, and sometimes misinterpreted, by the media. Fueled by these media reports, many concerned parents are now questioning otolaryngologists as to the efficacy and safety of ventilation tube placement. Whereas the indications for tube placement in children may be in a state of flux, the indications for tube placement in adults has (and is) fairly static. I will discuss the current published guidelines and the potential for changing trends in tube placement rates. I will also review the literature for the past year regarding postoperative management and adjuvant therapies.

SUMMARY

Although there have been no radical changes in the indications for ventilation tube placement, recent studies have challenged the current clinical indicators and the ramifications of these studies may be more evident in the years to come.

[Tympanic membrane perforation and tympanoplasty]

OBJECTIVES

To report anatomic and physiologic characteristics of the tympanic membrane, to discuss the etiology and pathogenesis of tympanic perforation, and to discuss its management.

MATERIAL AND METHODS

After a review of the literature, different surgical techniques and the postoperative results were evaluated.

RESULTS

The rate of tympanic membrane closure is greater than 90% for the majority of authors. Age, mucosa inflammation, pathological contralateral ear (perforation, otitis media, cholesteatoma), and surgical experience influence this result.

DISCUSSION

Even if surgical results are good, abstention must always be proposed and all complications must be explained.

CONCLUSION

Palisade cartilage tympanoplasty is an effective technique for both tympanic membrane closures.

Pediatric myringoplasty: factors that affect success-a retrospective study

OBJECTIVE

To evaluate the impact of patient and graft variables on the successful closure of tympanic membrane perforations treated with myringoplasty at the Children's Hospital of Pittsburgh from 2000 to 2005.

STUDY DESIGN

Retrospective chart review at an academic tertiary-care children's hospital.

METHODS

Charts were reviewed for 604 children, ages 1 to 18 years old, with complete records who underwent myringoplasty by the pediatric otolaryngology practice at Children's Hospital of Pittsburgh of UPMC from 2000 to 2005, totaling 777 procedures.

RESULTS

Significant variables include patient age, number of prior tubes, perforation etiology (P < .000), presence of a retained tube (P < .000) as well as tube type (P = .016), graft material (P = .001), and history of Down syndrome (P = .035). Nonsignificant variables include season of procedure (P = .599), status of adenoid tissue (P = .910), prior otorrhea (P = .175), as well as perforation location (P = .318) and duration (P = .150).

CONCLUSIONS

Proper patient and graft material selection can affect the outcome of myringoplasty procedures. Practical implications from these data suggest that Gelfoam myringoplasty is more successful than either paper patch or fat graft closures, with a 90.8% success rate (P = .001). Myringoplasty should not be deferred during the winter months as the season of procedure does appear to not affect the success of closure (P = .60). Similarly, the presence or absence of adenoid tissue did not affect the success of closure (P = .91).

Factors affecting the persistence of tympanic membrane perforation developed with the extubation of ventilation tube

OBJECTIVE

To determine which factors are associated with persistence of the tympanic membrane (TM) perforation detected after a spontaneous extrusion or surgical removal of a ventilation tube (VT).

METHODS

We conducted a retrospective chart review of all patients who underwent ventilation tube insertion from 1995 to 2003 at our institution. We identified 909 ears in which we could see the final state of TM and found 89 ears that fitted the inclusion/exclusion criteria. Various factors were analyzed to determine the factors associated with persistence of a TM perforation after VT extrusion or removal in 89 ears, including age at the time of tube extrusion or removal, sex, extubation pattern, intubation period, reason for VT insertion, history of previous VT insertions, condition of the TM when a perforation was detected, and previous adenoidectomy.

RESULTS

Three factors were found to be statistically significant predictors of permanent perforation including age, extubation pattern and intubation period on univariate analysis. However, on multivariate analysis, extubation pattern, intubation period remained as statistically significant predictors.

CONCLUSIONS

Our data shows that factors affecting the permanent TM perforation after the spontaneous extrusion or surgical removal of VT include extubation pattern and intubation period.

The influence of ventilation tube design on the magnitude of stress imposed at the implant/tympanic membrane interface

The design of ventilation tubes or grommets is thought to have a considerable influence on their performance. A computational model (finite element method) was used to investigate the significance of four design parameters of a commonly used design of ventilation tube. The design parameters were: the length of the shaft, the diameter of the flanges, the thickness of the flanges, and the material type. A statistical analysis technique, known as a factorial analysis of variance, was used to examine the importance of the four design parameters on the dynamical behaviour of the middle ear with the implant in situ and on the magnitude of stress induced at the implant/tympanic membrane interface. We predicted that the ventilation tube alters the frequency response of the middle ear; specifically the shaft length and the thickness of the flanges were found to have a significant effect upon the vibratory pattern at the umbo. A reduced length of tube and an increased size of flange were also found to be significant for minimising membrane stress (both with P<0.001). Thus, design parameters of critical influence on optimising performance were identified.

