Anterior subannular T-tube for long-term middle ear ventilation during tympanoplasty.

OBJECTIVE: A technique for providing long-term ventilation of the middle ear (ME) during tympanoplasty is described, and the results using this technique in 20 patients with chronic Eustachian tube dysfunction (ETD) are reported. STUDY DESIGN: This study was a retrospective, nonrandomized case review. SETTING: This study was conducted at an otology clinic in a tertiary referral center. PATIENTS: Twenty consecutive patients who underwent tympanoplasty with ETD, adhesive otitis media, or chronic otitis media with perforation were included in this study. INTERVENTION: All patients had a subannular T-tube placed anteriorly at the time of tympanoplasty for long-term ventilation of the ME space. MAIN OUTCOME MEASURES: The two main outcome measures were tube position and patency. Preoperative and postoperative hearing levels were also tested in most patients, and any complications were documented. RESULTS: Twenty patients (20 ears) received anterior subannular T-tubes at the time of tympanoplasty. Fourteen females and 6 males were evaluated (median age, 36 years; range, 7 to 72 years). All patients had ETD; 7 had adhesive otitis media, 10 had chronic otitis media, 8 had cholesteatoma, and 2 had cleft palate. All patients had conductive hearing loss and previous surgery. All patients underwent tympanoplasty; 11 had concomitant ossiculoplasty, and 5 had mastoidectomy. Follow-up ranged from 8 to 22 months (mean, 13.4 months). One patient was lost to follow-up. One tube extruded after 16 months. Two patients had persistent mild retraction of the tympanic membrane. All other tubes are patent and have not migrated or plugged. There has been no evidence of anterior blunting or ingrowth of epithelium around the tube. CONCLUSIONS: Anterior subannular T-tube placement is a simple, safe, and effective alternative for long-term ME ventilation in patients in whom standard transtympanic sites are not available. At their last follow-up visit, all but one patient had a patent tube. All MEs were aerated. This technique offers the advantage of ease of placement during simultaneous tympanoplasty, mastoidectomy, or ossiculoplasty. Longer follow-up is necessary to confirm these initial findings.     

Long-term middle ear ventilation.

This is a 16 year experience report on the author's wide flange ventilation tube, used for permanent or severe chronic Eustachian tube dysfunction. Two hundred and twenty-eight implants in 198 ears of 126 patients were adequately followed. A small series of 13 Paparella implants is included. Patient age ranges from 6 months to 72 years. Tube longevity up to elective removal averaged 51.2 months (longest — 159 months). Average longevity for tubes removed for uncontrolled complications was 34.6 months (longest — 162 months). Comparable figures for the Paparella tube are 15 and 31 months. There were 249 complications in 228 Per-Lee tube implants and 12 in 9 Paparella tube implants; 69.6% of Per-Lee tubes and 100% of Paparella tubes were associated with complication. Per-Lee tube complications occurred from 1 to 162 months after implantation. The most common was infection (68.6% of all complications). The others included bleeding (10.9%), peritubal drum atrophy (11.7%), extrusion (4.8%), tissue growth into the tube (0.8%), tube migration into the middle ear (1.2%), squamous epithelial invasion (1.2%), and obstruction for other causes (0.8%); 75 infections and 8 bleeding episodes required tube removal. The drum did not heal in 14 and 2 cases respectively. Peritubal drum atrophy, an important complication, occurred 29 times and led to 14 unhealed perforations; 12 tubes (5%) extruded leaving 4 drums unhealed. Squamous epithelium invaded the middle ear three times; in one instance it was due to the tube. A total of 49 permanent perforations (24.8% of 198 ears) occurred including those remaining after elective tube removal. This compares with a 2% or less incidence with a grommet and other standard tubes. Since long-term ventilation is sought, this outcome is less serious than one suspects. Follow-up hearing data was available for 7 unhealed and 32 healed drums. For unhealed drums (mostly anterior perforations) the average SRT was 7.1 db. The average SRT for healed drums was 11 1b. Other approaches to long-term ventilation are discussed, specifically Wright's Eustachian tube prosthesis and laser myringotomy. Both approaches seem unreliable. If permanent ventilation is desired, a permanent perforation resulting from a long-term ventilation tube would seem to be an acceptable result.     

Physiological tympanostomy. A new technique of middle ear ventilation.

