耳内镜下鼓膜切开置管治疗分泌性中耳炎技法探讨

目的介绍在耳内镜下进行鼓膜切开置管手术的技法。方法探讨95例（119耳）分泌性中耳炎病例在耳内镜下进行鼓膜切开置管的技法。结果耳内镜下鼓膜切开置管术均一次完成，手术更为精确，操作更为简单。结论在耳内镜下进行鼓膜切开置管手术优于在显微镜下手术。     

Shepard grommet tympanostomy tube complications in children with chronic otitis media with effusion

The objective of this study was to determine tympanostomy tube complications in children with chronic otitis media with effusion who were treated with Shepard grommet tympanostomy tube insertion. This tube type was selected as it is the most commonly used one in our clinic. The medical records of 162 ears of 87 children (52 male and 35 female) were reviewed retrospectively. The children were between 3 to 16 years old (mean age = 8.1 ± 3.1). The patients were followed up 6–66 months (mean 23.3 ± 14.9 months) after tympanostomy tube insertion. We reviewed age, sex, time to tube extrusion and complications. In all patients the indication for surgery was chronic middle ear effusion. Otorrhea occurred in nine ears (5.6%). Granulation tissue was seen in two ears (1.2%). Complications after tympanostomy tube extrusion included myringosclerosis (34.6%), persistent perforation (5.6%), atrophy (23.5%), retraction (16.7%) and medial displacement of tubes (1.2%). The average extrusion time was 8.5 ± 4.6 months (range 1–24) for Shepard grommet tympanostomy tubes. Complications of tympanostomy tube insertion are common. Myringosclerosis, tympanic membrane atrophy and otorrhea are the most frequently appearing complications. But they are generally insignificant and cosmetic. Consequently, in the majority of these complications there is no need for any management.     

Pepsin deteriorates prognosis of children with otitis media with effusion who undergo myringotomy or tympanostomy tube insertion

ObjectiveTo investigate the concentrations of pepsin and pepsinogen within the middle ear cavity and determine whether pepsin and pepsinogen affect the prognosis of children with otitis media with effusion (OME).MethodsAll middle-ear lavage fluid from patients with OME undergoing myringotomy (M subgroup) or tympanostomy tube insertion (T subgroup) was collected and pepsin and pepsinogen were detected using enzyme-linked immunosorbent assay. After close follow-up over 2 years, the effects of pepsin and pepsinogen on the prognosis of the patients with OME in the M and T subgroups were analyzed.ResultsThe average pepsin and pepsinogen concentrations were significantly lower in the M subgroup (n = 54; 24.38 ± 16.10 mg/mL and 286.49 ± 91.95 mg/mL, respectively) than in the T subgroup (n = 55; 45.56 ± 16.60 mg/mL and 664.92 ± 107.06 mg/mL; t = 2.484, P = 0.018 and t = 2.670, P = 0.011, respectively). In the M subgroup, the average time to tympanic membrane healing and tympanic pressure restoration to normal was much longer in pepsin(+) patients (17.0 ± 2.0 days and 26.0 ± 2.5 days, respectively) than in pepsin(−) patients (14.0 ± 1.1 days and 22.0 ± 1.0 days; t = 3.871, P = 0.001 and t = 5.734, P = 0.000, respectively), and the hearing level of pepsin(+) patients with OME ascended to 13.08 ± 1.19 dB, which was much lower than that of pepsin(−) patients (18.29 ± 1.27 dB; t = 11.001, P = 0.000). In the T subgroup, the complication rate including otorrhea and myringosclerosis was much higher in patients with high pepsin concentrations than in those with low pepsin concentrations (P < 0.05). Finally, in both subgroups, the recurrence rates of OME in pepsin(+) or patients with high pepsin concentrations (34.6% [9/26] and 28.6% [10/35]) were significantly higher than those in pepsin(−) or low pepsin concentrations (10.7% [3/28] and 5.0% [1/20]; χ² = 4.456, P = 0.035 and χ² = 4.420, P = 0.036). However, pepsinogen had no significant effect on OME prognosis or recurrence.ConclusionPepsin but not pepsinogen could postpone tympanic membrane healing and pressure restoration in children with OME undergoing myringotomy and increase the incidence of recurrence and complications including otorrhea and myringosclerosis for those undergoing tympanostomy tube insertion. Therefore, pepsin could be considered a poor prognostic factor for OME, further emphasizing the important role of pepsin in OME pathogenesis.     

Efficacy of tympanostomy tube insertion for otitis media with effusion in children with Down syndrome.

