Organic change of effusion in the mastoid in otitis media with effusion and its relation to attic retraction

To try to solve the pathogenesis of severe attic retraction viewed from mastoid condition, we examined the residual soft tissue density (RSTD) in the mastoid by computed tomography (CT) in 85 patients (107 ears) with otitis media with effusion (OME) 3 months after tympanostomy tube insertion or later. The incidence of RSTD in the mastoid was significantly higher in OME of adults (52.6%) than in children (24.1%). Ears with severe attic retraction had RSTD significantly more frequently (80%) than those with no or mild attic retraction, and many of the mastoids with severe attic retraction were occupied totally by RSTD. The area of the mastoid (mastoid pneumatization) was significantly smaller, and CT density of the mastoid (sclerotic tendency) was significantly higher in ears with RSTD than in those without. RSTD after tympanostomy tube insertion in the mastoid indicating organic change of effusion was considered one of the important factors relating to the pathogenesis of severe attic retraction.     

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.     

腭裂患儿分泌性中耳炎鼓室置管术疗效分析

目的　观察鼓室置管术在治疗腭裂患儿分泌性中耳炎听力损失的疗效 ,探讨中耳通气管的选择、手术适应证及注意事项。方法　双耳伴发分泌性中耳炎伴听力损失的住院腭裂患儿 19例 ,平均年龄 5 8岁 ,平均气导语频听阈较大的一侧耳在腭裂修复术同期行鼓室置管术 ,对侧未置管耳作为对照组 ,术后 2周至 18个月复查 ,比较置管组及对照组腭裂术前、术后听阈的变化情况。结果置管组耳术后平均气导语频听阈 (2 7 0± 6 5 )dB较术前 (42 7± 8 2 )dB显著降低 ,而对照组耳术前(2 9 0± 6 1)dB、术后 (2 7 0± 4 1)dB听阈差异无显著性。置管组未见严重耳科并发症。结论　腭裂修复术同期鼓室置管术安全、有效 ,可恢复患者听力 ,有利于腭裂术后语音学习。     

鼓膜置管治疗成人渗出性中耳炎的长期观察

目的探讨鼓膜置管术对成人渗出性中耳炎治疗的长期结果.方法总结分析1996年6月至1999年6月治疗的42例成人渗出性中耳炎患者.男24例,女18例,左耳17例,右耳19例,双耳6例,共计48耳;年龄20～70岁,平均37岁;病程1个月至1年.通气管常规置入加冲洗治疗,8个月内取管,随访4-8年.结果症状全部消失29例;耳鸣6例,伴听力下降4例;时有耳堵塞感发作5例;鼓室积液复发2耳.鼓膜正常者28耳,鼓膜瘢痕、钙化10耳,鼓膜内陷8耳,鼓膜变薄、松弛2耳,鼓膜穿孔2耳.结论成人渗出性中耳炎行鼓膜置管治疗的远期效果良好,其并发症及后期的鼓膜改变较儿童期少.     

Clinical studies on attic retraction]

Attic retraction was studied in 327 ears of 264 patients in whom photographs of the tympanic membrane were taken from 1983 to 1989. Attic retraction was investigated clinically on the basis of findings of the tympanic membrane in reference to the photographs and ear X-ray findings, including CT. Attic retraction was also observed in 4.5% of cases without inflammation, but its severity was mild. The incidence of attic retraction in cases of adhesive otitis media was 42.7% in mild adhesive otitis media (adhesive grade I) and 60.8% in severe adhesive otitis media (adhesive grade II), both incidences were significantly higher than the incidence of 23.8% in cases of otitis media with effusion. Thus, the incidence of attic retraction increased as the grade of adhesion became severer. In cases of otitis media with effusion, the incidence was significantly higher in the adult group (32.3%) than in the child group (17.4%). In many of the ears with otitis media with effusion, adhesive grade I and chronic otitis media, the severity of attic retraction was mild. There were more cases of milder retraction in the child group than in the adult group. Attic retraction underwent change with time in 2.8% of cases, and cholesteatoma occurred in 1.8% of cases. No improvement in attic retraction was achieved by insertion of a ventilation tube. Bilateral attic retraction was observed in 56.9% of the child group and 30.2% of the adult group, and the difference was statistically significant. Ear X-ray findings by Schüller's method revealed many ears with poorly developed mastoid cells and poor pneumatization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of the Gas Exchange Function Through the Middle Ear Mucosa on the Development of Sniff-Induced Middle Ear Diseases

