Titanium grommets: a trial to assess function and extrusion rates

Titanium grommets have been promoted as having the advantage of a slower extrusion rate than other types of ventilation tube. A prospective trial was therefore designed to compare the function and extrusion rates of these grommets with those of the widely used Shepard design of Teflon grommet in a single group of patients. Thirty-one children had one type of grommet inserted in one ear and the other type in the opposite ear. After eight months there were significantly more Titanium grommets still functioning (p less than 0.05) but after 12 and after 16 months there was no significant difference in the extrusion rates of the two types of grommet. There was a higher incidence of infection with granulation tissue formation around the Titanium grommet. Accordingly it is concluded that the extra expense of the Titanium grommet is not justified, particularly as the long-term effects of these grommets on the tympanic membrane are not known.     

Late ear sequelae in cleft palate patients

This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in infancy. Half of these patients had a history of grommet insertion. We found that most patients had normal hearing (81%) and middle-ear pressures (86%), although about half had tympanic membrane abnormalities. Grommet insertion did not result in better long-term hearing in this study but was strongly associated with tympanosclerosis. Cleft type did not influence the degree of ear disease although more patients with complete clefts had a history of repeated grommet insertion. Otitis media with effusion is almost universal in cleft palate infants and may influence later language, speech and educational development. At the time of palatal repair grommets should be inserted to improve hearing in these infants.     

Congenital middle ear cholesteatoma: report of 3 cases.

In this report, we presented 3 cases of congenital middle ear cholesteatoma which occurred in a 12-year-old girl, a 4-year-old boy, and a 6-year-old boy. In all 3 cases, there was a whitish mass behind a normal tympanic membrane. Congenital middle ear cholesteatoma is not a rare disease. In the early stage, it is asymptomatic. But when it progresses, this disorder can destroy conductive systems of the middle ear and cause many symptoms. One patient (Case 1) had a complaint of hearing impairment. She underwent mastoidectomy and tympanoplasty; however, the cholesteatoma recurred. The other 2 patients had no symptoms. The abnormal appearance of their tympanic membrane was found by chance at their local otologists. We performed tympanotomies and removed cholesteatomas without aftereffects. When otologists note an abnormal appearance behind a normal tympanic membrane, with or without symptoms, tympanotomy should be done due to the possibility of congenital middle ear cholesteatoma.     

Grommets versus paracentesis in secretory otitis media. A prospective, controlled study

One hundred and ninety-three consecutive children with bilateral secretory otitis media were treated by adenoidectomy, bilateral paracentesis, and evacuation of middle ear effusion, but with insertion of a grommet in the right ear only. At follow-up one to three years later, the audiometric and tympanometric results were similar in right and left ears. The primary advantage of grommet insertion was normalization of the hearing ability for as long as the grommet was functioning. Thus, only 1% of the ears with grommets had hearing losses exceeding 30 dB HL, whereas this occurred in about 20% of ears without grommets. The adverse effects of grommet insertion included periodic aural discharge during the functioning period of the grommet in 14% and tympanosclerosis of the drum in 48%. In the group of ears treated with paracentesis only, tympanosclerosis occurred in 10%. However, reinsertion of grommets was indicated in 10% of right ears, and 23% of left ears required grommets as well. Of the various pre- and perioperative factors analyzed, only a granulating mucous membrane and copious middle ear effusion could be correlated to frequent and protracted episodes of secretory otitis that required repeated treatment. The implications of these findings are discussed.     

Congenital Cholesteatomas in the Tympanic Membrane

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3-year-old nor 14-year-old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.     

