Post-myringotomy care: a prospective study

Children with tympanostomy tubes have always been considered somewhat handicapped in regard to swimming and bathing. Their parents had to maintain constant surveillance to prevent then from getting water in their ears. A prospective study involving more than 1,000 children was conducted between June 1981 and August 1982 on two groups of randomly selected patients to determine the prevalence of suppurative otitis media and its relationship to bathing and swimming. One group had to follow strict rules to prevent water entering the ear (bathing caps, earplugs) whereas the other group was allowed to bathe and swim without any precaution upon the condition of using a polymyxin B/gramicidin ear drop combination at bedtime on the day they swam. The study shows no increase in prevalence of suppurative otitis media in the "open canal" group as compared to the "closed canal" group. Furthermore, the monthly distribution of infections shows a relatively evan distribution throughout the year. This study implies that swimming and bathing are safe for the vast majority of children with tympanostomy tubes and thus simplifies enormously the post-myringotomy care for the child, the parents, and the physician.     

Effect of artificial airway on ear complications from hyperbaric oxygen

Hyperbaric oxygen treatment is associated with an increased risk of barotrauma to the tympanic membrane and middle ear. An artificial airway may compromise normal eustachian tube function and equilibration of middle ear pressures. This retrospective study was designed to evaluate the risk of middle ear complications in 267 patients receiving hyperbaric oxygen (HBO) therapy and to compare those with and without artificial airways. Charts of all patients were reviewed for middle ear and tympanic membrane complications and myringotomy tube placement. Eighteen of the 267 patients had artificial airways. Seventeen (94%) of these 18 patients developed middle ear or tympanic membrane complications, and 11 (61%) required tympanostomy tubes for pain, hemo-tympanum, or serous otitis. In contrast, 114 (45.8%) of the 249 patients without airways developed ear complications, and 53 (21.3%) required tympanostomy tubes. These results suggest that patients with an artificial airway who are receiving HBO therapy are at greater risk for developing tympanic membrane and middle ear complications than nonintubated patients. Similarly, patients with artificial airways receiving HBO frequently require placement of tympanostomy tubes.     

Ventilation tubes after surgery for otitis media with effusion or acute otitis media and swimming. Systematic review and meta-analysis

OBJECTIVE: To determine if the use of ear protection when swimming of children with ventilation tubes modifies the risk of acute otitis media (AOM) compared to not swimming. METHODS: Systematic review. DATA SOURCES: Search conducted in MEDLINE, EMBASE and The Cochrane Library databases. STUDY SELECTION: Prospective cohort studies and controlled clinical trials of children with ventilation tubes, with a minimum follow-up of 2 months. Data extraction: Two reviewers independently assessed trial quality and extracted data. RESULTS: 11 studies were selected. No difference was found in risk of AOM in children who swim without ear protection compared with those who do not swim: Odds ratio=0.78, 95% confidence interval 0.42-1.44; nor compared with those who use earplugs and swimming caps, odds ratio=0.75, 95% confidence interval 0.38-1.48; nor in those who use ear drops after swimming compared with those who used earplugs or swimming caps, odds ratio=0.76, 95% confidence interval 0.56 to 1.02. The use of ear drops after swimming increases the risk of AOM in children with ventilation tubes as compared with those who do not swim, odds ratio=3.14, 95% confidence interval 1.40 to 7.05. CONCLUSIONS: There is no evidence to suggest that protection when swimming with earplugs, swimming caps or ear drops in children with ventilation tubes reduces the risk of AOM. Ear drops may even increase this risk.     

Pacific Northwest survey: posttympanostomy tube water precautions

OBJECTIVES: To determine what recommendations are given to patients or parents of patients with tympanostomy tubes regarding water exposure and to elucidate any recommendation differences between primary care and specialty care physicians. DESIGN: Clinical survey. SETTING: General community in the Pacific Northwest, including Washington, Oregon, and Idaho. PARTICIPANTS: Physician surveys (N = 1116) were mailed to otolaryngologists, pediatricians, and family practitioners in the Pacific Northwest. Questions included what, if any, water precautions are given to patients or parents of patients who underwent tympanostomy tube insertion. Data were tabulated and compared among the 3 physician groups. MAIN OUTCOME MEASURES: Recommendations regarding water exposure. RESULTS: A response rate of 23.5% (n = 263) was obtained. Most respondents were self-described otolaryngologists (n = 150) followed by family practitioners (n = 77) and pediatricians (n = 36). chi(2) Analysis of the responses from each specialty group showed an overall significant difference about swimming precautions (P < .001). Further analysis of these data shows that many otolaryngologists (47% [n = 71]) and most primary care physicians (73% [n = 83]) recommend the use of barrier devices for swimming. Another 47% of otolaryngologist respondents allow swimming without any water precautions. With regard to depth of dive, there was no statistical significance found between the physician groups. CONCLUSIONS: Recommendations for swimming precautions are not universal among the physician groups that routinely see patients with tympanostomy tubes. Most primary care physicians and many otolaryngologists continue to prescribe water precautions to patients or parents of patients with tympanostomy tubes, despite published articles that have shown no reduction in the incidence of otorrhea from the use of barrier devices or from the avoidance of swimming.     