Outcomes in children with perforated tympanic membranes after tympanostomy tube placement: results using a pilot treatment algorithm

PURPOSE

The objective of this study was to examine the success of a pilot treatment algorithm for tympanic membrane perforations in children after tympanostomy tube placement.

MATERIALS AND METHODS

A retrospective chart review of children with diagnosed tympanic membrane perforations after tympanostomy tube placement from 1998 to 2003 at a tertiary care children's hospital was performed. The patients had been treated according to an algorithm used by 2 pediatric otolaryngologists for management of tympanic membrane perforations: observation vs myringoplasty. Success rates were examined.

RESULTS

Ninety-five children were identified, 27% of whom had nonhealing perforations after tube extrusion; 73% of the perforations were caused by a retained tube. The median duration of tube retention was 48 months, ranging from 13 to 120 months. After the treatment protocol, 76% of the patients underwent gelatin film or paper patch myringoplasty, 23% had adipose myringoplasty, and 1% were observed. Overall, 91% had healed perforations after the first intervention. Among those requiring a second intervention, the sizes of initial perforations were between 15% and 40%, with postrepair perforation sizes between 5% and 40%. In addition, 75% of those requiring a second intervention underwent tympanoplasty repair and 25% had fat patch myringoplasty. None required a third intervention.

CONCLUSIONS

Our treatment algorithm for children with tympanic membrane perforations after tympanostomy tube placement appears to be successful and is an excellent model for other clinicians.

Tissue-Engineered Calcium Alginate Patches in the Repair of Chronic Chinchilla Tympanic Membrane Perforations

OBJECTIVE

Chronic tympanic membrane perforations are a common problem in the United States. A high number of these cases results from placement of pressure equalization tubes. These perforations may initially be treated with paper patch techniques and although safe and well tolerated, the procedure demonstrates poor efficacy. The ideal treatment for small perforations should be rapid, minimally invasive, and efficacious. Calcium alginate-based tissue engineered tympanic membrane patches represent an attractive option, but in vivo data are required.

METHODS

A controlled prospective study of tympanic membrane perforation repair using a well-known chinchilla model of chronic tympanic membrane perforation was performed. Calcium alginate-based tympanic membrane patches were created using computer-aided design techniques. A previously described chinchilla model of chronic tympanic membrane perforations was used to create stable perforations ranging from 2 to 5 mm. Ears with chronic perforations were divided into three groups: control (no patch), paper patch, and calcium alginate plugs. At 10 weeks postimplantation, all animals were killed and inspected both grossly and histologically for healing.

RESULTS

In the chinchilla model, the alginate grafts demonstrated significantly improved healing rates over both the untreated control group (spontaneous repair) and the paper patch group; nine of 13 healed in the alginate group versus two of nine healed in the paper patch group (P < .05) versus one of 11 healed in the control group (P < .05).

CONCLUSION

Calcium alginate tympanic membrane perforation patches offer a significant advantage in the repair of chronic perforations over traditional techniques in the chinchilla perforation model and may offer attractive opportunities in the clinical setting.

Immediate repair of the tympanic membrane to prevent persistent perforation after intentional removal of long-lasting tubes

OBJECTIVE

Our purpose was to evaluate efficiency of immediate repair of the tympanic membrane perforation after intentional removal of the long-lasting tubes.

METHODS

This study was done in 36 ears of 27 patients who had either Goode-T or Paparella-II silicone tube insertion due to chronic OME or ROM and tube removal. Only the ears in which tube removal was performed due to no longer need for middle ear ventilation were included to the study. After removal of the tube, the perforation edges were refreshed and Steri-Strip (3M) patch was adhered on the perforation site. Otoscopic, tympanometric and audiologic data were reported.

RESULTS

Mean duration of the tube persistence was 49.58+/-11.94 months. It was found that there were two subgroups in the study group: those under regular follow-up (20 ears), and the ears which were out of regular follow-up (16 ears). Mean tube persistence times were 34.10 and 52.11 months in these subgroups, respectively (chi2-test, p=0.056). In six ears (16.67%), persistent perforation (PP) was found. PP rate (PPR) was higher in group-B (25%) than in group-A (10%) (chi2-test, p>0.1). The rest perforation was anteriorly marginal in five of six PP (83.33%). The PPR in the ears in which rest perforation was anteriorly marginal was 35.71% (5/14) while it was 4.54% (1/22) in the ears with central rest perforation (chi2-test, p<0.02).

CONCLUSIONS

Even immediate repair of the perforation after removal of the long-lasting tubes resulted in a high PPR. The data in this study documented that this high PPR was associated with type and localisation of rest perforation and tube persistence time. Anteriorly, marginal perforations had about eight times higher risk of PP and longer tube persistence caused higher anterior marginal perforations after tube removal.

Surgical indications and outcomes of tympanostomy tube removal

OBJECTIVE

To evaluate factors affecting perforation healing in children with surgical removal of retained tympanostomy tubes.

