Myringotomy and ventilation tube insertion: a ten-year follow-up

Impact of advancement of otitis media with effusion on vestibular organ condition in children

Introduction

Otitis media with effusion (OME) is one of the most common otorhinolaryngological (ENT) disorders in childhood. This study aimed to investigate the vestibular organ condition in children with OME and whether the presence of vestibular disturbances depends on the advancement of OME.

Materials and Methods

Subjects were 53 children between 4 and 14 years old with bilateral OME and treated with middle ear drainage. The study group was divided into two subgroups according to the advancement of the disease. The participants were submitted to an evaluation consisting of anamnesis, ENT evaluation, static posturography, and electronystagmography (ENG). Examination was performed before surgery and one month after drainage.

Results

The posturography revealed the presence of disturbances before and after ME drainage. After drainage, the assessed parameters improved; they still, however, remained elevated. Disturbances in posturography, both before and after drainage, were expressed more fully in the subgroup with stage II compared to the stage I subgroup, especially before drainage. The analysis of the ENG confirmed that the stage of clinical advancement affects the severity of vestibular disorders in children with OME. Greater vestibular disorders in the form of the presence of spontaneous nystagmus and position were more frequent in the subgroup with stage II.

Conclusions

ME effusion affects the vestibular organ in children with OME. The degree of vestibular disturbances depends on the clinical advancement of the disease. The assessment of the vestibular organ condition is beneficial and should be included in the OME diagnostic and for qualification for surgical treatment.

Effect of Insurance Type on Postoperative Tympanostomy Tube Follow-up

OBJECTIVE

Bilateral myringotomy with tube insertion (BMT) is a common procedure performed in children. Appropriate follow-up is necessary to ensure management of postoperative sequalae. The objectives are to investigate (1) the relationship between insurance type and postoperative follow-up attendance and (2) the effect of follow-up on need for further care after BMT.

STUDY DESIGN

Retrospective cohort study.

SETTING

The study included patients <3 years of age undergoing BMT for recurrent acute otitis media at a tertiary care children's hospital within a single year and followed for 3 years. Patients were excluded if they had received a prior BMT; underwent a concurrent otolaryngologic procedure; or had a syndromic diagnosis, craniofacial abnormality, or any significant cardiac or respiratory comorbidity.

METHODS

Number of follow-up appointments, demographics, socioeconomic status, and postoperative outcomes were analyzed.

RESULTS

A total of 734 patients were included with mean (SD) age of 1.4 years (0.50). The majority of patients had private insurance (520/734, 70.8%). Patients with public insurance attended fewer postoperative appointments (1.5 vs 1.8, P < .001) and had a higher incidence of BMT-related emergency department (ED) visits (10.3% vs 3.8%, P = .001). There was no significance found when different insurance providers were compared. An adjusted multivariate regression analysis showed that patients with private insurance were more likely to attend postoperative appointments (odds ratio, 3.52 [95% CI, 2.12-5.82]; P < .001) and less likely to have a BMT-related ED visit (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .024).

CONCLUSION

Insurance type is related to outcomes after the treatment of recurrent acute otitis media with BMT. Future studies that survey individuals will help identify barriers that contribute to patient absence at follow-ups and need for subsequent ED visits.

Evaluating the Efficacy of Intratympanic Dexamethasone in Protecting Against Irreversible Hearing Loss in Patients on Cisplatin-Based Cancer Treatment: A Randomized Controlled Phase IIIB Clinical Trial

OBJECTIVE

To determine the efficacy of long-term high-dose intratympanic dexamethasone in protecting the hearing capacity of cancer patients undergoing cisplatin-based ototoxic treatment.

