Laser-assisted myringotomy for otitis media: a feasibility study with short-term followup

Intermediate-duration middle ear ventilation appears to be a good treatment option for selected children with otitis media. Laser-assisted myringotomy is one way to provide such ventilation. It can provide prompt pain relief and resolution of middle ear effusion and effusion-related hearing loss, and it can provide an opportunity for surveillance of antibiotic-resistant organisms. We performed laser-assisted myringotomy on 97 ears of 54 children over a 5-month period. All children had acute or recurrent otitis media or persistent middle ear effusions. Our experience suggests that laser-assisted myringotomy is a feasible treatment option for selected patients. Practitioner experience and patient and family considerations will contribute to the decision whether to use general or topical anesthesia.     

Middle Ear Ventilation in Conjunction with Adenotonsillectomy

If the tonsils and adenoids are causing eustachian tube dysfunction with middle ear effusion, the need for a ventilation tube at the time of the T&A and myringotomy is unresolved. Thirty-one patients with bilateral symmetrical middle ear effusion had T&A and myringotomies. In one ear, a ventilation tube was inserted; the other ear acted as a control. In addition to the clinical impressions, preoperative and serial postoperative audiograms and tympanograms are compared through a 12month time frame. Discussion is presented regarding middle ventilation at the time of the primary operation.     

Thermal myringotomy (an alternative to grommet insertion in childhood secretory otitis media?)

Thirty-six children with bilateral secretory otitis media were treated by thermal myringotomy and middle ear aspiration in one ear, and conventional myringotomy, middle ear aspiration and Shepard grommet insertion in the other ear. All children underwent adenoidectomy. Comparing the effectiveness of the two different procedures over a three-month review period, our main findings are as follows. All thermal perforations were closed by 42 days. Elimination of middle ear fluid was achieved in 81 per cent of the thermal myringotomy group, and in 100 per cent of the grommet group. While there was no significant difference in the hearing improvement between the procedures, conventional myringotomy and grommet insertion provided significantly better sustained middle ear ventilation.     

Chronic otitis media with effusion and Helicobacter pylori

OBJECTIVE: The aim of this study is to investigate the presence of Helicobacter pylori (HP) in the middle ear effusion by Campylobacter-like organism (CLO) test and whether it has a role in the ethiopathogenesis of chronic otitis media with effusion (OME). STUDY DESIGN: A prospective randomized and controlled study. METHODS: This study was performed with 45 patients with the diagnosis of chronic OME and adenoid hypertrophy, between the ages 3 and 13 (median 6). Thirty patients constituted the study group (18 male (60%) and 12 (40%) female). Adenoidectomy with myringotomy with ventilation tube insertion were performed to this group. Middle ear effusion and adenoid tissue pieces were collected and H. pylori presence was investigated by "CLO" testing. Fifteen patients of the matching age group (9 male (66.7%) and 6 (33.3%) female) constituted the control group to whom adenoidectomy with myringotomy were performed but no middle ear effusion could be determined (empty myringotomy patients). The wash out liquid of middle ear and pieces of adenoid tissue samples were also collected from the control group. By using CLO testing, the presence of H. pylori was investigated in the adenoid tissues and middle ear of the empty myringotomy patients. RESULTS: In 20 (66.6%) patients of the study group, CLO testing was positive in the middle ear effusions. None of the patients demonstrated positive CLO test in the wash out liquid of middle ear. There was significant difference of positive CLO testing in the middle ear effusions of two groups (p<0.001). CONCLUSIONS: These findings showed us that presence of HP in the middle ear effusion using CLO testing and this may be responsible for the ethiopathogenesis of chronic OME.     

Effect of irradiation on middle ear effusion due to nasopharyngeal carcinoma.

The management of middle ear effusion by myringotomy and insertion of ventilation tubes in 75 adult patients was evaluated. In Group 1 the middle ear effusion was not related to nasopharyngeal carcinoma. The patients with nasopharyngeal carcinoma were subdivided into pre and post-radiotherapy groups (Group 2 and Group 3) according to the time of insertion of the ventilation tubes. Myringotomy and insertion of ventilation tubes achieved significant hearing gain in all three groups. The pre and post-radiotherapy groups had a higher post-operative infection rate than Group 1 (P greater than 0.01). The duration of a persistent tympanic membrane defect in the post-radiotherapy group was significantly longer than Group 1 (P = 0.03). The post-radiotherapy group had more perforations than Group 1 (P = 0.02). A total of 28% of ears in the post-radiotherapy group were discharging at the last visit. In view of the higher complication rate in the post-radiotherapy group, the role of myringotomy and insertion of ventilation tube is reassessed.     