To investigate the influence of gas exchange function through the middle ear mucosa on the development of sniff-induced middle ear diseases, the authors examined the mastoid pneumatization among patients with sniffing habit using computed tomography, and also examined the change of negative middle ear pressure induced by sniffing using tympanogram. In 20 ears with cholesteatoma or adhesive otitis media, the areas of mastoid cavity measured at the level of the lateral semicircular canal were significantly smaller than those in 26 ears with otitis media with effusion (OME) or attic retraction and in eight normal ears with sniffing habit (P < .01 and P < .0001, respectively). In 26 ears with OME or attic retraction, the areas of mastoid cavity were significantly smaller than those in eight normal ears with sniffing habit (P < .0001). By contrast, in the four ears with sniff-induced middle ear disease, the recovery of negative middle ear pressure in 5 minutes without swallowing was less than 10 mm H₂O, whereas in all seven ears with normal eardrum, negative middle ear pressure recovered by more than 20 mm H₂O in 5 minutes. These findings suggested that impairment of gas exchange function through the middle ear mucosa, as well as eustachian tube dysfunction, might be closely related to the development of sniff-induced middle ear diseases.     

上鼓室内陷袋的临床特征分析

目的：探讨上鼓室内陷袋的临床特征。方法：分析92例（118耳）上鼓室内陷袋患者的临床资料、临床表现（常以耳闷胀感、听力下降及耳鸣为主诉）、耳内镜检查及分级、听力学、影像学检查及并发病变。结果：118耳中,TosⅠ～Ⅳ级分别为15耳（12．7％）,48耳（40．7％）,23耳（19．5％）及32耳（27．1％）。耳内镜下可见并发的分泌性中耳炎41耳（34．7％）、中耳膨胀不全16耳（13．6％）、粘连性中耳炎8耳（6．8％）及内陷袋胆脂瘤。纯音测听以传导性聋为主,少数还有以传导性聋为主的混合性聋。因并发中耳疾病及疾病性质的不同,而对听力的影响也不同,且差异也有统计学意义（P〈0．01）。Ⅰ～Ⅲ级各病变组与Ⅳ级病变对听力的影响有统计学意义（P〈0．01）,Ⅰ～Ⅲ级之间的听阈无统计学意义（P〉0．01）,声阻抗以平坦型及负压为主。其中97耳CT及X线摄片结果显示,乳突气化不良程度与对照组有差异（P〈0．01）。结论：上鼓室内陷袋反映中耳负压状态,其发病机制与咽鼓管功能、炎症、乳突气化程度相关;因其存在发展为内陷袋胆脂瘤的潜在危险,故临床上应加强早、中期病变的随访及干预。     

Otitis media with effusion: treatment by autoinflammation using a balloon

Resolution of negative middle ear pressure is important in treating otitis media with effusion (OME). We treated 34 children and 21 adults with OME by autoinflammation using a nose tube and balloon in the 16 months from June 2001 to September 2002. Of these, 7 children and 5 adults had been treated for 3 years or longer, and had had grommets inserted. In 49 ears of 27 early cases of children, 34 ears (69%) improved in tympanometric findings converting to type A from type B, C2 and C5, and 9 ears (18%) of type B converted to type C1. In 23 ears of 16 early cases of adults, 12 ears (52%) improved converting to type A from type B, C2, C5 and C1, and 3 ears (13%) to type C1 from type B. However, 4 ears of 4 children and 5 ears of 5 adults did not recover by autoinflammation. In 7 children with prolonged OME in whom grommets had been inserted, 5 recovered due to autoinflammation, whereas only one of 5 adults recovered. Of 6 patients who had not recovered, 2 were associated with asthma and nasal polyposis and eosinophils infiltrated into the middle ear effusion. In other 2 patients, even when the middle ear effusion disappeared by grommets insertion, they had still dysfunction of the Eustachian tubes confirmed by sonotubometric examination. It seems no beneficial effects of autoinflammation were maintained if patients had tubal dysfunction due to intensive inflammatory changes of the middle ear and tubal mucosa or other unknown origin. Two patients used the device irregularly and rarely. There is a theoretical risk associated with this maneuver of causing baroinjury and forcing infected nasopharyngeal secretions into the middle ear, but we found no complications.     