DESIGN

A randomized controlled phase IIIB clinical trial to evaluate the efficacy of dexamethasone in protecting against hearing loss in patients undergoing cisplatin treatment. The subjects participating in the clinical trial were patients with a neoplastic disease whose treatment protocol included cisplatin. The average dose of cisplatin was 444.87 mg (SD 235.2 mg). Treatment consisted of intratympanically administering dexamethasone via a passive diffusion device called Microwick (8 mg/24 h dose) from the start of treatment with cisplatin to 3 weeks after the last cycle. Patients were administered the medication to one ear, and the contralateral ear was used as the control. The treated ears were randomly chosen using a computer system (randomization). The hearing threshold was evaluated using pure tone audiometry before each cisplatin cycle.

RESULTS

Thirty-four patients were recruited over a 2-year period at a reference tertiary hospital, of whom 11 were excluded. Forty-six ears were analyzed (23 treated and 23 control ears). When treatment was completed, the audiometric analysis showed a higher hearing threshold in the study group than in the control group. Differences were statistically significant at frequencies of 500, 1000, and 6000 Hz: 4.9 dB (1.1 to 8.7), 5.5 dB (0.8 to 10.3), and 16 dB (3.2 to 28.7), respectively, (p < 0.05, 95% confidence interval), but were not clinically significant according to the ASHA hearing loss criteria. Both 8.69% infection complications during treatment and 34.8% permanent perforation at 6 mo were detected after device removal.

CONCLUSIONS

Long-term high-dose intratympanic dexamethasone treatment did not prevent cisplatin-induced hearing loss.

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.

Hearing Loss in Young Adults Who Had Ventilation Tube Insertion in Childhood

It is known that insertion of ventilation tubes can cause damage to the tympanic membrane and hearing deterioration in the long term. To investigate long-term effects of recurrent otitis media and of ventilation tube insertion, we used a study group (n = 358 subjects), with or without a history of otitis media and/or ventilation tube insertion, derived from a birth cohort that had been followed for 16 years. At 18 years of age, a standardized audiometric and otoscopic examination was performed. We found that ventilation tube insertion in childhood was associated with a mean persistent hearing loss in young adults of about 5 to 10 dB at the group level with a sensorineural component of 3 to 4 dB. This hearing loss could not be explained by the disease load of otitis media in childhood. Repeated insertions of ventilation tubes caused a greater deterioration of hearing than did a single insertion. Structural changes of the tympanic membrane were a mediating factor in the causal relationship between ventilation tube insertion and hearing loss. We conclude that ventilation tube insertion in childhood may induce hearing deterioration in the long term.

[Assessment of Tumor Necrosis Factor alpha gene expression profile in selected structures of middle ear in patients with tympanosclerosis]

AIM OF THE STUDY

Tympanosclerosis is a middle ear disease located in submucous membrane. It leads to the tympanic membrane and ear ossicles fixation which results in severe conductive hearing impairment. The etiology of tympanosclerosis remains unclear. Cytokines play very important role in development of tympanosclerosis. The research aimed to assess gene expression level of pro inflammatory cytokine TNF-α in selected structures of middle ear in patients with chronic otitis media with tympanosclerosis.

METHODOLOGY

The research was performed on middle ear tissues with tympanosclerosis achieved from 30 patients operated on in the Otolaryngology Department of the Medical University of Gdańsk. The control group was formed by tympanic membranes sampled from 17 corpses of patients who died suddenly. Advancement of tympanosclerotic changes were grouped based on Tos classification. The TNF-α gene expression level was measured by real time PCR with specific hydrolysed probes (TaqMan). The gene expression level for TNF-α was correlated with clinical classification of tympanosclerosis.

RESULTS

The level of gene profile expression for TNF-α in selected structures of the middle ear with tympanosclerosis was statistically significant, higher in comparison with the control group. The highest level of expression was observed in group two which is relevant to more advanced tympanosclerosis.

CONCLUSION

Tympanosclerosis is a result of constant inflammatory process and it is modulated by cytokines including TNF-α. The positive correlation between gene expression level of TNF-α and tympanosclerosis could in the future contribute to antiinflammatory, medical treatment of tympanosclerosis.