筋膜外植法鼓室成形术的手术体会

目的 探讨筋膜外植法在鼓室成形术中的应用及价值.方法 回顾分析筋膜外植法鼓室成形术63耳,随访观察患者的外耳道宽敞度、鼓膜形态及听力恢复情况.结果 本组病例包括中耳胆脂瘤25耳,慢性化脓性中耳炎38耳.手术方式分别为筋膜外植法鼓室成形术、筋膜外植法鼓窜成形术+完肇式乳突根治术和筋膜外植法鼓室成形术+开放式乳突根治术三种类型,中耳胆脂瘤和慢性化脓性中耳炎患者实施三种手术的数最分别为4、17、4耳和19、18、1耳.术后切口全部Ⅰ期愈合.随访0.5～3.5年,外耳道宽敞,鼓膜形态良好,听力提高或维持术前水平,未有听力下降者.按时随访者未发现有明显并发症.结论 筋膜外植法鼓室成形术具有操作流程规范、术野暴露充分、病变清除彻底等优点,在慢性中耳炎的外科治疗中具有积极意义.     

Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects.

Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pressure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.     

Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects

Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pessure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.     

Does passive smoking affect the outcome of grommet insertion in children?

Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.     

The cholesteatomatous ear one year after surgery with obliteration technique

Fifty-seven patients with middle ear cholesteatoma were treated surgically by eradicating the cholesteatoma after a canal wall-down procedure had been performed. During the same session the canal wall was rebuilt with autologous bone, the tympanic membrane repaired with fascia, and the mastoid cavity and epitympanic space obliterated with autologous cortical mastoid bone chips and a retroauricular, anteriorly based muscle flap. One year later a second look procedure was performed in all the patients (N = 57), which permitted the anatomic effects of the obliteration operation to be mapped out before ossicular reconstruction was undertaken. At three, six, and twelve months after the first operation any secretion from the ear was recorded. Recurrent cholesteatoma was not found in any single case, residual cholesteatoma in only three cases (5.3%). The tympanic membrane was intact in fifty-four cases (94.7%) and perforated in three, none of which was combined with a residual cholesteatoma. Even though twenty-four of the fifty-seven cases had a secreting ear before the eradicating operation, fifty-six (98.2%) stayed dry during the year of observation between the two operations. Therefore, with very few exceptions, a dry, cholesteatoma-free ear and an intact tympanic membrane may be expected one year postoperatively in patients with middle ear cholesteatoma surgically treated using the described obliteration technique.     

Iatrogenic cholesteatoma in children with OME in a training program

PURPOSE: To report the occurrence of cholesteatoma following myringotomy and insertion of ventilating tube (VT) in a residency training program. MATERIALS AND METHODS: Nine hundred and eighty-four children who were operated for grommet insertion with or without adenotonsillectomy during the year 1999-2003 were included in the study. Children were divided into two groups: group 1 (648 children) operated by residents and group 2 (305 children) operated by consultant. All procedures were carried out under general anesthesia using Ziess operating microscope. Shah ventilating tubes were used in most cases and Goody T tube in some others. RESULTS: Nine ears developed cholesteatoma, six with perforation and three with pearl cholesteatoma cyst and intact tympanic membrane. The rate of iatrogenic cholesteatoma occurrence was 0.62% when done by residents (group 1) and 0.33% when operated by consultants (group 2). The overall prevalence was 0.48%. CONCLUSION: Iatrogenic cholesteatoma occuring as a complication following VT insertion is not uncommon. It occurs more often following surgery done by inexperienced surgeons. Excessive manipulation may cause meatal wall and drum surface epithelium injury. This epithelium might be pushed with the VT into the middle ear.     

Tympanic membrane/middle ear pathologic correlates in chronic otitis media.