Transtympanic endoscopic findings in patients with otitis media with effusion

Using a fine, rigid endoscope (Olympus, SES-1711K), we examined the middle ear, including the tympanic orifice of the eustachian tube, of children with otitis media with effusion (OME) in its active stage (26 ears), in the convalescent stage (13 ears), and during treatment with ventilation tubes for 10 days to 6 months (five ears) through myringotomy with the patients under general anesthesia. Several color photographs of representative ears are shown. In the active stage of OME, edema (73.1%) and hyperemia (23.1%) were characteristic features of the middle ear mucosa, and normal mucosa was seen in only one ear (3.1%). The tympanic orifice of the eustachian tube, which could be examined in 12 ears, were stenosed with edema in four ears (33.3%) or plugged with effusion in three ears (25.0%) in this group. In the convalescent stage of OME, dilated vessels were most often seen (69.2%), but the rest of the patients had normal mucosa (30.8%) in the middle ear, and none of them had edema nor hyperemia. The tympanic orifice of the eustachian tube, which could be examined in five ears, was clearly patent in all the patients in this group. One ear that was treated with a ventilation tube for 1 month showed dilated vessels and less severe inflammation than did ears that were in the active stage of OME, and three ears that were treated for more than 3 months showed almost normal middle ear mucosa.     

27例鼻咽癌患者合并分泌性中耳炎的临床分析

目的探讨鼻咽癌患者放疗前后分泌性中耳炎的临床特点及治疗措施。方法回顾性分析2003年一2006年我院经治的27例鼻咽癌患者,将其放疗前、放疗后的情况进行回顾分析。21例（32耳）中耳炎患者被分为鼓膜穿刺组与鼓膜置管组。结果27例患者放疗前有14例（17耳）并发分泌性中耳炎,放疗后分泌性中耳炎的患者增至21例（32耳）,双耳发病11例,6例未发生分泌性中耳炎。鼓膜穿刺组12例（19耳）,显效率为78.9％（15／19）,1例患者发展为慢性化脓性中耳炎;置管组9例（13耳）,有5例（7耳）疗效显著,显效率为54％（7／13）,有2例患者鼓膜穿孔。MRI检查显示,21例分泌性中耳炎患者中,19例有明显咽鼓管挤压和腭帆张肌肿胀。结论MRI检查有助于鼻咽癌患者放疗前后并发分泌性中耳炎的评估;鼓膜穿刺抽吸是治疗鼻咽癌并发分泌性中耳炎的有效和实用的措施。     

Otitis media with effusion in children shows a progressive resolution with time

The course of chronic otitis media with effusion (OME) was studied in 117 children (207 ears). Diagnosis was based on otoscopy and a flat (type B) tympanogram. This was compared with the presence or absence of middle ear effusion at myringotomy carried out 0-3, 3-6, 6-9 and more than 9 months after diagnosis. There was a highly significant reduction in the number of effusions diagnosed at myringotomy in those patients who had waited longer for operation. The effects of previous ventilation tube insertion, adenoidectomy, medical treatment between diagnosis and operation, month of diagnosis and month of admission on the results were examined. Tympanosclerosis and atelectasis occurred in 7.3 and 6.3% of ears respectively and in most cases were associated with previous grommet insertion.     

Development of tympanosclerosis in children with otitis media with effusion and ventilation tubes

Ventilation tube (VT) insertion is an accepted treatment for chronic otitis media with effusion (OME) in children. One hundred and eighty five children with bilateral OME were treated by unilateral myringotomy and VT insertion with no treatment to the contralateral ear. During a 5 year follow-up 95 of the children required only one VT but the remainer required more than one but always treatment was carried out to the same ear. The rate of development of tympanosclerosis was measured and scored. After 2-3 years the extent of the sclerotic changes stabilised and the rate of development reached 37-39 per cent in ears receiving only one VT, compared with 47-49 per cent in ears treated by more than one tube. The extent of the changes was no different whether or not one or more than one tube had been inserted. There was no overall evidence of resolution of sclerotic change with time.     

