Otitis media surgery: large variability between Finland and Norway

OBJECTIVE: Bi-national comparison of surgical treatment for paediatric otitis media. METHODS: Registry based cross-sectional study with complete data on surgery for otitis media in 2002; 21,811 Finnish and Norwegian children aged 0-16 years. RESULTS: Total rates for otitis media surgery were 82.5 and 146.5 per 10,000 children in Norway and Finland, respectively. Adenoidectomies were four times more frequently performed in Finland and rates for tympanostomy tube insertions differed 2-3-fold, Finland having the higher rate. The contrast in surgery rates was most striking in the age group 0-2 years. Further, the more sparsely populated regions had significantly higher overall surgery rates. CONCLUSION: The large variability in the incidence of otitis media surgery between two similar countries questions whether present guidelines ensure equal treatment in similarly affected children and pinpoints the difficulty in giving advice on age, time and type of surgery.     

Acute mastoiditis in Norway: no evidence for an increase

OBJECTIVE: In a large Norwegian newspaper in November 2005, an otolaryngologist at Rikshospitalet claimed that the increasing number of children hospitalized for acute mastoiditis was worrying and questioned the restrictive use of antibiotics in Norway. Based on latter he recommended that all children below age 2 with symptoms of uncomplicated acute otitis media should receive antibiotics. Our purpose was to incidence variation and characteristics of acute mastoiditis in children. METHODS: Registry based study with complete data on hospitalization for acute mastoiditis and cortical mastoidectomy in Norway during 1999-2005. RESULTS: Three hundred and ninety-nine Norwegian children aged 0-16 years were included. The incidence of acute mastoiditis in children below 2 ranged from 13.5 to 16.8 per 100,000 during the study period. Corresponding numbers for children 2-16 years were 4.3-7.1 per 100,000 children. No incidence increase was found during the study period. Age-specific incidence revealed a peak during the second and third year of life, and acute mastoiditis was most common in boys. Cortical mastoidectomy was equally common in the young and older age group, 22% received surgery. For children aged 2 and above, significantly fewer children were hospitalized for acute mastoiditis media during the period July, August and September. CONCLUSION: Despite the introduction of restrictive Norwegian guidelines for antibiotic treatment of acute otitis media in children aged 1 year and above, our data did not give evidence for an increase in acute mastoiditis. Except for the high incidence of acute mastoiditis in young children, hospitalization characteristics were remarkably similar in children below and above 2 years.     

Prevention of otitis media by adenoidectomy in children younger than 2 years

OBJECTIVES: To test the effect of adenoidectomy in connection with tympanostomy compared with tympanostomy only in preventing otitis media in children younger than 2 years. DESIGN: Prospective trial with randomized and nonrandomized arms. SETTING: Primary care study clinics. PARTICIPANTS AND INTERVENTIONS: The study participants were selected from 2497 children who had been enrolled in the Finnish Otitis Media Vaccine Trial at the age of 2 months. A total of 306 children, aged 1 to 2 years, who had experienced recurrent episodes of otitis media were randomized into 2 treatment groups: tympanostomy with or without adenoidectomy. Of the 306 children, 137 were operated on according to random basis (randomized trial). The 169 children whose parents declined participation in the randomized trial were operated on according to the parents' preferences (nonrandomized trial). All children were followed up until 2 years of age. The mean follow-up time was 7 months. MAIN OUTCOME MEASURE: The rate of acute otitis media episodes. RESULTS: The average reduction in the rate of all acute otitis media episodes in the adenoidectomy group was 19% (95% confidence interval [CI], -14% to 43%) among children enrolled in the randomized trial and 25% (95% CI, -13% to 50%) in the nonrandomized trial. The reduction in the randomized trial was mainly due to reduction in the rate of pneumococcal otitis media (58%, 95% CI, 16%-79%). CONCLUSION: In children younger than 2 years, concurrent adenoidectomy during the insertion of tympanostomy tubes does not seem to have a major advantage over the insertion of tympanostomy tubes alone in preventing otitis media.     

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.     