OBJECTIVE: Although the insertion of tympanostomy tubes is regarded as an effective treatment for otitis media with effusion in the general population, it remains to be determined whether tympanostomy tube insertion is also effective for otitis media with effusion in children with Down syndrome. The present study was carried out to determine the efficacy of tympanostomy tube insertion in children with Down syndrome. PATIENTS AND METHODS: We studied 28 children (18 males and ten females) with Down syndrome and 28 age-matched control children who underwent tympanostomy tube insertion and were followed up for more than 2 years, up to 7 years of age or older. The children were followed up every month for 6 months after the operation and every 2 months thereafter. The tympanostomy tubes were not removed unless granulation tissue appeared around the ventilation tubes. RESULTS: The cure rate for otitis media with effusion was lower in the children with Down syndrome than in the age-matched control children. Sequelae of otitis media with effusion (atelectatic eardrum, permanent perforation of the eardrum and middle ear cholesteatoma) were significantly often encountered in the former group. The children with Down syndrome had more frequent episodes of otorrhea from the tympanostomy tubes than the control children and antibiotic-resistant-bacteria were frequently isolated. Moreover, improvement in hearing acuity after the placement of tympanostomy tubes was not always achieved in children with Down syndrome. CONCLUSION: The efficacy of the tympanostomy tube insertion for children with Down syndrome was much lower than in control children. We propose that in children with Down syndrome conservative management should be the treatment of first choice and that the insertion of tympanostomy tubes should be indicated only when hearing loss due to middle ear effusion is in a severe degree and when pathological changes of the eardrum, such as adhesion and deep retraction pocket formation, are going to occur.     

Myringotomy with and without tympanostomy tubes for chronic otitis media with effusion

We studied 109 children with otitis media with effusion of 2 months' duration or longer that was unresponsive to medical management. Eighty-six subjects who had neither "significant" hearing loss nor defined symptoms were randomly assigned to receive myringotomy, myringotomy with tympanostomy tube insertion, or no surgery, and 23 subjects with significant hearing loss, defined symptoms, or both were randomly assigned to receive either myringotomy or myringotomy with tube insertion. Myringotomy with tube insertion provided more disease-free time and better hearing than either myringotomy alone or no surgery; however, some subjects who underwent myringotomy with tube insertion developed otorrhea or persistent perforation of the tympanic membrane. Myringotomy offered no advantage over no surgery regarding percent of time with middle-ear effusion, number of acute otitis media episodes, and number of subsequent surgical procedures. These results may not properly be extrapolated to less severely affected children.     

鼓膜穿刺或鼓膜置管联合腺样体切除治疗儿童分泌性中耳炎疗效分析

目的　对比分析腺样体切除术联合鼓膜穿刺（adenoidectomy with auripuncture,AT+A）与腺样体切除术联合鼓膜置管（adenoidectomy with tympanostomy tube,AT+T）对儿童分泌性中耳炎的临床疗效。方法　选取我院于2010年9月至2014年9月收入治疗的分泌性中耳炎患儿92例,将其根据治疗方式的不同分为AT+T组和AT+A组,其中AT+T组48例,AT+A组44例,回顾性分析两组患者的治疗效果,治疗前后听阈的变化以及术后复发率和感染并发症等一系列临床资料。结果　治疗后随访一年内两组患者听阈得到了明显的下降,纯音听力提高,但两者不存在显著性差异（P >0.05）。AT+T组总有效率97.9%,AT+A组的总有效率为95.4%,两者无显著差异（P >0.05）。AT+T组中耳积液的平均时间为（7.3±0.8）d,感染率为6.3%,复发率为4.2%,AT+A组中耳积液的平均时间为（11.7±0.4）d,感染率为15.9%,复发率为11.4%,均存在显著性差异（P <0.05或P <0.01）。结论　AT+T和AT+A两种治疗方式均能有效的提高分泌性中耳炎患儿的听力水平,对分泌性中耳炎患儿具有良好的治疗效果,但是AT+T较AT+A能显著缩短中耳积液时间,有效降低患儿的复发率和感染率,更加适用于分泌性中耳炎患儿的临床治疗。     

Otitis media with effusion: Recurrence after tympanostomy tube extrusion

Objective

The incidence rate of recurrence of otitis media with effusion (OME) in children after tympanostomy tube extrusion and the relationship between recurrence and tube retention time was investigated. Also relationship between recurrence rate and initial age of tube insertion was analysed.

Study Design

A retrospective case series of patients who had tympanostomy tube insertion.

