Incidence of perforation with Goode T-tube

Residual Perforation Risk Assessment of Intratympanic Steroids via Tympanostomy Tube Versus Transtympanic Injections

OBJECTIVES/HYPOTHESIS

To investigate the risk of residual tympanic membrane (TM) perforation after intratympanic (IT) steroidal treatment administered via transtympanic injection compared with trans-tympanostomy tube (TyT).

STUDY DESIGN

Case series, systematic review and meta analysis.

METHODS

Data were retrieved from the medical files of an original cohort of all consecutive patients with sudden sensorineural hearing loss necessitating IT steroidal treatment in a tertiary medical center between January 1, 2016 and November 20, 2020. A systematic literature search of "MEDLINE" via "PubMed," "Embase," and "Web of Science" on comparable published cases was performed and meta-analysis was established.

RESULTS

Eighteen studies describing 818 ears were included in the quantitative meta-analysis in addition to a local cohort of 140 ears. The proportion of residual TM perforation was 1.11% and 1.14% (95% confidence interval: 0.01%-3.27% and 0.028%-2.38%) in the TyT and trans-tympanic groups, respectively, suggesting no significant difference in residual TM perforation risk between these techniques.

CONCLUSION

IT steroid therapy via trans-TyT is not associated with more residual perforations than IT steroid therapy via transtympanic injections.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E2583-E2591, 2021.

Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist

OBJECTIVES

To illustrate some of the common dilemmas in tympanostomy tube care and describe time-tested ways to address them.

METHODS

Computerized literature review.

RESULTS

Issues including the correct diagnosis of recurrent acute otitis media, tympanostomy tube types and techniques for tube placement, management of tube clogging and otorrhea, and methods for tube removal and patching are illustrated.

CONCLUSIONS

Tympanostomy tube placement is the most common surgery performed in children requiring general anesthesia. While some elements of tympanostomy tube care have been addressed in clinical studies, much of clinical practice is guided by shared experience.

Long-term outcomes of cartilage-buttressed T-tube tympanoplasty for prolonged middle ear ventilation

OBJECTIVES/HYPOTHESIS

To report on the safety and efficacy of cartilage-buttressed T-tube tympanoplasty for long-term middle ear ventilation, specifically by examining duration of tube survival, as well as adverse events associated with prolonged middle ear intubation, including persistent tympanic membrane perforation.

STUDY DESIGN

Retrospective case series of patients undergoing cartilage-buttressed T-tube tympanoplasty between January 2005 and December 2016 in a tertiary-care neurotology private practice.

METHODS

Patients who underwent cartilage T-tube tympanoplasty with complete pre- and postoperative audiometric data and a minimum follow-up duration of 12 months were analyzed. T-tube survival and adverse events including persistent tympanic membrane perforation were recorded and compared to published data for other long-term middle ear ventilation techniques.

RESULTS

The study cohort included 72 cartilage-buttressed T-tube tympanoplasties in 68 patients. Median tube survival was 34 months (range, 2-131 months). Incidence of persistent tympanic membrane perforation (n = 1) was 1.4% CONCLUSIONS: Cartilage-buttressed T-tube tympanoplasty is a safe and effective means of accomplishing long-term middle ear ventilation with a considerably lower rate of persistent tympanic membrane perforation as compared to alternative methods of prolonged middle ear ventilation.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:203-208, 2019.

Should Children With Cleft Palate Receive Early Long-Term Tympanostomy Tubes

Objectives:

To determine whether children with cleft palate might benefit from early long-term tympanostomy tubes with the hypothesis that receiving multiple tubes is associated with shorter duration of first tubes.

Design:

Retrospective cohort study.

Setting:

Tertiary care children’s hospital.

Participants:

Records from 401 consecutive children with cleft palate ± cleft lip, born April 2005 to April 2010, were reviewed. After exclusion of children with cleft repair at an outside hospital, no follow-up after 5 years of age, intact secondary palate, no tubes, or tube replacement at palatoplasty, 105 children remained.

Main Outcome Measure:

Number of tubes.

Results:

Armstrong grommet tubes were placed at a median age of 6.7 months (range 2.3-19.6 months). Tubes were replaced in 55.3% of patients, with 34.0% receiving ≥3 sets. Duration of first tubes was significantly longer for children with 1 set of tubes compared with those with multiple sets (median 26 vs 19 months, P = .004). Otorrhea, but not perforation, was associated with longer duration of first tubes (median 27 vs 20.5 months, P = .028). Cleft type did not impact the proportion of patients with multiple tubes. Median age at last tube placement for children with multiple tubes was 5.0 years (range 1.9-8.7 years).