Antioxidant effect of pomegranate extract in reducing acute inflammation due to myringotomy

OBJECTIVE

To assess the effect of pomegranate extract on acute inflammation due to myringotomy.

DESIGN

Prospective, randomised study.

SUBJECTS

Thirty Sprague-Dawley rats were divided into three groups. Group one constituted controls. Group two underwent myringotomy. Group three underwent myringotomy and also received 100 µl/day pomegranate extract, via gavage, one day before and two days after surgery. Following sacrifice 48 hours after myringotomy, the animals' right ears were used to determine the concentration of reactive oxygen species, using the chemiluminescence method; left ears were used for histological study.

RESULTS

Reactive oxygen species levels were significantly decreased in group three compared with group two (p < 0.01). The density of inflammatory cells in group three was significantly less than that in group two (p < 0.01). Lamina propria thickness and vessel density were also significantly decreased in group three compared with group two (p < 0.01).

CONCLUSION

Our results indicate that oral pomegranate extract decreases reactive oxygen species concentration and acute inflammation in the tympanic membrane after myringotomy.

Myringosclerosis after tympanostomy tube insertion: relation with tube retention time and gender

OBJECTIVE

To determine relationship between myringosclerosis and tube retention time and sex in children with chronic otitis media with effusion who were treated with tympanostomy tube insertion. Also, the relationship between myringosclerosis both sex and initial age of tube insertion were investigated.

METHODS

A total of 101 children (195 ears) were reviewed. Ears were divided into four groups according to retention time of tympanostomy tubes. Group I: Retention time of tympanostomy tube less than 6 months. Group II: Retention time of tympanostomy tube from 6 months to 12 months. Group III: Retention time of tympanostomy tube of 12 months or more. Group IV: Myringotomy group without tympanostomy tube insertion.

RESULTS

The order of the myringosclerosis rates were as follows from the highest to lowest one; group III (44.1%), group II (42.4%), group I (14.3%), and group IV (7.7%). Myringosclerosis was more common in group I compared with group IV, but the difference was statistically not significant (p>0.05). There were no statistically significant differences in myringosclerosis rates between the group II and group III (p>0.05). On the other hand, statistically significant differences were observed in myringosclerosis rates between group I and group II (p<0.05), and between group I and group III (p<0.05); also similar significant differences were present in myringosclerosis rates between group IV and group II (p<0.05), and between group IV and group III (p<0.05). There was no significant difference between preschool age group and school age group. Myringosclerosis was observed in 40% of boys and in 51.2% of girls.

CONCLUSION

Myringosclerosis is frequent in patients who underwent tympanostomy tube insertion. The frequency of myringosclerosis is much higher in tympanic membranes with tympanostomy tube insertion than tympanic membranes with myringotomy, and the location of sclerotic plaques does not always correspond to the tympanostomy area. The myringosclerosis rate was increased when the tympanostomy tubes stay on tympanic membrane for a long time. Highest myringosclerosis rates were observed if the extrusion time was 12 months or longer. In our analysis, sex and initial age of tube insertion were not significant factors for the development of myringosclerosis after extrusion of tympanostomy tubes.

A Comparison of Outcomes following Tympanostomy Tube Placement or Conservative measures for Management of Otitis Media with Effusion