OBJECTIVE: To correlate pathologic findings of the tympanic membrane with pathologic changes in the middle ear cleft in chronic otitis media. STUDY DESIGN: Retrospective. MATERIAL AND METHODS: One hundred-fifty temporal bones from 97 subjects with chronic otitis media (defined as middle ear pathologic changes including granulation tissue, fluid, cholesteatoma, cholesterol granuloma, tympanosclerosis, and ossicular changes) were selected to correlate the presence of these middle ear pathologies with histopathologic changes of the tympanic membrane. The tympanic membrane pathologies included perforation, myringosclerosis, retraction, hemorrhage, fluid-filled cystic spaces, or dilated vessels. Temporal bones were also assessed for atelectasis. Fifty-six normal temporal bones were taken as controls for measurements. RESULTS: Significant correlations between tympanic membrane and middle ear pathology included myringosclerosis and granulation tissue, myringosclerosis and ossicular pathology, retraction and cholesterol granuloma, retraction and cholesteatoma, retraction and ossicular pathology, perforation and ossicular pathology, and hemorrhage and granulation tissue. Additive effects of some pathologies were also observed. Almost half the bones with middle ear pathology had no associated tympanic membrane pathology, whereas multiple pathologic changes in the tympanic membrane generally showed underlying multiple pathologic changes in the middle ear. CONCLUSION: When tympanic membrane pathology is detected otoscopically, its presence, alone or in combination, can be a strong indicator of underlying middle ear pathology. However, a normal-appearing tympanic membrane does not exclude the possibility of middle ear pathology. These findings suggest the need for other diagnostic tools such as multifrequency tympanometry and otoacoustic emissions to complement otoscopy for diagnosis of middle ear pathology, especially in a tympanic membrane that appears "normal."     

Cholesteatoma in children: Recurrence related to observation period

From 1965 to 1978, 122 children with cholesteatoma had one-stage surgery. Follow-up examinations were carried out several times, with the last two taking place in 1980/81 and 1985/86. Ninety-eight percent of the children were seen at follow-up; the median observation time was 11 years, with a range of three to 21 years. The increase in recurrence rate with increasing observation time was analyzed. In 1980/81 there was a total recurrence rate of 12 percent of patients, including residual cholesteatoma in the tympanic cavity in 8%, in the attic in 2%, and recurrent cholesteatoma in 2%. In 1985/86 the recurrence rate had increased to 17%, distributed among residual cholesteatoma in the tympanic cavity in 10.6%, in the attic in 1.6%, and recurrent cholesteatoma in 4.8%. The recurrence rate was the same regardless of whether modified canal-wall-up mastoidectomy or canal-wall-down mastoidectomy had been employed. We conclude that cholesteatoma surgery should be individualized according to pathologic findings in the tympanic cavity, tubal function, and size of the mastoid air cell system. Small cholesteatomas confined to the tympanic cavity may be removed by tympanoplasty alone, without mastoidectomy. In ears with adhesive otitis, canal-wall-down mastoidectomy is preferred; and in ears with a reasonably good tubal function and a large air cell system, canal-wall-up mastoidectomy is recommended. The long-term results reported here seem to indicate that, in children, canal-wall-up mastoidectomy is preferable to canal-wall-down mastoidectomy.     

Ten-year results of canal wall down mastoidectomy for acquired cholesteatoma

OBJECTIVE: To examine 10-year results of canal wall down mastoidectomy (CWDM) for acquired cholesteatoma. METHODS: Medical records of 136 patients with cholesteatoma who has undergone CWDM in a university hospital and who had a follow-up of at least 10 years were checked. RESULTS: During follow-up, 21% of patients had undergone one revision operation and 3% two revisions. The recurrence rate of cholesteatoma was 17% and in three patients the cholesteatoma recurred twice. Ten years after CWDM, 98% of the operated ears were dry, 1% moist, and one ear (0.7%) was discharging. The tympanic membrane was intact in 92% and perforated in 8%. Only 14% of patients had hearing levels of 20 dB or better and 46% had 40 dB or better. CONCLUSION: It is concluded that the surgical technique of CWDM should be improved in order to lower the recurrence rate and to improve hearing results.     