Physiological tympanostomy is advanced as a 'substitute' eustachian tube because it opens regularly only on swallowing, as does the 'natural' eustachian tube. The efficacy of the physiological tympanostomy operation was first proved in experimental animals (two dogs). Subsequently, six patients with eustachian insufficiency were successfully managed by this new surgical technique within period of one year, with no post-operative complications. The hearing improved and the middle ears remained air-filled. The method seems to have the following merits: permanent ventilation of the tympanum with preservation of an intact drum (from the functional point of view); no tympanophonia or autophonia; simple technique, short operative period (five minutes); no risk of postoperative complications; and no danger of ascending infection of the middle ear from the ear canal. The demerits appear to be: drainage not ensured; no facility to increase the middle ear pressure by the Valsalva manoeuvre or, Politzerization.     

Complications following ventilation of the middle ear using Goode T tubes

This is a 3.5-year retrospective review on the insertion of 210 Goode T tubes into 182 ears of 93 patients. Otorrhea was noted postoperatively in 35.2% of the ears treated, with chronic drainage lasting longer than 4 months developing in more than 7% of the cases. Perforations were found in 34 ears (18.7%) following removal or extrusion of the T tubes; in 13 (7.1%) of these patients, chronic perforations requiring tympanoplasties developed. The literature was screened for additional studies addressing the complications associated with tympanostomy tubes. The documented incidence of perforations between conventional tubes and Goode T tubes was emphasized, and comparisons were made. Our findings indicate that, even with the immediate placement of paper patches following removal of all Goode T tubes, the percentage of tympanic membrane perforations resulting from the use of Goode T tubes is significantly greater than previously reported.     

Resistant bacteria in middle ear fluid at the time of tympanotomy tube surgery

This study was performed to determine the prevalence of resistant Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis isolated from middle ear fluid of children undergoing placement of ventilation tubes. The extent of resistance to commonly prescribed antibiotics and the risk factors associated with this resistance were also examined. Children who had fluid present in their middle ears at the time of ventilation tube placement from May 1996 to May 1997 were included in the study. Middle ear fluid was plated onto culture media in the operating room, and antimicrobial resistance of cultured organisms was ascertained. Risk factors for this resistance were determined from the medical history and analyzed. Cultures of 244 patients (355 ears) were positive for organisms in 29.6%. Penicillin resistance was found in 38.2% of S pneumoniae cultures. Beta-lactamase production was found in 65.1% and 100% of H influenzae and M catarrhalis specimens, respectively. Risk factor analysis revealed young age, day care attendance, and number of antibiotic courses to most reliably predict the presence of resistant microorganisms.     

Long-term results using a piezoelectric semi-implantable middle ear hearing device: the Rion Device E-type

The Rion Device E-type (RDE) has been applied to 39 patients with severe mixed deafness that could not be rehabilitated by surgical means or the conventional hearing aid. Careful follow-up studies have been conducted on all of them to assess clinical and audiologic results. The device could function more than 10 years, affording natural quality of hearing without howling and wearing discomforts. Functional principles of the device, indications, and surgical methods of implantation are described. The failures and delayed problems were also presented together with the preventive measures.     

Hamartoma of the middle ear: a case study

Hamartomas and teratomas are rare tumors in children. Its location in head and neck is quite exceptional. An unusual case of hamartoma in the middle ear is reported in a 5-month-old child. The tumor was isolated without associated malformation. Definitive diagnosis was made after surgery and based on histological results. At 2 years follow-up, no recurrence was observed. CT-scan is useful in order to reach a final diagnosis. Although rare, this type of tumor should be considered in the differential diagnosis of a middle ear mass during childhood.     

Vitreous carbon: a new material for middle ear ventilation tubes

Synthetic allotropic carbons have been used for nearly 20 years as biomedical implants. Vitreous carbons in particular appear to possess very favourable biocompatibility characteristics. The middle ear compatibility of Sigradur has been tested in the mastoid bulla of gerbils. The period of implantation varied from 1 to 13 months. Light and electron-microscopic examination revealed good middle ear tolerance of the material, especially when the surface had not been modelled. Our animal experiments suggest that this material could be suitable for ventilation tubes, but was less ideal for ossicular replacement prostheses, particularly because of the specific surface properties. Consequently, we have used such carbon ventilation tubes in 38 patients. The results obtained using this material were excellent thanks to the favourable biocompatibility, advantageous surface properties, and low weight.     