METHODS

We conducted a retrospective chart review of 82 pediatric patients (111 ears) who underwent surgical tube removal at a tertiary care pediatric hospital from 1/1/1999 to 12/31/2001. Patients included 47 males and 35 females with an age range of 2-15 years (average age, 6.8 years and median, 6 years). The length of intubation ranged from 12 months to 108 months (average, 44.6 months). The indications for removal included: prolonged intubation (61.3%), otorrhea or recurrent infection (21.6%), obstruction (7.2%), tube in middle ear (6.3%), enlarging perforation (2.7%), and in preparation for future cochlear implant surgery (9.9%). Interventions included removal of tympanostomy tubes and techniques for encouraging perforation closure. Seventy-six percent of the ears had a technique used to encourage healing. These techniques included freshen edges (11.8%), Gelfoam or Gelfilm (14.1%), Gelfoam and/or Gelfilm with freshened edges (50.6%). The main outcome measure was perforation healing. Chi-square statistical analysis were used to determine the statistical significant of observations.

RESULTS

Overall closure rate for all patients available for follow up was 87.0%, regardless of technique used to encourage healing. There was no statistically significant difference between the average intubation time in ears that healed (44 months), versus those with persistent perforation after removal (42 months). There was no statistical significant difference in closure rate based on patient age. When tubes were removed for prolonged intubation, 87.0% closed. If the indication was otorrhea or recurrent infections, 93.0% healed.

CONCLUSIONS

The overwhelming majority of patients who undergo surgical removal of tubes will show complete tympanic membrane healing independent of technique at time of removal, duration of intubation, patient age, or indication for removal.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes

OBJECTIVE

To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes.

METHOD

Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears.

RESULTS

In all 27 cases, complete healing of the perforation was attained.

CONCLUSION

A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.

Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.

Long-Term Results of Armstrong Beveled Grommet Tympanostomy Tubes in Children

OBJECTIVE

Many different tympanostomy tubes have been developed with different sizes, shapes, compositions, and coatings. Despite the frequency of ventilation tube placement, very few large studies have examined the outcomes of patients receiving this procedure. An ideal tube would be easy to insert and would extrude at a predictable interval without complications. This study was performed to assess outcome measures and complication rates of the Armstrong beveled grommet tube.

DESIGN

A retrospective case series of patients who had Armstrong beveled grommet tympanostomy tubes placed over a 3 year period by two Children's Hospital of Wisconsin pediatric Otolaryngology staff.

MAIN OUTCOME MEASURES

Patient age, diagnosis, operative findings, and time to tube extrusion were reviewed. Otorrhea, perforation, and cholesteatoma rates were also assessed.

RESULTS

Five hundred seven consecutive patients who had Armstrong tubes placed were reviewed. One thousand ninety-six Armstrong tubes were placed in these patients. Follow-up to extrusion rates were available for 756 tubes. The mean patient age at tube placement was 33.3 months, and the median age was 23 months. Mean and median times to extrusion were 16.5 and 15.5 months. One hundred sixty episodes of otorrhea were noted in 148 patients. Four patients had histories of cholesteatoma, none of which developed in conjunction with Armstrong tubes. Ten (1.32%) perforations that have not resolved over time were noted after Armstrong tube placement.

CONCLUSIONS

Armstrong beveled grommet tympanostomy tubes have complication rates comparable with those reported for Armstrong or other short-acting tubes in smaller series.

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.

Ventilation tube removal: does treatment affect perforation closure?

OBJECTIVE

The study goal was to determine whether treatment of the tympanic membrane at the time of ventilation tube (VT) removal affects closure of the perforation.

STUDY DESIGN

We conducted a retrospective chart review and telephone follow-up of children who underwent VT removal from 1995 through 1998.

RESULTS

Among 109 patients (162 ears; 58% male), the mean age at VT removal was 6.7 years. Most VTs (59%) were T-tubes, and most (91%) were removed because of prolonged retention (mean 2.3 years). After VT removal, 111 ears (69%) received treatment, most commonly (44%) with 25% trichloroacetic acid (TCA). At the latest follow-up, 151 of the ears (93%) had healed without additional treatment. Treatment failure occurred more frequently in ears not initially treated with TCA (TCA 3% failure, other treatment 13%, no treatment 8%) and in ears with VTs removed because of otorrhea.

CONCLUSIONS

Most perforations healed. TCA may promote closure, but a large randomized clinical trial is needed to eliminate physician bias.

Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Tympanostomy tubes: types, indications, techniques, and complications

This article reviews current concepts and applications involving tympanostomy tubes. The various types of tympanostomy tubes, indications, complications, and techniques are discussed. Applications ranging from otitis media to dysfunction of the eustachian tube associated with nasopharyngeal carcinoma are included. Experience drawn from patient care and currently published studies support the conclusions made in this article.