Adenoidectomy with laser or incisional myringotomy for otitis media with effusion

Efficacy of laser myringotomy compared with incisional myringotomy for the treatment of otitis media with effusion in pediatric patients: A systematic review

BACKGROUND

Recent reports have shown that laser myringotomy (LM) is increasingly used to treat otitis media with effusion (OME), with higher effectiveness, fewer complications, and lower recurrence rate.

OBJECTIVE

A systematic review of the published literature was conducted to assess the efficacy of LM compared with incisional myringotomy (IM) with or without tympanostomy ventilation tube (VT) for the surgical treatment of OME in pediatric patients (age ≤ 18 years).

METHODS

We searched the PubMed, Web of Science, Ovid, VIP Chinese, China National Knowledge Infrastructure (CNKI), and Wanfang Chinese databases for articles published before Nov 20, 2018. All relevant articles were reviewed and selectively collected according to inclusion and exclusion criteria. The quality of the included studies was assessed. The data in the eligible studies were extracted and analyzed.

RESULTS

A total of 8 studies, including 698 patients and 1262 ears, were included. The types of studies examined include randomized controlled trials (RCTs) and case-control studies of varying quality. The outcomes and complications of LM and IM with or without VT were charted and compared. No quantitative meta-analysis could be performed.

CONCLUSIONS

LM, characterized by much higher recurrence of OME and less complications, is less effective than IM+VT in keeping the middle ear ventilated and relieving middle ear effusion, but more effective than IM alone. The different interventions seem to show no significant differences in hearing improvement. Nevertheless, additional high-quality research is needed to perform more advanced analyses and to confirm and update our results and conclusions.

Surgical treatments for otitis media with effusion: a systematic review

BACKGROUND AND OBJECTIVE

The near universality of otitis media with effusion (OME) in children makes a comparative review of treatment modalities important. This study's objective was to compare the effectiveness of surgical strategies currently used for managing OME.

METHODS

We identified 3 recent systematic reviews and searched 4 major electronic databases. Eligible studies included randomized controlled trials, nonrandomized trials, and cohort studies that compared myringotomy, adenoidectomy, tympanostomy tubes (tubes), and watchful waiting. Using established criteria, pairs of reviewers independently selected, extracted data, rated risk of bias, and graded strength of evidence of relevant studies. We incorporated meta-analyses from the earlier reviews and synthesized additional evidence qualitatively.

RESULTS

We identified 41 unique studies through the earlier reviews and our independent searches. In comparison with watchful waiting or myringotomy (or both), tubes decreased time with OME and improved hearing; no specific tube type was superior. Adenoidectomy alone, as an adjunct to myringotomy, or combined with tubes, reduced OME and improved hearing in comparison with either myringotomy or watchful waiting. Tubes and watchful waiting did not differ in language, cognitive, or academic outcomes. Otorrhea and tympanosclerosis were more common in ears with tubes. Adenoidectomy increased the risk of postsurgical hemorrhage.

CONCLUSIONS

Tubes and adenoidectomy reduce time with OME and improve hearing in the short-term. Both treatments have associated harms. Large, well-controlled studies could help resolve the risk-benefit ratio by measuring acute otitis media recurrence, functional outcomes, quality of life, and long-term outcomes. Research is needed to support treatment decisions in subpopulations, particularly in patients with comorbidities.

Laser-assisted myringotomy versus conventional myringotomy with ventilation tube insertion in treatment of otitis media with effusion: Long-term follow-up

BACKGROUND

Otitis media with effusion is the most common cause of conductive hearing loss in the pediatric population. Insertion of ventilation tubes with or without adenoidectomy is the accepted and standard surgical procedure. CO2 laser myringotomy without tube placement has been advocated as an alternative treatment.

AIM

To compare long-term follow-up results of laser versus classical myringotomy with ventilation tube insertion over five years.

MATERIALS AND METHODS

86 patients with bilateral otitis media with effusion were divided into two groups: laser myringotomy group and myringotomy with ventilation tube insertion group, with follow-up in hearing results and recurrence rates over five years.

RESULTS

The mean patency time of myringotomy in laser group was 23 days, while the mean patency time of the ventilation tubes ears was 4.0 months in myringotomy group. Twelve patients in laser group (13.9%) showed a recurrent otitis media with effusion compared to 9 patients in myringotomy group (10.4%).

CONCLUSION

Laser fenestration is a less effective alternative to myringotomy and tube placement. The recurrence rates after both procedures did not show statistical significance over long follow-up. It might be considered as an effective alternative to classical surgery and ideal for short-term ventilation.

Mitomycin C-associated radiofrequency microelectrocautery used in myringotomy in an animal model

This study aimed at describing an alternative surgical technique to the insertion of a ventilation tube in the tympanic membrane: myringotomy by radiofrequency alone and associated with mitomycin C.