Impact of mastoidectomy on simple tympanic membrane perforation repair

OBJECTIVES/HYPOTHESIS: Mastoidectomy has long been identified as an effective method of treatment for chronic ear infection. The effect of mastoidectomy on patients without evidence of active infectious disease remains highly debated and unproven. The objective in the study was to examine the impact of mastoidectomy on the repair of uncomplicated tympanic membrane perforations. STUDY DESIGN: Retrospective study of patients at tertiary referral center. METHODS: Four hundred eighty-four patients who underwent surgical repair of simple tympanic membrane perforations were identified and reviewed in a retrospective manner. Simple tympanic membrane perforations were defined as tympanic membrane perforations of any size and location without any of the following confounding variables: 1). active infection (active otorrhea, abnormal middle ear mucosa, or granulations tissue); 2). ossicular abnormalities (ossicular fixation, ossicular discontinuity, ossicular malformation, or ossicular absence); 3). cholesteatoma; or 4). prior attempt at tympanic membrane repair (prior tympanoplasty or mastoidectomy). Surgical outcome and clinical course were assessed to compare results of tympanic membrane perforation repair with and without canal wall up mastoidectomy. RESULTS: Tympanic membrane repair was equally effective in both groups at 91%. Hearing results were comparable. Development of persistent ipsilateral otological disease requiring a subsequent ipsilateral procedure was approximately twice as common in the tympanoplasty group. In the tympanoplasty group, 14.1% of patients underwent subsequent ipsilateral otological procedures, and 6.1% of patients in the tympanoplasty with mastoidectomy intact canal wall group underwent subsequent ipsilateral procedures (P <.05). The most common subsequent ipsilateral procedures were tympanoplasty, tympanostomy tube placement, tympanoplasty with mastoidectomy canal wall up, and tympanoplasty with mastoidectomy canal wall down, in that order. After including untreated tympanic membrane perforations as subsequent procedures, the adjusted rate of subsequent procedures was 15.5% in the tympanoplasty group and 12.2% in the tympanoplasty with mastoidectomy group (P >.05). CONCLUSION: Mastoidectomy was not necessary for successful repair of simple tympanic membrane perforations. However, mastoidectomy impacted the clinical course in patients by reducing the number of patients requiring future procedures and by decreasing disease progression. This suggests that even in the absence of active evidence of infection, mastoidectomy improved the underlying disease process. Combining mastoidectomy with tympanoplasty during repair of simple perforations in patients with no active evidence of infection remains an appropriate option and may be valuable in reducing the need for future surgery.     

中耳胆固醇肉芽肿手术治疗策略探讨

目的:探讨中耳胆固醇肉芽肿手术治疗的策略。方法:对19例中耳胆固醇肉芽肿患者的临床资料进行回顾性分析。其中4例行单纯鼓膜置管术,8例行完壁式乳突切除+后鼓室切开+鼓膜置管术,7例行开放式乳突切除+鼓膜置管术。结果:术后随访0.5～3.3年。4例行单纯鼓膜置管术的患儿中,2例术后复发;8例行完壁式乳突切除+后鼓室切开+鼓膜置管术的患者中,3例术后复发;7例行开放式乳突切除+鼓膜置管术的患者无一例复发。在目前情况良好的14例患者中,有12例患者听力较术前明显改善。结论:对初发、病变范围局限的青少年患者,术前应完善检查以排除咽鼓管机械性阻塞因素,可选择单纯鼓膜置管术,术后定期观察;对症状反复发作、单纯置管或完壁式乳突切除+后鼓室切开+鼓膜置管术无效、病程较长或病变范围广泛的患者,应选择做保留鼓室完整性的开放式乳突切除+鼓膜置管术。     

A comparison of audiometric performance and complications of T tubes and Shepard grommets

Since T tubes were introduced in 1972 their use in cases of chronic Eustachian-tubal insufficiency has been reported on several occasions, (Goode, 1973, 1983; Rothera and Grant, 1985). T tubes remain in-situ for longer than grommets, and they are frequently used in cases where multiple grommet insertions have failed to provide adequate middle ear ventilation. They have also been used when prolonged Eustachian-tubal insufficiency is anticipated, for instance in children with cleft palate. Shepard grommets continue to be the most commonly used type of ventilating tube for short-term use and a significant proportion of children with glue ear require repeated insertions. In an attempt to reduce the need for repeated myringotomy, and also to reduce the need for adenoidectomy in children with glue ear, it has been the recent practice of one Consultant (K.S.M.) to use T tubes routinely in all cases of glue ear. This study analyses the audiometric performance and complications of 32 children (60 ears) who underwent myringotomy and insertion of T tubes for glue ear. In all cases no previous treatment for glue ear had been undertaken. The results are compared with those of a control group who underwent myringotomy with insertion of Shepard grommets and adenoidectomy as a first-line treatment.     