Conclusion:

Short duration of first tubes is associated with receiving multiple tubes. Because most patients require repeat tubes and many require tubes until school age, there is a significant need for controlled, prospective trials of early long-term tube placement in this population.

Pediatric myringoplasty: Prognostic factors in surgical outcome and hearing threshold recovery

CONCLUSIONS

This study shows as decisive factors the history of tympanostomy tube insertion and surgical approach. The closure of the perforation observed at the 6th post-operative month is almost definitive, without finding significant differences ahead. The myringoplasty can be performed simultaneously in bilateral perforations and in a day-case basis with same success rates. Astatistically significant audiometric improvement area is described, after myringoplasty, undescribed previously in literature.

OBJECTIVES

The aim of this study was to evaluate prognostic factors in surgical outcome and hearing threshold after myringoplasty, in pediatric age.

METHODS

A 10-year retrospective review of 142 myringoplasties performed by a single surgeon of the Pediatric ENT Department of 12 de Octubre University Hospital. Multiple prognostic factors were investigated, such as those related to perforation and surgery, contralateral ear status, and pre- and post-operative hearing threshold.

RESULTS

The overall rate of closure of the perforation was 74.64%. The re-perforation rate was directly proportional to the number of tympanostomy tube insertion (OR = 1.64). Other determining factors were the surgical approach, the graft position and side. There was a post-operative significant improvement (p < 0.001) insuring that the more affected frequencies, low (125-500 Hz) and high frequencies (4000-8000 Hz), were the more improved after the procedure.

[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).

Long-term ventilation tubes: results of 726 insertions

Patients with chronic or recurrent otitis media with effusion who do not respond to treatment with conventional ventilation tubes are often treated with long-term ventilation tubes. The aim of this retrospective study was to determine the extrusion and complication rates of long-term ventilation tubes. The median ventilation time of the tubes was 31.5 months. The most common complication was otorrhoea. One episode of otorrhoea occurred after 24% of all tube insertions, and recurrent otorrhoea occurred in 29%. A persisting perforation developed in 19% after extrusion or removal of the tube. Other, mostly minor, complications occurred in 36% with the tube in situ and in 3% after extrusion or removal of the tube. Long-term ventilation tubes provided prolonged ventilation of the middle ear, but also resulted in a considerable number of complications. For each individual case, one should therefore determine whether the advantages of long-term ventilation tubes outweigh the possible complications in view of the available alternatives for middle ear ventilation.

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.

Effect of topical 5-fluorouracil on closure time of myringotomies created by a radiofrequency surgical unit in guinea pigs

PURPOSE

To delay the closure time of myringotomy without inserting a ventilation tube by creating a myringotomies in guinea pigs by a radiofrequency surgical unit and using topical 5-fluorouracil (5-FU).

BACKGROUND

Topical 5-FU was used successfully in glaucoma surgery to depress the proliferation of fibroblasts, but the effects of 5-FU in the myringotomy site in delaying closure are not known. The availability of the use of a radiofrequency surgical unit in performing myringotomy and the effects of a radiofrequency surgical unit myringotomy in the patency period of the myringotomy opening are not known.

METHODS

A myringotomy in the tympanic membranes of 30 guinea pigs was created by using a radiofrequency surgical unit. Right ears of these guinea pigs were identified as the study group and sponges with 50 mg/ml 5-FU were applied topically. Saline-soaked sponges were applied to the left myringotomy site, which served as the control side for 15 minutes. Guinea pigs were separated into 2 groups. In Group 2, an additional 20 mg/ml 5-FU and saline solution were dropped into the right and left external ear on the fourth and on the 11th day, respectively.

RESULTS

In all guinea pigs, it was found that all the left-ear myringotomy sites were closed at the end of the first week. In the right ears, the myringotomy sites were closed in 75% of Group 1 and in 80% of Group 2 at the end of the second week. In the histopathologic examination of tympanic membranes, there was no apparent difference between study and control sides, but a slight increase in inflammatory findings were encountered in the study sides.

CONCLUSION

The closure time of the myringotomy site was delayed twice as much as in the control group in the site where topical 5-FU was applied, and the drop form of 5-FU did not create any additional delay in the closure time.

Ventilation tubes and persisting tympanic membrane perforations

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

Overlay versus underlay tympanoplasty. Part I: historical review of the literature

The history of otology is the history of the successful treatment of infections of the middle ear and the eardrum. Otologists have sought to restore hearing lost to infections of the eardrum since the 1600s. The development of instruments, techniques, and materials to treat infection is fascinating because of the serendipitous nature of the discoveries and the insight of the discoverers. This historical review describes the history of the treatment of infections of the ear and the development of modern techniques of ear surgery. Two contemporary methods of tympanic membrane repair are then described.