Methods

A total of 91 children (169 ears) were reviewed. Ears of children divided into three groups according to retention time of tympanostomy tubes. Group I: tympanostomy tube retention time less than 6 months. Group II: tympanostomy tube retention time 6 months to 12 months. Group III: tympanostomy tube retention time 12 months or more.

Results

OME recurrence rate after tube extrusion was 20.7% in the study. The longer the tympanostomy tube retention time was the lower was the recurrence rate of OME. The comparison of the three groups indicated that recurrence rates were higher in group I (36.54%), than in group II (17.74%) and in group III (9.1%). There were statistically significant differences in recurrence rates between group I and group III, and between group I and II (p < 0.05, p < 0.05). However, the difference in recurrence rates between group II and group III was statistically not significant (p > 0.05). In the preschool age group and school age group, the recurrence rates were 5.5% and 15.4%, respectively. There was no significant difference between these two groups (p > 0.05). OME recurrence was observed in 9.9% of males and in 11% of females. There was no significant difference in recurrence rates between males and females (p > 0.05).

Conclusion

After extrusion of tympanostomy tube, children should be followed-up regularly for recurrence of OME. The shorter the retention time of tympanostomy tubes was the higher was the recurrence rate. For the treatment of OME the ideal type of tubes should have the lowest complication and recurrence rates. Further studies are needed to ascertain the relationship between the incidence of OME and optimal tympanostomy tubes duration of tube stay in tympanic membrane. Therefore, new studies with larger series are necessary to investigate the correlation between the recurrence rates and different tympanostomy tubes after extrusion of tubes.     

Adult-onset otitis media with effusion: results following ventilation tube insertion.

The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube insertion. Furthermore, at 15-27 months following ventilation tube insertion, the ventilation tube had already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic examination revealed that many patients still had evidence of inflammation at the lateral nasal wall (26.4 per cent) and at the eustachian tube orifice (51 per cent). There is also a strong history of atopy in the studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME following ventilation tube extrusion.     

两种位置鼓膜置管疗效比较

目的　研究将鼓膜通气管置于鼓膜紧张部前下象限及后下象限时其疗效有无差别。方法　选取双侧分泌性中耳炎患儿40例,每例均随机选取一侧在鼓膜紧张部前下象限置管,对侧在鼓膜紧张部后下象限置管。术后1周,1、6、12个月分别行门诊复查。术后1周复查纯音听力测试,其余每次复查均记录通气管是否脱落。统计分析两个位置 的疗效有无差异。结果　术后1周前下象限组与后下象限组气导听阈平均值配对t 检验,P =0.006,差异有统计学意义。前下象限组均值10.4575,后下象限组均值10.2300,后下象限组气导平均听阈较前下象限组低。术后12个月两组间脱管率两独立样本率比较的卡方检验,P =0.034,差异有统计学意义,前下象限组较后下象限组脱管率高。结论　将通气管放置于鼓膜紧张部后下象限较将其放置于前下象限对听力的改善程度更大,且操作更方便,术后更稳固。     

Treatment of chronic otitis media with effusion: results of tympanostomy tubes

Insertion of tympanostomy tubes to provide prolonged aeration and drainage of the tympanum in cases of chronic secretory otitis media has become the most commonly performed operation in children. To investigate the therapeutic efficacy of current treatments of chronic secretory otitis media, the authors undertook a randomized clinical trial with four treatment arms: myringotomy alone, tympanostomy tubes, adenoidectomy and myringotomy, and the combination of adenoidectomy and tympanostomy tubes. This report describes the preliminary (one-year) outcome in the group of children who were treated with tympanostomy tubes. The observed average differences between the myringotomy and tympanostomy tube groups were small, with the exception of one variable (time to first recurrence). Although the clinical importance of these differences remains to be established, the authors believe they are substantial enough to justify continued use of tympanostomy tubes in the primary surgical therapy of chronic secretory otitis media, when medical therapy and observation indicate the need for drainage to improve hearing or correct anatomic deformities of the tympanum.     

鼓膜置管术治疗分泌性中耳炎20例

目的探讨鼓膜置管术及鼓室药物灌洗治疗分泌性中耳炎的疗效。方法分泌性中耳炎20例均为经门诊行药物治疗、鼓膜穿刺、鼓室注药保守治疗2~3个月后无效,考虑主要为咽鼓管功能障碍所致。收入院行鼓膜置管术,并定期局部灌注药物冲洗,置管时间1~3个月后拔管。结果术后随访6~12个月,获得良好效果,总有效率100%,治愈率75%(15/20)。全部患者听力明显改善,纯音测听术后平均提高20~30dBHL。声导抗检查恢复为"A"型曲线15例,"A s"型曲线5例。拔管后鼓膜均自然愈合,无遗留鼓膜永久性穿孔、鼓膜萎缩、化脓性中耳炎等并发症。结论鼓膜置管术是治疗顽固性分泌性中耳炎的主要方法,其中术后的鼓室药物灌注冲洗尤其重要,同时要预防脱管、感染、鼓膜不愈合等并发症。     

A conservative approach to the management of otitis media with effusion in cleft palate children.

Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.     

Complications of otitis media before placement of tympanostomy tubes in children

OBJECTIVES: To report the incidence of short-term complications from otitis media in children before placement of tympanostomy tubes (TTs) and to compare children treated according to the Agency for Health Care Policy and Research guidelines with those who were treated earlier or later than recommended. DESIGN: Retrospective outcomes review. PATIENTS: Subjects were children aged 10 or younger who had TTs inserted at a tertiary care county hospital from January 1, 1999, to December 31, 2000. Exclusion criteria included prior TT placement, any concurrent head and neck procedure, and craniofacial defects. INTERVENTION: Tympanostomy tube placement. MAIN OUTCOME MEASURES: Any occurrences of otorrhea, tympanic membrane perforation, tinnitus, antibiotic reactions, speech or language delay, febrile seizures, or meningitis before placement of TTs documented in the county hospital records were recorded as complications. Hearing loss was considered separately. RESULTS: Of 147 children who met our criteria, 81 (55.1%) had 1 or more complications from otitis media before placement of TTs. Fifty-five (37.4%) had 2 to 6 complications documented. Adverse reactions to antibiotics were the most common complication, reported in 34 (23.1%). CONCLUSIONS: Most children in this county hospital experienced short-term complications of otitis media before receiving TTs. Even the children treated "on time" according to the guidelines from the Agency for Health Care Policy and Research experienced complications; however, adherence to the guidelines had no significant effect on complications.     

Alternative treatment for otitis media with effusion: eustachian tube rehabilitation

In this study, we evaluated the effectiveness of eustachian tube rehabilitation (ETR) as treatment for otitis media with effusion (OME). Thirty-five children with persistent OME were enrolled. Patients were divided into three groups: group I (isolated OME); group II (OME and atypical swallowing); group II (OME, habitual mouth breathing and atypical swallowing). All children underwent ETR. Otomicroscopy and tympanograms were performed before treatment, and at one and three months following ETR. Considering the overall patient population after ETR (one and three months later), the prevalence of type A tympanogram increased significantly compared to before therapy (p < 0.005), while the prevalence of type B tympanogram decreased significantly (p < 0.005). We found significant differences between pre- and both post-therapy control in groups I and II. However, children in group II experienced significant improvement of middle ear conditions only three months after the end of therapy (p < 0.005). On the basis of the physiopathologic knowledge of OME and the underlying principles of ETR, we conclude that ETR can be considered a useful therapy in management of OME.     

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.     

Clinical outcomes of otitis media with effusion following palatoplasty in patients with incomplete cleft palate

Background: Diagnosis and treatment strategies for CP with OME and the timing of ear tube insertion remain controversial.

Objectives: To analyze the clinical outcomes of otitis media with effusion in children with incomplete cleft palate after palatoplasty prospectively.

Methods: A total of 30 children (10 months–2 years old) with incomplete CP were enrolled in this study and received at least 6 months of follow-up evaluations after palatoplasty.

Results: The overall improvement rate of OME was as high as 26% in this group. Average air conduction hearing threshold was significantly better than that before surgery in the 8 patients with improved OME (p?<?.05). Among the 8 children with improved OME, 7 (87.5%) were found to have middle ear effusion that improved within 6 months after CP repair. There was no significant difference in the improvement rate between the severe degree II group and the mild group.

Conclusion: A 6-month follow-up period is recommended. The severity of incomplete CP is not fully related to the function of the eustachian tube.

Significance: The overall improvement rate was as high as 26%, and effusion in the tympanic cavity subsided in 7 out of 8 cases within 6 months after the CP repair.     

Tuberculous otitis media developing as a complication of tympanostomy tube insertion

Primary tuberculous otitis media of which infection focus cannot be found elsewhere in the body is a rare disease. Route of the infection has been hypothesized as Eustachian tube or external auditory canal with tympanic membrane perforation but it is hard to ascertain in the patient. We present a case of an 8-year-old child who suffered chronic otorrhea after tympanostomy tube insertion. The radiological and histopathological findings revealed tuberculous otitis media, which occurred as a complication of tympanostomy tube insertion.