Neuro-endocrine adenoma of the middle ear: a case study

Neuroendocrine adenomas are rare tumors, which can appear in the middle ear. Approximately a hundred cases have been reported in the literature. We report the case of a 58-year-old man who consulted for an abnormal sensation of fullness in the right ear. The otoscopic examination showed a retrotympanic tumefaction. The CT scan and MRI of the middle ear demonstrated a well-defined tissue mass without any osteolysis. We performed surgical exeresis by transcanal procedure with a cartilage graft tympanoplasty. Microscopic examination and immunohistochemistry revealed an endocrine adenoma of the middle ear. Neuroendocrine adenomas can develop in a number of different sites. When they appear in the middle ear they usually produce hypoacousia. The otoscopic examination shows non-specific findings with only retrotympanic swelling. Surgical exeresis enables histologic and immunohistochemically analysis of the surgical specimen. The adenoma is composed of two cellular types: neuroendocrine (which closely resemble carcinoid tumors) and glandular. Regular clinical and radiologic follow-up is necessary since recurrence is possible. The formal diagnosis of neuroendocrine adenomas of the middle ear requires histologic and immunohistochemically confirmations since the clinical symptoms are non-specific. Surgical excision with removal of the ossicular chain is the treatment of choice in order to prevent recurrence.     

Standardized measurements of the sound transmission of middle ear implants using a mechanical middle ear model

Several ways to evaluate the sound transmission properties of middle ear implants are now established. Besides computer-based simulations using acoustic and electrical analog circuits or finite element analysis, measurements can be performed with temporal bone preparations. Experiments with these preparations consider various anatomical properties, but a large number of parameters influence the outcome of measurements. To facilitate standardized measurements, a mechanical middle ear model was developed that allows comparison of the transfer function of middle ear implants on defined conditions. The model approximates the impedances of the tympanic membrane and inner ear with the aid of thin, flexible membranes. The implants are fit between the membranes, and displacement at an artificial stapes footplate is measured with an optical probe. Fundamental influences on the sound transmission properties of nine different middle ear implants (total ossicular replacement prostheses) were examined. Although the material and shape were different, some of the prostheses revealed very similar transfer functions. The mass of the implant showed the largest influence on sound conduction. With a higher mass, the frequency area above approximately 1 kHz was found to be significantly deteriorated. The lightest implant used was 4 mg and showed the best overall results. These findings show that middle ear prostheses should be as light as possible for optimum high-frequency transmission. Received: 24 May 1998 / Accepted: 9 July 1998     

Long-term ototoxic effects of neomycin applied topically in the middle ear: a morphological study in the guinea pig

Neomycin was instilled daily, uni- or bilaterally, into the middle ear of guinea pigs for three months. The cochleae were examined, by light and electron microscopy, six months after the end of treatment. The organs of Corti of the treated ears were completely destroyed, and in the most advanced lesions, were substituted by a single layer of very thin flat cells. In the spiral ganglion only some glial cells and a few neurons could be observed. All surviving neurons were myelinated, and their ultrastructure was greatly altered, with disorganization of the rough endoplasmic reticulum and ribosomes. The basilar membrane almost disappeared, losing it amorphous and filamentous components. The spiral limbus and the stria vascularis were atrophic and were also covered, in the final stages, by flat elongated cells. In view of its morphological characteristics, this epithelium may arise from the displacement of the interdental cells and perhaps from the cochlear surface of Reissner's membrane.     

Medium-term middle ear ventilation with self-manufactured polyethylene T-tubes for the treatment of children with middle ear effusion

We present the results of the insertion of self-made polyethylene T-tubes for a period of 15-24 months for the treatment of chronic middle-ear effusion. We compare the outcome of our patients to the reported outcome of patients treated with other commonly used ventilation tubes for either shorter or longer periods of time. In a retrospective review of 603 T-tubes inserted in 306 children up to the age of 12 years, charts were reviewed for age, sex, surgical procedure performed, duration of ventilation and complications. In all cases the indication for surgery was chronic middle-ear effusion. The tubes were electively removed by the authors after 15-24 months of ventilation. Spontaneous extrusion was considered a complication. The mean period of ventilation was 20 months. Post-operative otorrhoea was experienced in 6.6 per cent of ears; 4.8 per cent of tubes extruded spontaneously, whereas 3.15 per cent had to be removed earlier than originally planned; 4.9 per cent of ears were re-ventilated at a later date, and 1.49 per cent of ears developed a persistent perforation. We demonstrate that the outcome of patients treated with our self-manufactured tubes for a period of 15-24 months is, in many respects, better or at least comparable to the reported outcome of patients treated with other commonly used ventilation tubes for either shorter or longer periods of time, and that the many complications associated with the conventional T-tube can be reduced. We suggest that our favourable outcome may be due to the duration of ventilation, which was controlled to be shorter than the conventional long-term T-tubes and longer than that of grommets.     