Cholesteatoma in an Asian population

Two hundred Malaysian patients representing 227 ears with previously untreated cholesteatoma disease were analysed retrospectively in terms of i) type of disease, i.e. primary acquired attic defect or posterior superior retraction pocket and secondary acquired type cholesteatoma; ii) positive history of previous middle ear effusion, atelectasis or grommet insertion; and iii) likelihood of complications as initial presenting feature. The high 47.1% incidence of secondary acquired cholesteatoma disease in our patients contrasts with the predominance of primary acquired cholesteatoma in the Caucasian patient. Correlation of these two disease types with a positive history showed a significant positive association between the primary acquired group and a positive history; and conversely a significant negative association for the secondary acquired type. This supports a role for the retraction theory in primary acquired cholesteatoma but negates this theory in secondary acquired cholesteatoma. Secondary acquired cholesteatoma had a significantly higher (35.5%) complication rate against 15.8% in the primary acquired type (p = 0.001). This fact together with a 47.1% incidence of secondary acquired disease, low otolaryngologist population ratio and patient attitudes to disease account for the high total complication rate of 27.3%.     

Otitis media with effusion: can erythromycin reduce the need for ventilating tubes?

Otitis media with effusion (OME) is a common condition among children and is characterized by nonpurulent fluid in the middle ear and fluctuating conductive hearing loss. Most children will spontaneously regain normal air-filled middle ears, but a certain number will have persistent problems. In our department we will treat annually about 500 children on an outpatient basis, with the insertion of ventilating tubes in the eardrum. The reason for this study was to evaluate the effect of erythromycin, instead of inserting a ventilation tube, in children with bilateral OME of longer duration than three months (double blind/placebo). The study comprises 147 children, 1-15 years of age, 83 boys and 64 girls, all with OME for more than three months. All the patients were candidates for tube insertion. In the group treated with erythromycin, 12 patients out of 69 had bilaterally air-filled middle ears after one month, as compared to 19 out of 72 in the group treated with the placebo. No difference was noted due to sex or age. The results support our indication and timing for ventilation tube insertion.     

Sequelae of otitis media with effusion among children with cleft lip and/or cleft palate

Otitis media with effusion (OME) is common among children with cleft palate, and may lead to such long-term consequences as hearing loss, tympanic membrane retraction, and chronic otitis media (COM). In total, 104 children with cleft lip and/or palate treated for OME at our institution were reviewed. Mean duration of follow-up was 6.9 years, and mean age at latest follow-up was 9.6 years. The incidence of COM was 19%, and the incidence of cholesteatoma was 1.9%. Ears showing such long-term sequelae of OME as hearing loss, tympanic membrane retraction, and chronic otitis media, were noted to have undergone a significantly greater number of ventilation tube insertions than ears not showing these sequalae. Our findings would suggest that a conservative approach to the management of OME in children with cleft palate is more likely to be beneficial in the long term.     

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 1: Clinical outcomes

OBJECTIVE: To determine 14-year otological outcomes in young children treated with early insertion of ventilation tubes (VTs) for recurrent acute otitis media or otitis media with effusion (OME). DESIGN: Prospective 14-year follow-up. SETTING: Central Hospital of Central Finland, a tertiary care hospital.Patients Three hundred five consecutive infants and young children aged 5 to 16 months with otitis media were enrolled for early initial tympanostomy tube insertion. The final study group comprised 237 patients (77.7%) attending the 14-year checkup. MAIN OUTCOME MEASURES: At the 14-year checkups, abnormal otological findings were recorded and results compared with those of the 5-year checkups. RESULTS: From 5 to 14 years' follow-up, the number of healed ears increased from 156 (65.8%) to 177 (74.7%), while the number healed of ears with abnormal outcomes decreased from 81 (34.2%) to 60 (25.3%). Of 156 healed ears, 142 (91.0%) remained healed, and 35 (43.2%) of 81 ears with abnormal outcomes healed. The proportion of abnormal outcomes was higher among ears with OME (P = .02) and with 3 or more VT insertions (P<.001). Repeated tympanostomy tube insertion was performed in 141 ears (59.5%), more often in those with OME (P = .003), and ear surgery was performed in 9 ears (3.8%), 8 with OME. CONCLUSIONS: Early VT treatment is recommended for young children with recurrent acute otitis media or persistent OME. Parents should be informed of the long follow-up, of the possible need for repeated VT insertion, and of potential sequelae that sometimes necessitate surgical intervention. Patients healed after 5 years do not need further follow-up.     