AIM

to show a surgical approach that can be simple to execute, not subject to complications arising from the ventilation tube.

MATERIALS AND METHODS

we compared myringotomy by microknife and by radiofrequency microcautery (0.3 mm and 0.7 mm tips) alone and associated with mitomycin C, considering the time of tympanic closure in Wistar rats. Experimental study.

RESULTS

there was a statistically significant difference between radiofrequency myringotomy and knife myringotomy. As we analyze the radiofrequency approach with the 0.7 mm tip associated with mitomycin C (Wilcoxon test), the p value found was lower than 0.001, showing a statistical significance. The maximum tympanic membrane closure time was 44 days and the median found was 14 days.

CONCLUSION

the radiofrequency myringotomy (with the larger diameter tip) associated with mitomycin C enhances the tympanic membrane healing time.

Could radiofrequency myringotomy be an alternative to incisional myringotomy?

OBJECTIVE

To evaluate the usefulness of radiofrequency myringotomy (RFM) and the closure time of the myringotomy site in comparison to incisional myringotomy (IM).

METHODS

We performed conventional surgical myringotomy on the right ears and RFM on the left ears of 40 rabbits. In order to investigate the effect of the power of energy delivered on the patency period we arranged the animals into two groups: three power grade in RFM group 1 (RFMg1; n: 20) and six power grade in RFM group 2 (RFMg2; n: 20). The follow-up of the myringotomy procedure was performed on days 5, 8, 11, 14 and 17 with examination under the operating microscope.

RESULTS

At the first examination on day 5 after the procedure, all IM openings were found to be closed while seven and eight (36 and 44%) of the tympanic membranes in the radiofrequency groups 1 and 2 remained open, respectively. In these remaining ears, RFM site was patent up to days 11 and 14, respectively in the two RFM groups. None of the RFMs was patent on study day 17. The difference between the closure time of myringotomy sites of the radiofrequency and IM groups was statistically significant (p < 0.05). In comparison of the two RFM groups, we found approximately equal rates regarding the myringotomy patency (p > 005; chi2 yates: 0.02). The complication rates were 5 and 2% for the IM and RFM groups, respectively.

CONCLUSIONS

Radiofrequency myringotomies last longer than incisional myringotomies. With the low complication rate, it is possible to perform this bloodless RF procedure in an office setting. Increased power grade of radiofrequency has no effect on prolonging the myringotomy patency. RFM appears to be a safe and simple procedure that can be used as an alternative to IM.

Prävalenz chronischer Trommelfellperforationen in der erwachsenen Bevölkerung

BACKGROUND

The goal of this study was to evaluate the prevalence of chronic tympanic membrane perforation in the adult population.

MATERIALS AND METHOD

The study population included 1,000 subjects (453 males, 547 females) aged 18-93 years. In addition to interview data, ear examinations were performed.

RESULTS

There were eight subjects with unilateral chronic tympanic membrane perforation and a single subject with a bilateral perforation. The age adjusted prevalence of chronic tympanic membrane perforation was 0.45% (95% confidence interval: 0.03-0.87). Eight out of nine subjects disliked tympanoplasty.

CONCLUSION

The high proportion of subjects with chronic tympanic membrane perforations who do not want to be operated suggests that there is a considerable need for novel therapeutic procedures.

Tympanic membrane healing in myringotomies performed with argon laser or microknife: an experimental study in rats

Secretory otitis media (SOM) and recurrent acute otitis media (RAOM) may require surgical treatment to proper ventilate the middle ear. Incisional myringotomy is usually done under microscopy with a micro-knife, but it remains patent for just a few days. Recent research indicates that laser assisted myringotomies remain open much longer, allowing middle ear ventilation and healing. Material and methods: In this experimental study 34 white, male, adult, Wistar rats, without middle ear disease were submited to anesthesia with ketamine 27 mg/kg and xylazine 2,7 mg/kg. Incisional myringotomy was done on the right ear, while laser myringotomy was done on the left. Myringotomies were evaluated periodically until healing. Results: The healing times were equivalent. All myringotomies healed within 10 days. Conclusion: Argon laser assisted myringotomy healed just as early on as incisional myringotomy on Wistar rats without middle ear diseases.

Laser myringotomy for otitis media with effusion in nasopharyngeal carcinoma patients

OBJECTIVE

To evaluate the effectiveness of laser myringotomy in otitis media with effusion (OME) in patients with nasopharyngeal carcinoma (NPC).

STUDY DESIGN AND SETTING

Laser myringotomy was performed with a CO 2 laser otoscope in 53 NPC patients (68 ears) and 32 non-NPC patients (37 ears). All patients had a history of OME.

RESULTS

In the NPC group, 40% of ears developed persistent perforation, 37% had recurrent OME, and 23% were free of disease. In the non-NPC group, only 3% of ears developed persistent perforation, and 43% were free of disease. Significant differences in perforation and disease-free state were evident between the 2 groups. Tumor stage was found to be a significant determining factor for clinical outcome in NPC group.

