Cicatricial changes of the eardrum after treatment with grommets

Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis

CONTEXT

Tympanostomy tube placement is the most common ambulatory surgery performed on children in the United States.

OBJECTIVES

The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute otitis media.

DATA SOURCES

Searches were conducted in Medline, the Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews, Embase, and the Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Abstracts and full-text articles were independently screened by 2 investigators.

DATA EXTRACTION

A total of 147 articles were included. When feasible, random effects network meta-analyses were performed.

RESULTS

Children with chronic otitis media with effusion treated with tympanostomy tubes compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB (95% credible interval: -14.0 to -3.4) at 1 to 3 months and 0.0 (95% credible interval: -4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly defined and reported.

LIMITATIONS

Sparse evidence is available, applicable only to otherwise healthy children.

CONCLUSIONS

Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.

Influence of tympanic membrane changes on audiometric and immittance findings in school-aged children

Six-hundred-and-eighty-seven 6 to 15-year-old children were examined for the association between tympanic membrane (TM) changes and audiometric or immittance findings. The hearing thresholds were between 20 and 30 dB in ears with amber TM, but between 25 and 45 dB in ears with adhesive TM. When the TM was retracted or the mobility decreased, the hearing thresholds were about 10 dB poorer than in ears with normal TM position or mobility. Thick TM caused hearing loss in the high-frequency areas. The hearing loss was only marginal (3-4 dB) in ears with retracted pars flaccida compared with ears with normal position of pars flaccida. The mean and median middle ear pressure value was lower than -200 da Pa in ears with dull, amber, retracted, poorly movable, adhesive or thick TM. It was between -100 and -200 da Pa in ears with red TM, locally retracted pars tensa or retracted pars flaccida. Stapedius reflex thresholds were higher in ears with one or several abnormal findings than in normal ears.

Tympanosclerosis of the drum in secretory otitis after insertion of grommets. A prospective, comparative study

In 193 consecutive children with bilateral secretory otitis, intubation and adenoidectomy were performed on the right ear and paracentesis on the left. Changes in the ear drum were analysed at re-evaluation one to three years after operation. In ears that had been intubated, tympanosclerosis occurred significantly more frequently (48 per cent) than in ears that had not been intubated (10 per cent). The frequency of atrophy of the pars tensa was the same. Of the right ears, 10 per cent were re-intubated, compared with 23 per cent of the left ears. The cause of the increased frequency of tympanosclerosis in the intubated ears must be mechanical, as decreased movements of the drum with inflammatory fibrous hyperplasia impede spontaneous normalization and promote hyalinization and calcification. The hearing was found to be similar in ears with and without tympanosclerosis.

Ventilation tubes in secretory otitis media. A randomized, controlled study of the course, the complications, and the sequelae of ventilation tubes

The purpose of this study has been to evaluate the use of ventilation tubes in the treatment of cases of primary secretory otitis media. Bilateral cases were selected and a tube inserted in one ear while the other ear was left intact. Adenoidectomy was performed on all children, tonsillectomy in 34% of the cases. A total of 150 children (mean age = 3.9 years) were included during the years 1976-1979 and check-ups performed every 3-6 months. The follow-up rate was 89.3%. The condition of each individual was assessed after a 5-year period, the mean period of observation was 3.2 years. The results of tympanometry and audiometry from the two types of ears were, on average, similar. Repeat operation was carried out in 17% of the cases and later otomicroscopy revealed a higher incidence of atrophy in these eardrums (p less than 0.01). A period of suppuration was noted in 25% of the ears with a ventilation tube, 2 months or more after operation; a higher incidence of tympanosclerosis was later found (p = 0.02). Twentythree per cent of the treated eardrums were characterized at the final check-up as "normal" by means of otomicroscopy, in contrast to 83% of the intact ears. The "end-result" of each ear was estimated using tympanometry, audiometry as well as otomicroscopy, and a difference in favour of the intact ears was found (p less than 0.01). A similar estimate for each child gave the result that 31% had one ear categorized as "pathological" while this was the case in both ears of 9% of the children. The children subjected to initial tonsillectomy showed a worse "end-result" (p less than 0.05). It is concluded that the use of ventilation tubes in children with primary secretory otitis media is not justified. Observation has shown that only a small proportion will require surgical treatment of the middle ear. A ventilation tube may be indicated in order to combat hearing loss, but it should be borne in mind that its use involves a high risk of complications and sequelae which may result in chronic middle ear disease.

Transtympanic drains in the treatment of serous otitis in children; anatomical versus functional long term results

The long term results are reported of transtympanic drains in 391 ears of 258 children affected by serous otitis; 150 ears have been evaluated at the end of a 3-7-year observation period. (1) A high percentage of ears with major anatomical lesions was found (46.6%), especially in the higher age group (greater than 7 years). (2) Functional hearing results are better than anatomical results; 84.6% of the subjects had a hearing level better than 20 dB (0-10 dB: 53.3%; 11-20 dB: 31.3%). (3) Anatomical and functional results are worse in case of recurrence (2 or more drains). (4) It is imperative to control periodically those children with major tympanic lesions and present good hearing.

Attic retractions following secretory otitis

At re-examination of 527 ears with secretory otitis 3 to 8 years after tubulation otomicroscopy and tympanometry revealed different types of retraction of Shrapnell's membrane in 34%, of these 4.2% had pronounced retraction with resorption of the osseous annulus and 0.2% had atticus cholesteatoma. There was a close correlation between the frequency and severity of retraction on the one hand and the age of the patient at reexamination, the tympanometric conditions, and the pathology of pars tensa on the other. The continued progression is further promoted by a lack of natural cleansing of the retraction. As the frequency of secretory otitis is very high in children the 4.2% of pronounced retractions constitute a sufficient quantitative basis for a direct progression to atticus cholesteatoma.

Unilateral grommet insertion and adenoidectomy in bilateral secretory otitis media: preliminary report of the results in 91 children

This study evaluates whether the use of grommets in the primary treatment really changes the course of secretory otitis media. The patient acts as his own control. Bilateral cases are selected and one ear is treated by a grommet, the other left intact, and all have their adenoids removed. Until now 91 children have been entered. A repeated operation was done in 13, and 6 of them had a contralateral grommet because of persisting middle ear effusion. A discharge occured from 25% of the operated ears. After the operation the intact ear showed a great improvement in the function of the Eustachian tube according to the tympanograms. The hearing level was normalized within 3 months in both intact and operated ears. In 28 children the grommets had been extruded for more than one month. By comparing the intact and the operated ears no significant statistical difference was found.

Secretory otitis media. Late results of treatment with grommets

In 108 children (184 ears) with chronic secretory otitis treated with grommets, the condition at one-to-five years follow-up was compared with that at five-to-eight years follow-up. At the latter time, hearing was extremely good, 97.5% of the ears having a speech reception threshold (SRT) of 20 dB or less. However, only 67% of patients could be classified as cured by normal tympanometry. The remaining ears showed a negative middle-ear pressure of 100 to 300 mm H2O (25%), recurrent accumulation of secretion (1.6%), adhesive otitis (3.3%), perforation (1.7%), or cholesteatoma (1%). The eardrum was normal in 44% of patients, while in 25% it was diffusely atrophic, lax, or retracted.