We obtained the charts of 183 patients (197 ears) who had undergone surgery for chronic otitis media (COM), and we reviewed their otic histories to analyze the series of events that ultimately culminated in surgery. All ears had originally been treated for otitis media with effusion (OME); 125 ears had been treated with tympanostomy tube placement, and 72 ears had been treated with conservative measures. Our goal was to compare the influence that these two strategies had on the subsequent development of COM and its sequelae (i.e., retraction pockets, tympanic membrane perforations, and cholesteatomas) and thereby determine which strategy is preferable. We found that although retraction pockets developed in a significantly higher proportion of the tympanostomy-treated ears than the conservatively treated ears (58 vs. 35%; p < 0.01), a significantly greater percentage of retractions in the tympanostomy-treated ears were mild and situated in the anterior part of the tympanic membrane (52 vs. 32%; p < 0.05). Moreover, severe retractions were significantly more common in the conservatively treated ears (40 vs. 16%; p < 0.02); the incidence of complete retractions in the two groups of ears was similar (tympanostomy: 32%; conservative treatment: 28%). Cholesteatomas developed in a significantly lower percentage of tympanostomy-treated ears (67 vs. 81%; p < 0.05), and the incidence of large cholesteatomas that involved the tympanic and mastoid cavities was likewise significantly lower in these ears (44 vs. 69%; p < 0.05). There was no significant difference in the incidence of tympanic membrane perforations. Finally, even though all of these ears eventually required surgery for COM, the tympanostomy-treated ears required significantly fewer repeat surgeries (16 vs. 28%; p < 0.05) and significantly fewer radical modified tympanomastoidectomies (30 vs. 44%; p < 0.05). Therefore, we conclude that myringotomy with insertion of tympanostomy tubes to treat OME is superior to conservative treatment.

Grommets in otitis media with effusion: the most frequent operation in children. But is it associated with significant complications?

INTRODUCTION

Otitis media with effusion is one of the most frequent diseases in children, and its management requires the attention of general practitioners, pediatricians and ear, nose and throat (ENT) surgeons. The main complications associated with tympanostomy tube insertion, are: (1) purulent otorrhea (10-26% of cases), in which local otic preparations might be effective, and biofilm-resistant tubes may decrease this complication in the future; (2) myringosclerosis (39-65% of operated ears), with usually no serious sequelae; (3) segmental atrophy (16-75% of cases); (4) atrophic scars and pars flaccida retraction pockets (28 and 21% of operated ears, respectively); (5) tympanic membrane perforations (3% of cases, although with T-tubes, the incidence may be as high as 24%); (6) cholesteatoma (1% of cases), although tympanostomy tubes may sometimes prevent, rather than contribute to its development; (7) granulation tissue (5-40% of instances), when the duration of tube retention is prolonged.

CONCLUSION

It would appear that the complications associated with tympanostomy tube insertion are more frequent than anticipated, reaching 80% of operated ears under specific circumstances and in certain subgroups of children. These complications may resolve with conservative management, but in persistent cases surgical removal of the tubes is mandatory.

The effect of Vitamin E treatment on the development of myringosclerosis after ventilation tube insertion

OBJECTIVES

Recent studies have established the relationship between the reactive oxygen species and myringosclerosis. Furthermore several antioxidants have been known to prevent myringosclerosis. All the previous studies supporting this hypothesis have been performed on animals. The aim of our study is to investigate the possible effect of Vitamin E on the development of tympanosclerosis after VT insertion on human subjects.

METHODS

72 children undergoing myringotomy and VT insertion were included in the study. Vitamin E was applied to the right ear and no treatment was applied to the left ear. Both ears were examined at the end of 9 months with otomicroscopy. Myringosclerosis formation at the end of the study period was noted for each ear.

RESULTS

Myringosclerosis was found in 33 of the 144 ears. The overall incidence was 22.9%. While 22 (30.6%) of the 72 left ears showed myringosclerosis otomicroscopically, in only 11 (15.3%) of the 72 right ears that were treated with Vitamin E was myringosclerosis observed at the end of the study period. Of these nine cases were bilateral.

CONCLUSION

Animal studies have well documented the development of myringosclerosis after myringotomy and VT insertion and beneficial effects of different antioxidants. Our study has shown similar results in human subjects. Further clinical studies consisting of a larger patient population are needed to bring about routine clinical use of antioxidants in myringotomy and VT insertion.