Water precautions in children with tympanostomy tubes.

PURPOSE: The necessity and effectiveness of taking precautions around water with children who have tympanostomy tubes is a source of some controversy among otolaryngologists. This study was undertaken to survey the practice standards of otolaryngologists treating these children. MATERIALS AND METHODS: A total of 1,266 board-certified otolaryngologists practicing (mean 14.8 years in practice) in the southern and eastern United States were surveyed to determine current recommendations. RESULTS: Among those surveyed, 13.1% forbid children with tympanostomy tubes from swimming, whereas 3.1% feel that no water precautions are needed. Limitations are placed in the depth of swimming by 68% and the type of swimming water by 18%. The most commonly recommended form of protection is the use of ear plugs, which is favored by 53.4%. Liberalization of recommendations concerning the need for water precautions was noted by 79% of respondents who cited personal experience as the single most influential factor. An overwhelming percentage of respondents indicated they would be willing to alter their current practice based on new information generated from a clinical trial. CONCLUSION: This survey demonstrates that diversity of opinion does exist among otolaryngologists relative to their recommendations for water precautions after placement of tympanostomy tubes. This survey demonstrates the need for a prospective randomized clinical trial designed to address this issue.     

Middle ear ventilation with the castelli membrane tube.

This report evaluates the use of the Castelli type membrane tympanostomy tube in combination with adenoidectomy or adenotonsillectomy. One hundred and sixty two ears were studied. Children with mucoid or seromucoid fluid only were included. The ears were unprotected during swimming, bathing, etc. The average length of intubation was 7 months; 7 1/2% developed middle ear problems with the tubes in place and 7% developed external ear problems. All of these complications were treated without residua.     

Swimming unprotected with long-shafted middle ear ventilation tubes

Patients, parents, and physicians are all concerned about the risks of swimming unprotected with middle ear ventilation tubes. The risks have not previously been carefully quantified or correlated with the degree of swimming activity. In this study, 53 children with tympanometrically proven patent long-shafted tubes were allowed to swim unprotected. They suffered six middle ear infections that were clearly caused by swimming. Five of these infections occurred in divers. The rate of infections for divers was approximately one per 100 days of swimming activity. The rate for non-divers was approximately one per 600 days. Unprotected swimming was well accepted by almost all parents and patients. The need for earplugs for all children who swim with long-shafted ventilation tubes is questioned.     

Tympanostomy tubes and liquids--an in vitro study

Placement of tympanostomy tubes is the most frequently performed otolaryngologic procedure. The common practice is to forbid swimming and to recommend limitation of liquids entering the external auditory canal based upon the premise that liquids entering the external auditory canal will pass freely into the middle ear space via the tube and thus contaminate the space. Indeed, otologic medications (drops) are presumed and are observed to enter the middle ear space by this same route. The physical characteristics of the middle ear and drumhead with a tube in place were examined and a model constructed to test by observation these characteristics. Measurements of the surface tension of water, 2N saline, Cortisporin suspension ear drops, and soapy bath water were performed to provide a clinical correlate. The study implies that limitation of swimming activities or liquid exposure of the ear with a tympanostomy tube in all children may be inappropriate.     

A meta-analysis of swimming and water precautions

OBJECTIVE: To reconcile conflicting reports concerning the incidence of otorrhea in children with tympanostomy tubes who swim without ear protection. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Controlled trials of water precautions following tympanostomy tube placement were selected by independent observers and scored on 10 measures of study validity. Five English-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an endpoint of otorrhea following swimming without ear protection with a minimum follow-up of 6 weeks. DATA SYNTHESIS: Pooled analysis of 619 children revealed a rate difference of -5.04 (95% confidence interval [CI], -11.62 to 1.54). No significant difference in the incidence of otorrhea was noted between patients who swam without ear protection and nonswimmers. CONCLUSION: There is no increase in incidence of otorrhea in children who swim without ear protection compared with children who do not swim following tympanostomy tube placement.     

