Hearing loss due to myringotomy and tube placement and the role of preoperative audiograms

Perioperative and postoperative management of tympanostomy tube insertion: a survey of otorhinolaryngologists in Israel

BACKGROUND

Tympanostomy tube insertion is a standard surgical procedure in children to address middle ear infections and effusion-related hearing and speech development issues. Perioperative treatments like ear drops containing antibiotics, steroids, and tube irrigation with saline aim to prevent complications, yet no universal gold standard treatment exists. Despite guidelines, practice preferences among ENT specialists vary, motivating this study to investigate perioperative management practices in Israel.

METHOD

A survey was distributed among ENT surgeons, collecting data on their main workplace, sub-specialty, preoperative hearing test requirements, tube irrigation practices, tube selection criteria, and timing of tube removal. Distribution and association with main workplaces were examined.

RESULTS

The survey achieved a response rate of 27.33%. Most participants routinely required preoperative hearing tests, with a preference for conducting them within three months prior to surgery (62.2%). Tube irrigation during the procedure was less common among surgeons in the public system (p = 0.007). In response to the COVID-19 pandemic, the majority of respondents maintained their established practices (96.3%), while a small proportion (3.7%) adapted by replacing two in-person meetings with one virtual session. Variations in tube removal timing based on the main workplace were noted, with private practitioners opting for earlier removal (p = 0.002) and were less permissive in water deprivation practices (p = 0.053).

CONCLUSION

This study provides insights into the practices and preferences of ENT surgeons in tympanostomy tube insertion procedures in Israel. Adherence to standardized practices was observed, with variations influenced by the primary workplace. Despite the COVID-19 pandemic, minimal changes were made to established practices. Further research and consensus are necessary to optimize patient outcomes and develop tailored guidelines in this field.

Helping Children with Special Needs: Who Receives Tympanostomy Tubes?

OBJECTIVES

Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion.

METHODS

A retrospective review using the Kids' Inpatient Database (KID) was conducted, with codes from International Classification of Diseases, Ninth Revision used to query data from the years 2003 to 2012 to determine a study group of children with a diagnosis of a developmental disorder undergoing myringotomy and tympanostomy insertion. This group was compared statistically to patients undergoing these procedures who did not have a diagnosed developmental disorder.

RESULTS

In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, P = .002) and higher mean hospital charges ($43 704.77 vs $32 764.22, P = .003). This cohort also had higher proportions of black (17.6% vs 12.3%, P < .001) and Hispanic (23.9% vs 20.6%, P = .014) patients, and had lower rates of private insurance coverage (39.6% vs 49%, P < .001).

CONCLUSION

The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

Should obtaining a preoperative audiogram before tympanostomy tube placement be used as a quality metric? A survey of pediatric otolaryngologists

INTRODUCTION

Obtaining a preoperative audiogram prior to tympanostomy tube placement is recommended by the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline (CPG): Tympanostomy tubes in Children, and this process measure is also used as a quality metric by payers. However, whether audiograms should be mandated in cases of tube placement for both chronic otitis media with effusion (COME) and recurrent acute otitis media (RAOM) is controversial. The objective of this study is to determine reports of practice patterns of pediatric otolaryngologists regarding obtaining audiograms before and after tympanostomy tube placement and opinions regarding utility of CPGs and use of this process measure as a quality metric.

METHODS

A 16-question cross-sectional survey of American Society of Pediatric Otolaryngology (ASPO) members was conducted. Per ASPO policy, no repeated requests or other enhanced response techniques were permitted. Independent t-tests for proportions were used to compare responses.

RESULTS

127 pediatric otolaryngologists completed the survey (response rate 26.9%). Nearly 70% of respondents reported being in practice for >10 years. 74% of respondents reported obtaining preoperative audiograms "always" or "most of the time" for COME, vs. 56.7% for RAOM (p < 0.0001). 76% agreed that obtaining a preoperative audiogram was representative of high quality for COME, vs. 52% for RAOM (p < 0.0001). 12% of respondents "completely agreed" that compliance with all aspects of CPGs represented high quality, while 68.8% responded that they somewhat agreed.