Hearing loss as a sequel of secretory and acute otitis media as reflected by audiometric screening of Swedish conscripts

OBJECTIVE

Many authors have shown a small effect on hearing from middle ear disease even a long time after active disease has subsided. We wanted to see to what extent those who have had otitis media in childhood in our district have normal hearing at the age of 18 years. The aim of the present study is to find out if a history of secretory otitis media (SOM) up to 14 years of age or acute otitis media (AOM) up to 4 years of age affects hearing at conscription in an age cohort of Swedish boys.

METHODS

For a cohort of 951 boys we have good knowledge of their ear diseases up to 14 years of age from previous studies. The prevalence of elevated thresholds in audiometric screening at conscription was compared for the group of boys who had been treated with tympanostomy tubes and the group of boys with no history of ear disease. Similarly, boys with a history of ear disease but no treatment with tubes were compared to boys without history of ear disease. We also compared the prevalence of elevated thresholds for boys with a history of at least four episodes of AOM up to the age of four to those who had had no episodes up to that age.

RESULTS

Those who had been treated with tympanostomy tubes because of longstanding SOM had a significantly higher prevalence of elevated thresholds for solitary frequencies. Two treated boys had a pure tone average greater than 25 dB, one unilaterally, one bilaterally. No difference could be seen between those who had had episodes of ear disease but no treatment with tympanostomy tubes and those who had had no documented ear disease. The prevalence of elevated thresholds was not correlated to more than three treated episodes of acute otitis media up to the age of 4 years.

CONCLUSIONS

Boys who had been treated with tympanostomy tubes had a higher prevalence of having a hearing threshold above 20 dB for at least one frequency at the age of 18. Hearing handicap was not a common sequel to SOM. We can show no relation between more than three treated episodes of AOM before the age of four and screening results at the age of 18.

Determination of Reactive Oxygen Species in Myringotomized Tympanic Membranes: Effect of Vitamin E Treatment

OBJECTIVES/HYPOTHESIS

Recent studies have established a strong relationship between the development of myringosclerosis and reactive oxygen species (ROS). The aims of the present study were to directly detect ROS in the tympanic membrane and middle ear mucosa of rats by measuring luminol amplified chemiluminescence, to evaluate the changes in the levels of ROS after treatment with vitamin E, and to examine the possible changes in the tympanic membranes otomicroscopically and histologically.

STUDY DESIGN

Prospective controlled animal study.

METHODS

Forty healthy Sprague-Dawley rats were divided into five groups of eight animals each. Animals in all groups except group 1 were bilaterally myringotomized. Group 2 received no treatment, group 3 was treated with topical olive oil, group 4 received topical vitamin E, and group 5 received intramuscular vitamin E. After 24 hours of myringotomy, tympanic membranes were examined otomicroscopically; thereafter, tympanic membranes and middle ear mucosa were peeled off. The right ears of the animals were used for biochemical assay, and the left ears were used for histological study.

RESULTS

Reactive oxygen species levels were significantly decreased in group 4 with topical application of vitamin E compared with untreated and myringotomized animals in group 2. Reactive oxygen species levels were also decreased in group 5, although the decrease was not statistically significant when compared with groups 2 and 3. Histological studies confirmed sclerotic changes in the untreated myringotomized animals. The tympanic membranes of animals in groups 2 and 3 showed a white, chalk-like pattern of sclerotic changes, whereas animals in groups 4 and 5, with the exception of two animals in group 5, lacked these changes.

CONCLUSION

Although the relationship between the development of myringosclerosis and ROS had been well documented previously, the present study is the first that has directly measured the levels of ROS in the tympanic membrane and middle ear mucosa. These results are relevant because they correlate with histological findings. It has also been demonstrated that topically applied vitamin E is effective in decreasing the ROS levels.

Parental perceptions of grommet insertion in children with cleft palate

Otitis media with effusion is almost universal in children with cleft palate and can delay speech, language and educational development by causing hearing loss. Grommet insertion at the time of cleft palate repair is common. There is debate about whether the benefits of grommets outweigh the risk of complications. A postal questionnaire was used to investigate parental perceptions of middle-ear ventilation via grommet insertion in children attending the multidisciplinary cleft palate clinic. These children's case notes were reviewed. Many children had speech and language delay, but parents thought this improved after grommet insertion. Overall parents were pleased with the results. This confirms that grommets have an important part to play in the management of children with cleft palate.