Results of middle ear ventilation with Goode's tubes

The results of a retrospective study of the effect and outcome of middle ear ventilation by Goode's tubes are presented. 83 ears from 50 patients were analyzed both as a group and in age-related sub-groups over a mean follow-up period of 1.83 years. The mean period of ventilation by Goode's tubes before removal or extrusion was 18.4 months. The tubes became infected in 70.4% and were spontaneously extruded in 44.9% of patients. Permanent perforation of the tympanic membrane ensued in 47.5% of patients and significantly more often in those aged between 10 and 20 years (P less than 0.002). Patients aged less than 10 years were significantly less likely to develop a retraction of their tympanic membranes after removal of the Goode's tube than those older (P less than 0.02). No significant relationship was found between the development of these complications and the period of ventilation, past experience of otitis media, consistency of effusion, degree of tympanosclerosis or the preoperative presence of tympanic retraction.     

Nuclear factor-kappaB in middle ear epithelial cells: a methodological study using an ELISA

OBJECTIVE: To contribute to the elucidation of the intracellular mechanisms relating to otitis media with effusion (OME) by detecting and quantifying nuclear factor (NF)-kappaB in middle ear epithelial cells by means of an ELISA. MATERIAL AND METHODS: Using an ELISA technique, NF-kappaB was identified and quantified in the cytoplasm of cultured epithelial cells from the rabbit middle ear exposed to a well-known inflammatory stimulus: lipopolysaccharide (LPS). RESULTS: NF-kappaB was measurable with the ELISA in a concentration range of 16-32 ng/microg total cell protein. LPS caused significant enhancement of NF-kappaB. Furthermore, the NF-kappaB concentration increased with the duration of LPS exposure. Western blot analysis confirmed the results obtained by ELISA. CONCLUSION: Further studies are required to determine the role of NF-kappaB in initiating and regulating the inflammatory response in the middle ear, including the significance of hyperoxia.     

Ventilating tubes in the middle ear. Long-term observations

This follow-up study is of the same patients we studied in 1976. Then we thought the results were unsatisfactory in 20.9% of the ears treated with ventilating tubes. The hearing losses varied from 25 to 60 dB and chronic otitis media developed in 7.7% of the cases. We think the results of treatment with ventilating tubes in chronic serous otitis media are not good enough. This study shows that there has been an increase in the number of patients with permanent hearing loss and chronic otitis media than in the first study.     

Odontoma of the middle ear: case report with 25-year follow-up

We report the 25-year follow-up on the first reported case of odontoma in the middle ear. Diagnosis of odontoma had been made on the basis of radiography films that showed a middle ear mass with multiple toothlike areas of radiopacity. No clinical intervention was recommended. At 25-year follow-up, audiometry showed progressive mixed hearing loss on the affected side and mild ipsilateral sensorineural hearing loss. Computed tomography better characterized the discrete mass, which was shaped similar to a dental crown. To avoid jeopardizing cochlear and facial nerve function, no surgical intervention was pursued, and we recommended use of a BiCROS (bilateral contralateral routing of signal) hearing aid.     

儿童分泌性中耳炎鼓膜置管后中耳功能的综合评价

目的:探讨儿童分泌性中耳炎(SOM)鼓膜置管后中耳功能综合评价的方法和临床意义。方法:选择31例(43耳)临床诊断为SOM的患儿,分别在鼓膜置管术前及术后1个月,进行纯音听阈测试、畸变产物耳声发射(DPOAE)、鼓室导抗图(记录外耳道容积,ECV)测试;术后1个月加咽鼓管功能正负压平衡测试,并在显微镜下观察置管情况。结果:置管后1个月,39耳置管通畅者ECV>2.0ml,听力比置管前明显提高;DPOAE引出率及部分频率幅值提高,与置管前比较,差异有统计学意义(P<0.01或P<0.05);咽鼓管功能尚无完全正常。结论:应用ECV、纯音听阈测试、DPOAE以及咽鼓管功能测试对患儿鼓膜置管术后中耳功能的恢复情况进行综合评价,具有临床指导意义。