Opening Plugged Tympanostomy Tubes

Objective To determine the most effective solvents for dissolving plugged tympanostomy tubes. Study Design In vitro laboratory study. Methods Twelve solvents (including ototopical antibiotics and water) were applied to fluoroplastic tympanostomy tubes (n = 260) plugged with dried mucoid middle ear effusion in an ear canal–tympanic membrane model. Time to clearance of the tympanostomy tubes was both visually and tympanometrically determined. Results Vinegar (P = .0030) and hyaluronidase solutions (P = .0030) were significantly better solvents than water. Conclusion Vinegar and hyaluronidase solutions are more likely to clear plugged tympanostomy tubes than water and ototopical antibiotics, but vinegar is the preferred solution because of its known relative safety for use in the ear.     

Swimming with earplugs: are they worthwhile?

The ears of 30 children were examined before and after swimming. Each ear was plugged with cotton wool which was then covered with petroleum jelly. Of the 60 earplugs, 4 (6.6%) were lost while swimming and water was seen in the ears. The remaining 56 (93.3%) earplugs were still in place after swimming. The plugs were removed and the ears, on otoscopy, were found to be dry. In a separate experiment with volunteers, water was instilled into 10 ear canals. Either 1 drop (0.05 ml), 2 drops (0.1 ml) or no water was instilled. Nine of the 10 ears were correctly judged to have either 'no water' or 'water present', suggesting that as little as 0.05 ml of water in an ear canal can be detected otoscopically.     

Medial migration of tympanostomy tubes: an overlooked complication

BACKGROUND: Frequently encountered complications associated with tympanostomy tube placement have been well documented and are globally recognized. The medial migration of tympanostomy tubes into the middle ear space is a rare complication for which pathogenesis, natural history, and management have not been clearly delineated. OBJECTIVE: To describe our experience with the medial migration of tympanostomy tubes into the middle ear space. To propose a simple classification system and define management recommendations. METHODS: A retrospective chart review of all patients with medial tube migration seen in a Pediatric Otolaryngology practice at a tertiary care university hospital between 1995 and 2005. RESULTS: Six pediatric patients (ages 3-19) were found to have seven tympanostomy tubes within the middle ear space at various intervals following tube placement. One patient had a migrated tympanostomy tube deep to a large myringotomy incision. Five patients (six ears) had migrated tubes medial to intact, healed tympanic membranes. Fifty percent of the patients had symptoms attributable to the migrated tube. All six patients underwent middle ear exploration with successful removal of the migrated tube. CONCLUSIONS: This process can be defined as primary, when the tympanostomy tube migrates due to a technical error, or secondary, when the tube is initially seen in the correct position but is later found medial to a healed, intact tympanic membrane. Medial migration is apparently independent of tube type and can occur at various intervals after placement. The process of secondary migration is most likely multifactorial but may in part be the result of persistent negative middle ear pressure. Migrated tubes should be removed surgically unless contraindicated.     

Tympanostomy tubes and otic drops

Otic drops have been proposed as a form of prophylaxis against the otitis media which follows middle ear contamination by water in patients with tympanostomy tubes. The potential adverse effects of this form of therapy were studied in chinchillas with tympanostomy tubes; 31 chinchillas underwent bilateral tympanostomy tube insertion. Seven animals had a mixture of green dye and Cortisporin otic suspension placed in both external auditory canals 24 hours following the placement of tympanostomy tubes and were sacrificed 30 minutes later for gross examination; 3 of these animals had previous eustachian tube obstruction with Silastic sponge. Twenty-one animals had Cortisporin otic suspension placed in the right external auditory canal on postoperative days 3, 4, 5, 6 and 7. No otic drops were placed in the left ear. Ten of these 20 animals had VIIIth nerve action potentials measured on postoperative day 17 and the other 11 animals had VIIIth nerve action potentials measured on postoperative day 42 followed by immediate sacrifice for histological examination and scanning electronmicroscopy. The remaining 3 animals had VIIIth nerve action potentials measured 21 days following tympanostomy tube insertion and served as electrophysiological controls. The 8 ears receiving Cortisporin otic drops mixed with green dye from animals with normal eustachian tubes showed staining of the round window membrane at sacrifice, while the 6 ears receiving Cortisporin otic suspension and green dye from animals with eustachian tube obstruction demonstrated no dye in the middle ear. All animals receiving Cortisporin otic drops in the right ear showed an intra-aural difference in action potentials with the right ear being attenuated by an average of 10.3 dB at 2,000 Hz, 12 dB at 4,000 Hz, 21 dB and 8,000 Hz, and 26 dB at 12,000 Hz. Morphological study revealed hair cell loss in the hook portion of the cochlea in those animals receiving Cortisporin otic drops. It was concluded from this study that, in patients with patent tympanostomy tubes in place, potentially ototoxic topical agents should be used with caution.     