CONCLUSION

Laser myringotomy for NPC group carries a significantly higher risk of persistent perforation and lower rate of cure. This procedure may be considered for early staging NPC patients with serious OME symptoms.

The Effect of Radiofrequency and Mitomycin C on the Closure Rate of Human Tympanostomy

OBJECTIVES

To conduct a prospective, randomized, controlled trial determining the feasibility of radiofrequency with or without topical mitomycin C application in delaying the closure time of human tympanostomy and screening its efficacy in management of recurrent acute otitis media and otitis media with effusion.

METHODS

From November 2002 to January 2004, 96 patients (180 ears) who were to undergo surgical intervention for recurrent acute otitis media or otitis media with effusion were included in this study. Sixty ears with a diagnosis of recurrent acute otitis media were equally randomized to three procedures: cold knife myringotomy (Group A), radiofrequency tympanostomy (Group B), and radiofrequency tympanostomy with topical mitomycin C application (Group C). One hundred twenty ears diagnosed as having otitis media with effusion were equally randomized to the last two procedures only. Patients were followed-up every week in the first month, every 2 weeks in the second month, and monthly after that until closure of the tympanostomy. A special follow-up setting was designed 3 months after tympanostomy closure where tympanograms and pure-tone audiograms were obtained.

RESULTS

Groups B and C showed a significantly slower rate of closure than Group A. At the same time, Group C demonstrated a slower rate when compared with Group B. The mean closure time of Group B was 3.5 weeks, with no difference between recurrent acute otitis media and otitis media with effusion. In contrast, the mean closure times for Group C were 5.3 and 7 weeks in cases of otitis media with effusion and recurrent acute otitis media, respectively, with the latter demonstrating a significantly slower closure rate. No recurrence of acute otitis media was reported in 10, 45, and 80% of Groups A, B, and C, respectively. Fifty-nine percent of Group C showed no clinical or tympanometric signs of otitis media with effusion 3 months after closure of tympanostomy. In contrast, Group B reported a lower cure rate (28%), with a statistically significant difference between both groups. Absence of recurrence and improvement in tympanometry signs correlated significantly with the duration of patency of tympanostomy (p < 0.01). The success rate was higher in patients who underwent adenoidectomy, but this did not reach statistical significance except in Group C (p < 0.01).

CONCLUSION

Radiofrequency and mitomycin C delay the closure rate of human tympanostomy. The efficacy of mitomycin C seems to be amplified in the presence of an inflamed tympanic membrane. Radiofrequency-assisted mitomycin-enhanced tympanostomy is a precise, safe, and cost-effective procedure that provides a viable approach in the management of recurrent acute otitis media and otitis media with effusion, especially when used in conjunction with adenoidectomy.

The effects of incisional myringotomy and CO2 laser myringotomy on rat tympanic membranes

OBJECTIVE

The purpose of this study was to compare closure rates and histopathological findings of carbon dioxide (CO(2)) laser myringotomies to those of incisional myringotomy.

STUDY DESIGN

We performed CO(2) laser round myringotomy on left ears and incisional round myringotomy on the right ears of 34 rats on the same day. The incisions were 2mm in size on both ears. Examination was made with otoendoscope on days 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 25, 30, 35, 40, 45, 50 with videorecording. Two rats were sacrificed every 2 days for 25 days and every 5 days thereafter, randomly. The tympanic membranes (TM) were excised and hyalinization, fibrosis and inflammation were assessed with light microscope.

RESULTS

Most of the CO(2) laser myringotomies healed after day 15, and all of them healed by day 50. Three of the incisional myringotomy perforations were closed at day 3, and the rest by day 15. Patency of CO(2) laser myringotomies was significantly longer than that of incisional myringotomies. Hyalinization, fibrosis and inflammation of the incisional myringotomy group were significantly less than those of the laser myringotomy group.

CONCLUSIONS

CO(2) laser myringotomies remain patent for a longer period of time than the incisional procedure, however, they cause more tissue inflammation. We believe that CO(2) laser myringotomy is an effective method, however, additional studies are needed to identify its complications.