Malleus removal and total cartilage reinforcement in intact canal wall tympanoplasty for cholesteatoma

This study analyzes the morphological and hearing results obtained from intact canal wall cholesteatoma surgery by removing the malleus, reinforcing the whole tympanic membrane with cartilage, and performing an ossiculoplasty with a hydroxyapatite prosthesis. The results were compared to those obtained in intact canal wall cholesteatoma surgery by preserving the malleus manubrium, partially reinforcing the tympanic membrane with cartilage, and predominantly using an ossicle to perform the ossiculoplasty. One- or two-stage intact canal wall procedures were performed in 390 adult patients (416 ears) who had a nonoperated middle ear cholesteatoma. Recurrent and residual cholesteatoma rates were evaluated. Hearing results were analyzed according to the Committee on Hearing and Equilibrium Guidelines of the American Academy of Otolaryngology-Head and Neck Surgery. There was a statistically significant decrease in the recurrence rate in patients who had total cartilage reinforcement of the tympanic membrane versus patients who had partial tympanic membrane cartilage reinforcement. This technique using a hydroxyapatite prosthesis for ossiculoplasty gave good hearing results.     

乳突鼓室成形手术的分期问题

目的探讨分期乳突鼓室成形术在以提高听力为目的的功能性耳显微外科中的作用.方法本文总结了海军总医院1993-2003年3月2700例各类中耳手术中分期鼓室成形术102例,随访1～5年,手术主要类型为保留外耳道后壁的乳突切开鼓室成形术、切除外耳道后壁的乳突切开鼓室成形术,保留骨桥的乳突切开鼓室成形术,文中对分期手术的理念、适应症选择、手术方式选择及移植筋膜感染、不愈合等问题进行了分析.结果 102例分期手术中,85例(83.3%)愈合良好,其中7例一期术后干耳,但二期手术中发现后鼓室及鼓窦处胆脂瘤珠及肉芽组织;17例存在不同程度的问题,出现率16%,包括一期术后出现移7植物穿孔或延迟愈合,在后鼓室、鼓窦、面神经隐窝等处发现胆脂瘤肉芽组织,但鼓室粘膜有不同程度的修复.102例分期手术术后1年气导听力(O.5K、1k、2k平均听力)较术前提高15 dBHL.结论在彻底清除病灶基础上,合理而有计划的行分期手术修复鼓室粘膜,恢复中耳含气空腔,为听骨链重建创造条件,以提高听力,不失为较佳的选择.     

Congenital cholesteatoma.

We present a British series of eleven patients with primary cholesteatoma, including one patient with bilateral disease. Eight children presented with a history of hearing loss, while one child had had recurrent otitis media and another had had earache. Operative findings were: in five ears, cholesteatoma confined to the antero-superior segment with intact ossicles, in a further four, cholesteatomas extending throughout the mesotympanum with ossicular erosion in one, and in two ears posterior disease throughout the middle ear and mastoid, which had eroded the ossicles in both cases. The five cases of antero-superior cholesteatoma lend most support to Michaels' concept of epidermoid formation as a possible source of congenital cholesteatoma. With a greater awareness of the problem and careful examination of the antero-superior quadrant of the tympanic membrane, earlier diagnosis may be possible enabling removal of small intact cholesteatoma sacs and preserving the structures of the middle ear and therefore the hearing. A screening programme for infants included as part of their routine examination which would be undertaken by examiners who are trained to be more aware of the problem and skilled at otoscopy, would help in the earlier detection of such cases as is shown by reports from the U.S.A.