The effects of chronic otitis media with effusion on the measurement of distortion products of otoacoustic emissions: presurgical and postsurgical examination

This study aims to determine the influence of middle ear effusion and inserted tympanostomy tubes on the feasibility of recording and of the amplitude of distortion product otoacoustic emissions (DPOAE). Effusion in the middle ear reduces the number of measurable responses and their amplitude in the whole range of frequencies from 0.5 to 8 kHz. These changes were more distinct in mucous than in serous effusion. There was an increase in the number of measurable responses and amplitude of DPOAE after surgery. Inserted tympanostomy tubes have no influence on the feasibility of DPOAE recording but reduce their amplitude in comparison to the control group.     

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.     

How easily do topical antibiotics pass through tympanostomy tubes?--an in vitro study

BACKGROUND: Despite potential ototoxicity, eardrops containing aminoglycosides remain in widespread use in the presence of indwelling tympanostomy tubes (grommets). It is unclear how readily they pass into the middle ear during administration, nor whether this is affected by middle ear secretions. MATERIALS AND METHODS: The trans-tympanic pressure required to force antibiotic solutions through a tympanostomy tube in an artificial middle ear model was investigated with six ototopical preparations and two sizes of tube. To assess the effect of middle ear secretions, tympanostomy tubes removed from patients ears were investigated in addition to new tubes. The intra-canal pressure generated during tragal massage was also measured. RESULTS: Pressures required for leakage of solutions differed significantly between solutions (P=0.001) and tube sizes, smaller lumen tubes requiring higher trans-tympanic pressure for leakage to occur. The presence of middle ear secretions reduced the pressure required for leakage of solution. Tragal massage generated pressures of over 20 cm of H20 which would be enough to force solution into the middle ear in all tube/solution combinations. DISCUSSION: Some antibiotic solution is likely to leak into the middle ear during most applications of antibiotic solution. Although the risk is small, this suggests the possibility of ototoxicity, previously demonstrated in animal experiments. The relatively low incidence of this occurrence in clinical practice is thought to be related to inter-species anatomical variations.     

Water precautions and tympanostomy tubes: a randomized, controlled trial

OBJECTIVES/HYPOTHESIS: The objective was to determine whether there is an increased incidence of otorrhea in young children with tympanostomy tubes who swim and bathe without water precautions as compared with children who use water precautions in the form of ear plugs. STUDY DESIGN: Prospective, randomized, investigator-blinded, controlled trial. METHODS: Two hundred one children (age range, 6 mo-6 y) who had undergone bilateral myringotomy and tube insertion were randomly assigned into one of two groups: swimming and bathing with or without ear plugs. Children were seen monthly for 1 year and whenever there was intercurrent otorrhea. RESULTS: Ninety children with and 82 children without ear plugs returned for at least one follow-up visit. Mean (SD) duration of follow-up was 9.4 (4.1) months for the children with ear plugs and 9.1 (4.4) months for the children without ear plugs. Forty-two children (47%) who wore ear plugs developed at least one episode of otorrhea, as compared with 46 (56%) who did not use ear plugs (logistic regression adjusting for stratification variables, P = .21). The mean (SD) rate of otorrhea per month was 0.07 (0.31) for the children who wore ear plugs as compared with 0.10 (0.31) for the children who did not wear ear plugs (Poisson regression adjusting for stratification variables, P = .05). CONCLUSION: There is a small but statistically significant increase in the rate of otorrhea in young children who swim and bathe without the use of ear plugs as compared with children who use ear plugs. Because the clinical impact of using ear plugs is small, their routine use may be unnecessary.     