Prevention of persistent ear drum perforation after long-term ventilation tube treatment for otitis media with effusion in children

The effect of tape patch technique using Steri-Strip tape in combination with freshening of the perforation edge after removal of long-term ventilation tubes for preventing permanent ear drum perforation was evaluated. The longer the tubes remained in place, the higher the incidence of persistent perforation after tube removal. The perforation rate after Goode T-tube treatment was 4.0% in the spontaneous extrusion group and 14.3% in the intentional removal group. In the ears treated by tape patch application, none of the perforations persisted after removal of the Goode T-tube. After removal or extrusion of Paparella Type II tube, perforations did not close in 13.2% of the group without tape patch application. When a tape patch was applied, only one perforation (3.3%) did not close. From these results, tape patch technique in combinations with freshening of the perforation edge at the time of tube removal was useful to promote healing and prevent persistent ear drum perforation.

Long-term follow-up of children inserted with T-tubes as a primary procedure for otitis media with effusion

This study reviews 90 children who underwent T-tube insertion as a primary procedure for otitis media with effusion over a 3-year period and compares the long-term results with a similar group, matched in terms of age, treated with conventional Shepard grommets during the same period. Fifty-one patients (102 ears) in the T-tube group and 53 patients (106 ears) in the Shepherd grommet group attended for clinical review, a minimum of 6 years post-surgery. No significant difference was found between the two groups in terms of pre-operative symptoms (P = 0.95), operative findings (P = 0.84), hearing loss (P = 0.75), or degree of retraction or tympanosclerosis of the tympanic membrane (P = 0.80). A perforation rate of 24% in the T-tube group, compared with 2% in the Shepard grommet group (P = 0.001) is directly attributable to T-tube insertion. Furthermore, the risk of perforation was related to the duration of the ventilation tube in the tympanic membrane.

Bilateral ear canal stenosis from retained Goode T-tubes

A 14-year old white male presented with a 2-year history of bilateral otorrhea. Purulent otorrhea with very stenotic external auditory canals (EAC) were found, and the patient was treated with topical otic solutions. Bilateral conductive hearing loss was found on audiometric studies. Biopsies were taken after the patient failed medical treatment. The results were consistent with granulation tissue and chronic inflammation. A CT scan revealed complete bilateral EAC stenosis. At surgery the patient was found to have bilateral retained Goode T-tubes, which were placed at 2 years of age. After removal of the tubes, the patient made a good recovery with improved hearing. This case illustrates a severe complication of retained tympanostomy tubes. Patients with these tubes require close long-term follow-up with careful management of problems such as granulation tissue or otorrhea to prevent this type of complication.

Ear drum perforations in children after ventilation tube treatment

About 1% of ears treated with straight Teflon tubes get permanent drum perforations after extrusion of the tubes, according to the literature. This paper reports the results of treatment of 20 ears in 17 children who underwent myringoplasty to repair such perforations at a mean age of 9.6 years and with a mean follow-up of 2.4 years. The following history was found: 60% (12/20) perforated after 1 insertion, 47% (9/19) perforated within 12 months after insertion. Seventy percent (14/20) had recurrent infectious problems during tube-treatment and after the perforation was diagnosed. The mean preoperative air-bone gap was 17.9 dB. In 85% (17/20) there was a pure perforation at the site of the previous tube while 3 children had perforations combined with retractions. All drums healed after surgery without serious ventilation problems except in one child. There was no serious infectious problems. The mean postoperative air-bone gap was 10.6 dB. Active removal of long-lasting tubes (> 12 months) is not motivated considering the positive effects of tube treatment in many children and the few perforations that occur. A Teflon tube is a good choice as a standard tube with few perforations that can be successfully surgically treated if self-ventilation and good ear-hygiene is instituted.

Closure of tympanic membrane perforation after the removal of Goode-type tympanostomy tubes: the use of silastic sheeting

The reported incidence of persistent tympanic membrane perforation after the extrusion or removal of Goode-type tympanostomy tubes varies from 3 per cent to 47.5 per cent. A prospective randomized study of 152 Goode-type T-tube removals is presented. In one group of 79 ears, the edge of the defect was just freshened, but in the other 73 ears, the edge was freshened and a small piece of 0.13 mm silastic sheeting placed over the defect. Follow-up was performed at six weeks and three, six and nine months and shows that the use of silastic sheeting increases the rate of closure of the perforation and also significantly decreases the number of persistent perforations at nine months.