CONCLUSION

There is no consensus among pediatric otolaryngologists regarding the necessity of a preoperative audiogram in tympanostomy tube placement, especially for RAOM. Further evidence demonstrating the benefit of preoperative audiogram obtainment should be developed prior to inclusion as a guideline recommendation and as a quality metric.

Otolaryngology training during paediatric residency: A survey of paediatricians in Canada

INTRODUCTION

There is a significant overlap between paediatrics and otolaryngology relating to clinical practice of the two specialties. A lack of cross-training has been identified in previous studies, but the specifics have not been established. The present study was directed at paediatricians in Canada, and examined the need for mandatory otolaryngology training during paediatric residency.

METHODS

Surveys were mailed out to paediatricians in Canada who had completed residency within the past 20 years. Guidelines for the mailing procedure were regulated by the Royal College of Physicians and Surgeons of Canada. A cover letter, survey form and return envelope were included in the package. Data were tabulated and described using descriptive statistics.

RESULTS

Six hundred sixty-six surveys were mailed; the response rate was 48%. Seventy-three per cent of paediatricians indicated that otolaryngology training should be mandatory during paediatric residency. Seventy-nine per cent of general paediatricians and 68% of subspecialists also believed that it should be mandatory training. Seventy per cent of paediatricians indicated that clinical experience was the best format for otolaryngology training, the other options being lectures or rotations. Postgraduate year 2 was the most preferred year for this training. For paediatricians who indicated mandatory training, 45% indicated that it could not replace something else, 38% said that it could replace another experience and the remainder were undecided. The respondents provided helpful commentary.

INTERPRETATION

The majority of surveyed paediatricians in Canada believe that otolaryngology training should be mandatory during paediatric residency. There was also a general consensus relating to the format (clinical experience) and the duration (two to four weeks) of the training.

Follow up after middle-ear ventilation tube insertion: what is needed and when?

Introduction:

There is a paucity of evidence to guide the post-operative follow up of patients undergoing middle-ear ventilation tube insertion for the first time. This study was conceived to identify current practice at our institution (Ninewells Hospital, Dundee) and to inform subsequent change in our follow-up procedure.

Methods:

Two cycles of data collection and analysis were performed. All paediatric patients undergoing ventilation tube insertion for the first time were identified. Patients who had previously undergone ventilation tube insertion or additional procedures such as adenoidectomy or tonsillectomy were excluded. The first data collection period comprised all of the year 2000, and the second 18 months over 2003–2004. A minimum of 20 months' follow up was allowed for. Data regarding clinical findings and audiometry were recorded at each follow-up appointment.

Results:

We identified a total of 50 patients meeting our criteria for inclusion in the first cohort. There were a total of 156 appointments between surgery and data collection (a mean of 3.12 per child). A total of 113 (72 per cent) appointments lead to no medical intervention. The only statistically significant difference between patients requiring further ventilation tube insertion (n = 10) and those not requiring further treatment during the study period (n = 40) was the average hearing threshold (p < 0.01). These findings prompted a change in the post-operative regime; all patients undergoing ventilation tube insertion were subsequently seen at three months for a pure tone audiogram, and further review depended on clinical and audiometric findings. Records for 84 children were identified and collected for the second cohort, there were a total of 154 appointments (a mean of 1.83 per child). In only 18 appointments (12 per cent) were normal findings and hearing recorded and children given a further review appointment. Sixteen of 29 (55 per cent) children with abnormal clinical findings (otorrhoea, tube blockage or extrusion) required some form of intervention (p < 0.05). Twenty-six had a mean hearing threshold worse than 20 dB at first review. Nineteen (73 per cent) required further intervention of some sort (p < 0.01).

Conclusions:

Our study demonstrated that the vast majority of review appointments resulted in no clinical intervention. We therefore question the need for regular follow up in this patient group. Twenty per cent (10 of 50 and 18 of 84) of our patients required further ventilation tube insertion within the study periods. This is consistent with rates reported in the literature. Children with abnormal clinical findings or a mean hearing threshold greater than 20 dB were significantly more likely to require further intervention. We would recommend one post-operative review with audiometry, three months after surgery. At this initial appointment, further review should be offered to those children with poor hearing, early extrusion, blockage or infection, as they are more likely to require further ventilation tube insertion. This strategy is dependent on good links with community primary care providers and easy access to secondary care for further management, should this be required.

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.