Sequelae of otitis media with effusion among children with cleft lip and/or cleft palate1

Otitis media with effusion (OME) is common among children with cleft palate, and may lead to such long‐term consequences as hearing loss, tympanic membrane retraction, and chronic otitis media (COM). In total, 104 children with cleft lip and/or palate treated for OME at our institution were reviewed. Mean duration of follow‐up was 6.9 years, and mean age at latest follow‐up was 9.6 years. The incidence of COM was 19%, and the incidence of cholesteatoma was 1.9%. Ears showing such long‐term sequelae of OME as hearing loss, tympanic membrane retraction, and chronic otitis media, were noted to have undergone a significantly greater number of ventilation tube insertions than ears not showing these sequalae. Our findings would suggest that a conservative approach to the management of OME in children with cleft palate is more likely to be beneficial in the long term.     

Failure of grommet insertion in post-irradiation otitis media with effusion

Nasopharyngeal carcinoma (NPC) survivors with post-irradiation otitis media with effusion (OME; 100 ears) were divided into 2 groups. One group underwent grommet insertion, and the other group was treated by repeated myringotomies plus aspiration to evaluate the outcome of the OME. Computed tomography, magnetic resonance imaging, audiometry, and local checks of the ear, nose, and nasopharyngeal fields were performed to evaluate the sinus and middle ear conditions over a long-term (more than 10 years) follow-up period. The results in these NPC survivors with OME indicated that the prevalence of middle ear complications in the myringotomized group (33%) was less than that in the grommeted group (90%). Grommets alone cannot eradicate inflammation outside the middle ear cavity, but rather, they can aggravate it by superinfection. We therefore recommend that controlling the radiation-induced inflammation in areas such as the ears, nose, sinuses, and nasopharynx is most important. In conclusion, post-irradiation OME should be treated in a different way from conventional OME. Restated, grommet insertion is contraindicated in post-irradiation OME.     

Microbiology of chronic and recurrent otitis media with effusion in young infants

Chronic otitis media with effusion (OME) has been assumed to be sterile, since several reports in the literature have described unsuccessful attempts to culture bacteria from it. However, several recent studies have confirmed an earlier report that there is a significant frequency of bacteria in the middle ears of children with chronic and/or recurrent OME. Similar studies in young infants with chronic and/or recurrent OME have not been previously reported. In this study, cultures were obtained at the time of myringotomy and tympanostomy tube insertion from 50 infants aged 1–12 months who had chronic and/or recurrent OME. From the 80 ears of 40 infants without cleft palate, 32% had bacteria isolated from their middle ears; 22% had Streptococcus pneumoniae or Haemophilus influenzae. In 21 of these ears, no effusion was apparent at myringotomy, but in 28% bacteria were isolated from middle ear washings. From the 20 ears of 10 infants with an unrepaired cleft palate, 55% had bacteria present in their middle ear aspirates; 50% had S. pneumoniae or H. influenzae. Even though the significance of bacteria in chronic OME in children, and now in young infants, is unclear at present, a therapeutic trial with an antimicrobial agent prior to surgical intervention would appear to be reasonable until such therapy is tested in a randomized, clinical trial.     

Eustachian tube function before recurrence of otitis media with effusion

OBJECTIVE: To study the role of eustachian tube function in the development of recurrent otitis media with effusion (OME) in children treated with tympanostomy tubes for OME. DESIGN: Prospective cohort study. SETTING: Three academic and general hospitals. PATIENTS: Children aged 2 to 7 years with a first clinical episode of OME that persisted for at least 3 months; 136 (81%) of 168 eligible children participated. All children received tympanostomy tubes for bilateral OME at study entry. MAIN OUTCOME MEASURE: Recurrence of OME within 6 months of tube extrusion. RESULTS: No statistically significant differences were present in eustachian tube function test results between ears that developed recurrent OME and those that did not. The difference in passive ventilatory function between ears with and without OME recurrence was 10 daPa (95% confidence interval, -24 to 43 daPa) for opening pressure and -3 daPa (95% confidence interval, -18 to 11 daPa) for closing pressure. The overall difference in the proportion of ears with and without OME recurrence that could not equilibrate positive and negative applied pressures was 12% (95% confidence interval, -2% to 26%). The proportions of ears with and without OME recurrence that induced negative pressure in the middle ear by forcefully sniffing were 22% and 31%, respectively (P = .75). CONCLUSION: Measurement of ventilatory and protective eustachian tube function using the forced response test, the pressure equilibration test, and the sniff test has no value in predicting whether children have an increased risk of OME recurrence.