Laser myringotomy in otitis media with effusion: long-term follow-up

Otitis media with effusion is a leading cause of conductive hearing loss in children. Myringotomy and insertion of tympanostomy tubes is the accepted form of treatment. Recently, several studies utilizing laser myringotomy have been published, but few of them present late results. The objective of this study was to compare late results of the treatment with laser and classical myringotomy. A clinical effectiveness trial was conducted in three groups of children: (1) 37 children treated with laser myringotomy (ML), (2) 29 children treated with laser myringotomy and the insertion of tympanostomy tubes (ML+V) and (3) 43 children treated with classical myringotomy and the insertion of tympanostomy tubes (MC+V). All types of surgery were performed under general anesthesia because adenoidectomy and/or tonsillectomy was done at the same time. The results of treatment were assessed on the basis of the otoscopic examination (recurrences of effusion, condition of the tympanic membrane, and audiological examination (pure-tone audiometry, tympanometry and DPOAE). The minimum follow-up period was 1 year. The recurrence rate was lowest in the ML+V (11%) group, and highest in the ML group (36%). The difference between ML+V and MC+V was not significant. Permanent changes in the tympanic membrane were observed in 8% of the ears after ML, 19% after ML+V and 31% after MC+V. The difference was significant between the ML and MC+V groups. PTA was significantly higher in the MC+V group than in the control group of otologically healthy children. Mean amplitudes of DPOAE, measured in treated children with normal tympanometry results, were significantly lower than in the control group, but within the normal range. The use of CO(2) laser during myringotomy has no negative effect on the function of the cochlea. Healing of the tympanic membrane after laser myringotomy was uneventful with a low percentage of permanent sequelae.

Medical and surgical management of otitis media in children

OM, though frequent and seemingly simple to evaluate and manage, remains a treatment challenge. Increasingly sophisticated clinical trials assessing OM medical treatment efficacy and outcome have demonstrated that many treatment regimens that were commonly used a decade ago are no longer recommended. Surgical therapy for OM, though remaining the same, has come under intense scrutiny from several angles but still plays a central role for this disease. Given the multiple facets of OM, its frequency, and its potential to cause short- and long-term morbidity in children, the next decade is sure to bring further treatment innovations.

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.

Effectiveness of adenoidectomy and laser tympanic membrane fenestration

OBJECTIVE

Adenoidectomy alone or with tonsillectomy (A+/-T) is an effective surgical intervention in the management of otitis media in children, especially when it is performed in conjunction with insertion of pressure equalization tubes (PETs). Otorrhea and persistent tympanic membrane (TM) perforation are frequent complications. This study evaluates the effectiveness of intermediate duration middle ear ventilation using laser tympanic membrane fenestration (LTMF) without tube insertion and as an adjunct to adenoidectomy in resolving middle ear disease within the first 90 days after surgery.

STUDY DESIGN

This pilot study was a multicenter, prospective clinical cohort trial. Institutional review board approval and informed consent were obtained. The study involved four tertiary care pediatric otolaryngology departments. Fifty children (96 ears) were treated with LTMF in conjunction with A+/-T from June 1, 1998, through March 30, 1999. Ages ranged from 9 months to 12 years. Patients undergoing A+/-T who would have been recommended for PET insertion instead underwent middle ear ventilation with LTMF using the Oto-LAM device (ESC/Sharplan, Yokneam, Israel). Patients were seen at 30, 60, and 90 days postoperatively. Resolution of otitis media with effusion was determined by clinical examination, which included pneumatic otoscopy, audiometry, and tympanometry.

RESULTS

Of the treated ears, 88%, 86%, and 83% had clinical resolution of middle ear disease at 30, 60, and 90 days, respectively. Preoperatively, 45% (n = 85) of ears had normal hearing; 92% (n = 49) had normal hearing at 90 days. Eighty-nine percent (n = 92) had type C2 or B tympanograms preoperatively, and 12% (n = 60) had type C2 or B at 90 days.

CONCLUSION

Laser tympanic membrane fenestration in conjunction with adenoidectomy was effective in restoring normal middle ear function at 90 days post-treatment in greater than 80% of children who otherwise may have had placement of PETs.

Atypical indications for OtoScan laser-assisted myringotomy

OBJECTIVE

To describe the role of OtoScan laser-assisted myringotomy (OtoLAM) for indications other than chronic otitis media or recurrent acute otitis media.

STUDY DESIGN

Cross-sectional review.

METHODS

Twenty-seven office-based OtoLAM procedures were performed in 21 patients for "atypical" reasons. The indications included middle ear dysfunction with necessary air travel (n = 10) or hyperbaric oxygen treatment (n = 6), mastoiditis with postauricular cellulitis (n = 2), canal exostosis prohibiting tympanostomy (n = 1), acute otitis media accompanied by seizures (n = 1), and chronic middle ear effusion in a patient with hemophilia (n = 1).

RESULTS

In each of the 20 cases available for follow-up, middle ear disease resolved with closure of the laser-assisted myringotomy. At a later date, two patients (10%) underwent another OtoLAM in the opposite ear and four patients (20%) required repeat OtoLAM in the same or both ears. Three patients (15%) ultimately underwent myringotomy tube placement because of recurrent middle ear dysfunction.

CONCLUSIONS

Although this report contains preliminary data, the data suggest that OtoLAM may provide an additional option in the care of certain patients who have previously been treated with myringotomy tubes.