Evaluation of the Polytetrafluoroethylene-Membrane Ventilation Tube

In an effort to evaluate the safety and efficacy of the currently available polytetrafluoroethylene (PTFE)-membrane ventilation tube, in a group of 41 children, the experimental tube was inserted into one ear and a conventional tympanostomy tube was placed in the other ear. The membrane tubes, except in a few instances, were inserted into ears without effusion. After the procedure the children were forbidden to swim and their ears were protected during bathing. In addition to pneumatic otoscopy, a specially designed tympanometric test—which determined if the membrane tube was functioning—was used to assess the operation of the new device postoperatively. In many of the children, Eustachian tube function studies were also performed on the ears with the conventional tympanostomy tubes. The study was aborted early in the clinical trial period due to the early findings: only 10 of 41 (24%) of the membrane tubes continued to function, the remainder having become occluded; whereas 35 of 41 (85%) of the conventional tympanostomy tubes were found to be still functioning during the same period of observation. Twelve of the 41 membrane tubes had to be removed prematurely and replaced with conventional tympanostomy tubes due to recurrence of middle ear effusion. Scanning electron microscopic studies of the removed tubes revealed blockage of the membrane pores. From the extraordinarily high failure rate of the PTFE-membrane ventilation tube in this study, it is evident that the experimental tube should not replace the conventional tympanostomy tube at this time. The selection of the PTFE covering-membrane on this tube was ill advised, but the rationale of a semipermeable-membrane ventilation tube has merit. However, should another membrane ventilation tube be designed, its routine use must await controlled clinical trials to determine safety and efficacy in humans.     

Transient-evoked otoacoustic emissions from ears with tympanostomy tubes

OBJECTIVE: Otoacoustic emissions (OAEs) are low-level acoustic signals which emanate from the cochlea and can be recorded in the ear canal. The two types of OAEs are spontaneous and evoked otoacoustic emissions. METHODS: In this retrospective study, transient-evoked otoacoustic emissions (TEOAEs) were measured in 385 ears from 204 children with normal hearing and tympanostomy tubes. RESULTS: The results indicate that, when using the Quick Screen option on the Oto-Dynamics ILO88 Otoacoustic Emission Analyzer, postoperative TEOAEs were present at all measured frequencies in 81% of the ears. The remaining 19% of ears showed the absence of an observable emission at one or more of the measured response frequencies. The overwhelming factor contributing to an absent emission was insufficient stimulus energy at 4 kHz. The use of T-type tympanostomy tubes also appeared to decrease the probabilities obtaining normal TEOAEs in ears with normal peripheral auditory function. The use of grommet-type tympanostomy tubes, the type of middle ear effusion, the age and gender of the child, and the physical volume of the ear canal as measured by tympanometry with the tympanostomy tube patent and in place had negligible effects on the measurement of TEOAEs. CONCLUSIONS: Clinicians must be cautious when interpreting click-evoked TEAOEs if the patient has a T-tube in place and may need to modify this testing to rule out high-frequency hearing loss when using TEOAEs with these patients. For those patients who have tympanostomy tubes and fail to meet the "pass criteria" for TEOAEs at 4 kHz in the Quick Screen option, TEOAE should be repeated either in the Diagnostic mode or by using a 4 kHz tone-burst stimulus centered at 4 kHz to recover the loss of energy in this region due to the high-frequency roll-off of the stimuli used in the Quick Screen option.     

The bifid UVULA: Is it a marker for an otitis prone child?

All children seen by a pediatrician in a suburban practice during an 18-month interval were examined carefully for the presence of an abnormal uvula. Isolated bifid uvula, without overt cleft palate, was detected among 44 children who had been followed in the practice during the first three years of life. A chart review was performed to determine the frequency of acute otitis media (AOM) and of insertion of tympanostomy tubes among these study patients and among age-matched controls with normal uvulas. Compared to control children, a slightly higher proportion of children with bifid uvulas had experienced more than one episode of AOM (64% vs. 49%) and more than three episodes of AOM (16% vs. 8%) during the first year of life, but these differences were not statistically significant. By age 3 years, the incidences of AOM in the compared groups were more nearly equal. Insertion of tympanostomy tubes during the first three years of life for persistent middle ear effusion was slightly more common among the bifid uvula group than among the controls (14% vs. 10%), but this difference again was not statistically significant. Children with bifid uvula may be at slightly increased risk of middle ear problems during the first years of life, but the magnitude of this increase, if any, appears small.