Effect of 23 valent pneumococcal polysaccharide and Haemophilus influenza conjugated vaccines on the clinical course of otitis media with effusion

Objective To determine if there is any clinical effect of 23‐valent pneumococcal and Haemophilus influenza type B conjugate vaccine on prognosis of otitis media with effusion. Method All children who have middle ear effusion despite long‐standing antibiotherapy with a beta lactamase stable agent were offered for tympanostomy tube insertion between February 1999 and December 2001. Patients who accepted the surgical intervention were operated under general anesthesia and a Shepard grommet‐type tympanostomy tube was inserted. Those who refused the surgical intervention were vaccinated with 23‐valent pneumococcal and Haemophilus influenza type B conjugate vaccine. State of the middle ear effusion was evaluated at the end of the 12th month in the vaccine group and 1 month after the myringotomy site was healed in the tympanostomy tube insertion group. Results Twenty‐six children in the vaccine group and 37 children in the tympanostomy tube insertion group proved the inclusion criteria at the end of study. Complete or partial resolution of middle ear effusion was observed in 73.1% of 26 children in the vaccine group and 59.5% of children in the tympanostomy tube insertion group. There was no significant difference between the two groups. Conclusion Vaccination against Streptococcus pneumonia and Haemophilus influenza type b seems to aid resolution of middle ear effusion in children with otitis media with effusion.     

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 2: Hearing outcomes

OBJECTIVE: To determine hearing outcomes in young children receiving early and repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion. 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 with otitis media received initial tympanostomy tube insertion at the age of 5 to 16 months. The final study group comprised 237 patients (77.7%) attending the 14-year checkups. MAIN OUTCOME MEASURES: At the 14-year checkups, children received clinical examinations and audiometric testing for the determination of bone and air conduction pure-tone thresholds. RESULTS: The mean pure-tone average of 177 healed ears was 4.3 dB. The mean pure-tone average of all ears was 5.8 dB, with significantly poorer results in ears with abnormal outcomes such as grade II or higher pars tensa retraction, otitis media with effusion, and tympanic membrane perforation. Thirteen (5.5%) of 237 ears had a hearing level worse than 15 dB, and the better ear hearing level was poorer than 15 dB in 3 patients. CONCLUSIONS: The hearing level of healed ears was comparable to that of age-matched normal ears. Hearing losses were infrequent, of slight grade, and, when present, almost exclusively conductive and related to unsuccessful otological outcomes. From the hearing point of view, repeated tympanostomy tube insertion for recurrent acute otitis media or otitis media with effusion early in life is a safe treatment.     

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.     

The relationship between repeat tympanostomy tube insertion and adenoidectomy

Objectives

To examine the relationship between adenoidectomy and repeat tympanostomy tube placement in the treatment of otitis media, and the relationship between potential risk factors for otitis media and repeat tympanostomy tube placement.

Methods

Retrospective, cross-sectional analysis of consecutive patients undergoing tympanostomy tube placement at an academic/teaching hospital with 400+ beds. Utilizing an electronic billing database, patients less than 18 years of age undergoing tympanostomy tube placement between January 1, 2000 and December 31, 2007 were identified. Information regarding initial and repeat tympanostomy tube placement as well as potential risk factors for otitis media were extracted from medical records.

Results

904 children were included in the study. Of the 780 children who initially underwent tympanostomy tube placement alone, 178 required additional tube placement; a repeat rate of 20%. Of the 90 children who initially underwent tympanostomy tube placement with adenoidectomy, only 6 required repeat tube placement, a statistically significant decrease in the incidence of repeat tympanostomy tube placement (95% CI, 0.056–0.334; p < 0.0001). The presence of craniofacial anomalies and day care/school attendance were significantly associated with additional tube placement. Children between the ages of 4 and 10 showed a significant (p < 0.0001) decrease in the risk of repeat tube placement when an adenoidectomy was performed at the initial tube placement.

Conclusion

Adenoidectomy performed at the first tympanostomy tube for the treatment of otitis media may decrease the risk of repeat tube placement, especially for children >4–10 years of age.     

Sex distribution in children with tympanosclerosis after insertion of a tympanostomy tube

Tympanostomy tube insertion is an accepted treatment for otitis media with effusion in children. Several clinical studies have shown that tube insertion may cause myringosclerosis. During the period 1988 to 1997 we treated 533 ears from 311 children who had otitis media with effusion by inserting tympanostomy tubes. Most of these (431 ears from 251 children) were re-examined in 1998 and sex and occurrence of myringosclerosis at the tube insertion site were noted. Myringosclerosis was observed in 31% of ears of girls treated with tubes, whereas in boys 71% of ears showed myringosclerosis. This difference between sexes may indicate a genetic predisposition such as that seen in atherosclerosis. Received: 8 May 2000 / Accepted: 29 September 2000     

Workload trends in Otolaryngology: some statistical observations from medical record linkage

Trends in admission rates, lengths of stay, and clinical case mix (adjusted for multiple admissions per person) for Otolaryngology from 1975 to 1985 are described using the Oxford Record Linkage Study. Person-based admission rates increased generally, most strikingly amongst children and adolescents. Both length of stay per episode and total number of days an individual stayed in hospital each year decreased. Operations on tonsils and adenoids decreased averaging 2.2% per annum; admissions for diagnoses for otitis media with effusion increased averaging 8.2% per annum; for the operations of myringotomy and tympanostomy tube insertion increased averaging 9.2% per annum; for other diagnoses related to the ear increased averaging 5.7% per annum; and admissions for malignant neoplasms decreased averaging 2.0% per annum. Clearly more people are being treated for a changing case mix. The largest increases are occurring with children and adolescents.     