Uncommon and unusual complications of otitis media with effusion

Some complications of otitis media with effusion (OME) are not obvious and not always associated with otitis media by physicians and patients; the authors propose to call them 'unusual complications', although they may be quite frequent. Complications such as dizziness, clumsiness and behavioural disorders are classified in this group. Other complications are rare and uncommon such as sensorineural hearing loss and cholesteatoma. Some of these sequelae are structural, others more functional. The impact of OME on complex functions such as language, learning or behaviour is still controversial but seems to have been underestimated until now. Not only withholding treatment in children with OME may cause complications but also the treatment of OME may lead to sequelae, although serious side effects caused by the treatment of OME are rare. In this literature review, the epidemiology, importance and diagnosis of the uncommon and unusual complications of OME will be discussed.

Assessment of complications of the condition and of the treatment of otitis media with effusion

Persistent otitis media with effusion (OME) may cause long-term changes of the tympanic membrane and middle ear, resulting in some degree of hearing loss. One of the traditional aims of treatment with ventilation tubes is to prevent these complications from developing. Ventilation tubes themselves, however, are also known to induce changes of the tympanic membrane. Several recent studies have addressed the questions: what are the effects of the disease, and what are the result of its treatment? The object of this study was to present the state of the art, by literature review, regarding structural and functional complications of OME and treatment with ventilation tubes. In both observational and experimental studies tympanosclerosis is reported to occur in 39-65% of ears treated with ventilation tubes as opposed to 0-10% of untreated ears. For segmental atrophy these percentages are 16-73 and 5-31, respectively. Regarding the prevalence of atelectasis and attic retraction, the difference between ventilated and untreated ears is less: 10-37% as opposed to 1-20% for atelectasis, and 10-52% as opposed to 29-40% for attic retraction. The average hearing loss associated with these tympanic membrane abnormalities is less than 5 dB. Although ventilation tubes have proven very effective in improving hearing in the short term, they have not proven effective in preventing long-term changes of the tympanic membrane related to OME, nor in keeping some degree of hearing loss from developing.

Timing for removal of tympanic ventilation tube in children

The medical records of 220 ears of 137 pediatric patients (85 male and 52 female) in which three kinds of ventilation tubes were inserted for treating otitis media with effusion (OME) were reviewed. The tubes selected were the Shepard grommet (75 ears), Goode-T (39 ears), and Paparella type II tube (106 ears). The criteria for tube placement were as follows: (1) continuous conductive hearing loss with over 25 dB air-bone gap, (2) resistance to conservative therapy for over 6 months, and (3) retracted and glue-colored tympanic membrane with type B tympanogram. The tubes that remained in place for over 18-24 months were removed intentionally in combination with a freshening of the perforation edge and tape-patch technique using Steri-Strip tape (3M) for preventing permanent eardrum perforation, because the incidence of persistent perforation became higher after long-term intubation. Shepard grommets tended to be extruded earlier, while Paparella type II tubes tended to stay longer. The OME recurrence rate decreased 12 months or more after tubal insertion. There was a tendency for the recurrence rate to decrease the longer the tube stayed in the eardrum. The number of recurrences decreased when the patient's age at the tube removal or extrusion was 7-8 years old. Adenoidectomy did not influence the recurrence rate of OME. Although the Goode-T and Paparella tube II tubes showed high perforation rates, the perforation rate after extrusion or removal of the tube was decreased by the use of the tape patch technique in combination with a freshening of the perforation edge. From these findings, it was concluded that the appropriate intubation period for the treatment of OME in children is over 12 months with the use of a long-term tube, and that if the patient's age at the time of tube insertion was below 6 years, it might be better that the removal of the tube is postponed until the patient is 8 years of age.