Predictors of chronic suppurative otitis media in children

OBJECTIVE: To determine which factors predict development of chronic suppurative otitis media (CSOM) in children. DESIGN: Case-control study, with univariate and multivariate logistic regression analysis applied to determine which factors independently predict CSOM. SUBJECTS: Prognostic factors for CSOM were identified in (1) 100 children with CSOM and 161 controls aged 1 to 12 years and (2) 83 children who developed CSOM in the presence of a tympanostomy tube and 136 children with tympanostomy tubes who did not develop CSOM. RESULTS: Independent predictors for CSOM were previous tympanostomy tube insertion (odds ratio [OR], 121.4 [95% confidence interval {CI}, 38.9-379.3]); having had more than 3 upper respiratory tract infections in the past 6 months (OR, 12.2 [95% CI, 3.5-42.3]); having parents with a low education level (OR, 14.1 [95% CI, 2.9-68.6]); and having older siblings (OR, 4.4 [95% CI, 1.6-12.6]). Independent predictors for CSOM after tympanostomy tube insertion were having experienced more than 3 episodes of otitis media in the past year (OR, 4.9 [95% CI, 2.2-11.0]; attending day care (OR, 3.6 [95% CI, 1.7-7.8]); and having older siblings (OR, 2.6 [95% CI, 1.2-5.5]). CONCLUSIONS: Treatment with tympanostomy tubes is the most important prognostic factor for CSOM in children. In children who are being treated with tympanostomy tubes for persistent middle ear effusion, the most important prognostic factor for CSOM is a history of recurrent episodes of acute otitis media. This information should be taken into consideration and discussed with parents when considering insertion of tympanostomy tubes in children.     

The feasibility of office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion: the duPont Hospital experience.

OBJECTIVE: To determine the feasibility of inserting tympanostomy tubes in children using office-based laser-assisted tympanic membrane fenestration. METHODS AND MATERIALS: Study consisted of a retrospective review of the charts of all children who underwent office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion from July 1, 1998 to August 31, 2000. Tetracaine eardrops were used for topical anesthesia. Fenestration was achieved with the OtoLAM flashscanner laser (ESC Sharplan, Yokneam, Israel). RESULTS: Of the 127 patients (185 ears) who underwent laser-assisted tympanic membrane fenestration, 61 ears underwent tympanostomy tube insertion. Ten ears were treated for otitis media with effusion, 43 for recurrent acute otitis media, and eight for acute otitis media not responding to antibiotics. Fifteen ears had purulent effusion, five had a serous effusion, and 23 had mucoid middle ear fluid. Eighteen ears had no middle ear fluid. At the first follow-up visit, all tested ears had hearing of 20 dB or better. Two children had tubes that were blocked. Blockage occurred in ears that required more than one laser firing to penetrate the tympanic membrane. Otorrhea was present in 13 ears (21%). Otorrhea occurred exclusively in ears with purulent or mucoid middle ear fluid. CONCLUSIONS: Office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion is a safe and effective alternative to tube placement in the operating room. The outcome compares favorably with previously published data.     

Implications of laser assisted tympanostomy in adults.

OBJECTIVES: To assess outcome in adult individuals undergoing laser-assisted tympanostomy without ventilation tube placement. STUDY DESIGN: Case series with 2-month follow-up. SETTING: Faculty practice, research protocol, tertiary care academic medical center. PATIENTS AND METHOD: Laser-assisted tympanostomy was performed on a total of 142 ears (108 individuals). Indications included serous otitis media with effusion (66 ears/47 patients), functional eustachian tube dysfunction (48 ears/36 patients), acute otitis media (19 ears/16 patients), and endoscopic visualization of the middle ear (9 ears/9 patients). INTERVENTION: The laser-assisted tympanostomy procedure is performed with a CO2 laser under local anesthesia on an outpatient basis. MAIN OUTCOME MEASURES: Patency time of the tympanostomy, presence of fluid after the closure of the tympanostomy, tympanometry and tone audiometry findings, relief of symptoms. RESULTS: Middle ear disease was resolved after the closure of tympanostomy in 47.9% of patients with serous otitis media with effusion. In 79.1% of patients with functional eustachian tube dysfunction, symptoms were diminished. All patients with acute otitis media had a satisfactory outcome. Laser-assisted tympanostomy was found to be quite helpful in patients undergoing middle ear endoscopy. CONCLUSIONS: Laser-assisted tympanostomy without ventilation tubes provides a safe alternative surgical option in adult patients in certain cases. The selection criteria for this procedure are addressed in detail.     

Passive smoking after tympanostomy and risk of recurrent acute otitis media

OBJECTIVE: Exposure to environmental tobacco smoke has been reported to be a risk factor for childhood otitis media. The effect of parental smoking on the risk of otitis media after the insertion of tympanostomy tubes is unknown. We evaluated the effect of parental smoking on the risk of recurrent otitis media in children who had received tympanostomy tubes. METHODS: We enrolled 217 children aged 1-4 years who underwent insertion of tympanostomy tubes because of middle ear disease. The children were followed-up for 12 months. Otitis media episodes were recorded in patient diaries by primary care physicians. Parental smoking habits were assessed by a questionnaire at the start of the trial and after the 12 month follow-up had ended. The main outcome measure was risk of recurrent otitis media as defined by four or more otitis media episodes after tympanostomy. Altogether 198 children completed the follow-up. RESULTS: Maternal smoking was associated with a highly increased risk of recurrent acute otitis media (OR 4.15, 95% CI 1.45-11.9) after the insertion of tympanostomy tubes. CONCLUSION: Exposure to passive smoking is associated with four-fold risk of recurrent otitis media after tympanostomy. This finding should be used to encourage parents to stop smoking even after the insertion of tympanostomy tubes to their children.     

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.     

The effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion at 7 and 24 months of age

OBJECTIVE: To explore the effect of a pneumococcal conjugate vaccine on the risk of otitis media with effusion and to search for subgroups in which the vaccine had a higher or lower effect. METHODS: Analyses were performed on data from the Finnish Otitis Media Vaccine Trial, a randomised controlled double-blind trial to evaluate the efficacy of pneumococcal conjugate vaccination against acute otitis media. Data on the vaccination effect against otitis media with effusion were obtained by means of symptom interview and pneumatic otoscopy during pre-scheduled follow-up visits at the age of 7 and 24 months. Two endpoint definitions were considered: otitis media/tube (otitis media or tympanostomy tube in situ (OM/T)) as the primary endpoint and otitis media with effusion as the secondary endpoint. No evidence was found of an age-dependent association with vaccination effect. Therefore, the final marginal logistic regression analyses were performed on the combined data from the two follow-up visits. RESULTS: The risk of otitis media tended to be lower in the pneumococcal vaccine group. The odds ratio for otitis media/tube was 0.94 (95% confidence interval 0.77-1.14) and the odds ratio for otitis media with effusion was 0.90 (95% confidence interval 0.69-1.19). Presence of older siblings increased the risk of otitis media/tube and otitis media with effusion at 7 months of age. In addition, it appeared that children without older siblings and attending day-care at 24 months of age tended to benefit more from the pneumococcal conjugate vaccine. In this subgroup, the odds ratio for otitis media/tube was 0.81 (95% confidence interval 0.55-1.20) and for otitis media with effusion the odds ratio was 0.43 (95% confidence interval 0.22-0.86). CONCLUSION: The effect of pneumococcal conjugate vaccination on the risk of otitis media with effusion was concordant with the efficacy seen against acute otitis media, although not distinguishable from no effect in the overall analysis. In children without older siblings, vaccination appeared to reduce the point prevalence of otitis media with effusion; this effect was not apparent in children with older siblings.     

Tympanostomy tubes for otitis media: quality-of-life improvement for children and parents

We measured quality of life issues for both children and their parents on the premise that parental quality of life should be an aspect of cost-effectiveness in otitis media treatment. The patients were less than 18 years of age and had had myringotomy with tube insertion at the head and neck surgery department of a large health maintenance organization. Quality of life for patients, parents, and caregivers was evaluated by telephone survey of parents or caregivers and by retrospective chart review of the number of pre- and postoperative healthcare visits and antibiotic usage. Chart review showed a significant postoperative reduction in the number of clinic visits and in use of antibiotic drugs after insertion of tympanostomy tubes. Improved postoperative hearing was noted, and tympanostomy tube insertion was shown to be safe. The chart-review cost analysis showed that tympanostomy tube insertion is a cost-effective treatment for otitis media in children, and the telephone survey results showed that it improves quality of life for children and their parents or other caregivers.