Diagnosis and therapy of seromucous otitis. Experience with 2766 operations on children

We compared tympanometric patterns with the type of ear effusion on 1693 ears of children with chronic seromucous otitis. There was no exact agreement between the tympanograms and the viscosity of the middle ear effusion. We inserted ventilating tubes in 943 of 2766 ears with SOM. A tube was only used if there was mucus in the middle ear. In cases of thin fluid we used myringotomy alone. A test to find the best tube is discussed. For a child with SOM the insertion of a ventilation tube is so helpful and complications so rare that in our opinion there is no better way of treatment. The complications are probably related more to the underlying disease than to the ventilation tube.     

Effect of irradiation on middle ear effusion due to nasopharyngeal carcinoma

The management of middle ear effusion by myringotomy and insertion of ventilation tubes in 75 adult patients was evaluated. In Group 1 the middle ear effusion was not related to nasopharyngeal carcinoma. The patients with nasopharyngeal carcinoma were subdivided into pre and post-radiotherapy groups (Group 2 and Group 3) according to the time of insertion of the ventilation tubes. Myringotomy and insertion of ventilation tubes achieved significant hearing gain in all three groups. The pre and post-radiotherapy groups had a higher post-operative infection rate than Group 1 (P > 0.01). The duration of a persistent tympanic membrane defect in the post-radiotherapy group was significantly longer than Group 1 (P = 0.03). The post-radiotherapy group had more perforations than Group 1 (P= 0.02). A total of 28% of ears in the post-radiotherapy group were discharging at the last visit. In view of the higher complication rate in the post-radiotherapy group, the role of myringotomy and insertion of ventilation tube is reassessed.     

Aspiration of middle ear effusions prior to grommet insertion an etiological factor in tympanosclerosis

Fifty-five children with bilateral middle ear effusions were entered into a prospective randomized double blind trial to determine whether aspiration of middle ear effusions prior to ventilation tube insertion influences ventilation tube extrusion time or the development of tympanosclerosis. Following myringotomy, aspiration of the left or right ear only was performed randomly prior to ventilation tube insertion. The tympanic membranes were inspected six-monthly to determine whether ventilation tube extrusion had occurred, and at 24 months after surgery for the presence of tympanosclerosis. Results showed no significant difference in extrusion time between aspirated and non-aspirated ears. Aspiration was found to be a factor in the development of tympanosclerosis. We conclude that routine aspiration of the middle ear effusion prior to ventilation tube insertion is associated with an increased risk of tympanosclerosis.     

Laser myringotomy versus ventilation tubes in children with otitis media with effusion: a randomized trial

OBJECTIVES: Insertion of ventilation tubes in children with otitis media with effusion (OME) is an accepted and common treatment procedure. The majority of patients require general anesthesia. Although laser myringotomy can be performed in local anesthesia, evidence is lacking that this treatment modality is an alternative for tubes, and outcome predictors for laser myringotomy are not available. STUDY DESIGN: Prospective randomized trial. METHODS: We screened 1,403 children with chronic OME that were indicated for placement of ventilation tubes. In the eligible patients, we performed laser myringotomy in one ear and placed a tube in the other ear, both within the same patient. Follow-up was scheduled each month for 6 months. Success was defined as absence of effusion or aural discharge. A logistic regression model was used with success of the therapy as binary outcome. This model was based on base-line variables, asked for in a parent's questionnaire. RESULTS: Two hundred eight children received the allocated intervention, and no complications occurred. The mean closure time of the laser perforation was 2.4 weeks, and the mean patency time of the ventilation tube was 4.0 months. The mean success rate was 40% for laser and 78% for tubes. Ten known variables were found to predict middle ear status after therapy. CONCLUSION: Laser myringotomy is a safe but less-effective procedure than insertion of a ventilation tube in the treatment of chronic OME. The prognostic model enables the otolaryngologist to choose the surgical treatment for the child that benefits most: laser myringotomy or ventilation tube.     

Contact diode laser myringotomy for medium-duration middle ear ventilation in children

OBJECTIVE: To prospectively compare contact diode laser for myringotomy (CDLM) to myringotomy with tube insertion (M&T) for the surgical management of otitis media with effusion (OME) in children. STUDY DESIGN AND SETTING: Prospective randomized controlled study at a tertiary care pediatric institution. METHODS: Thirty children for whom PE tube insertion was indicated were randomized for treatment by CDLM or by M&T, in order to investigate length of time for middle ear ventilation, and complication rates. Surgical time was measured, post-operative parental questionnaires were reviewed, and follow-up examinations were performed. INTERVENTION: Middle ear ventilation by CDLM or M&T. RESULTS: Middle ear ventilation by CDLM took an average of 4.1min, and was maintained for an average of 3.5 months, compared to surgical time of 10.2min for M&T, and duration of middle ear ventilation of 6.3 months. These differences were statistically significant (p=0.005 for surgical time, and p<0.001 for duration of ventilation). Complication rates were equivalent. CONCLUSION: CDLM allowed for medium-duration middle ear ventilation in children compared to M&T. Further study to clarify the role of CDLM in the management of OME in children is indicated.     

Effect of anesthetic gas on middle ear fluid

Tympanometry was performed before (preoperative) and after (intraoperative) the administration of inhalation anesthesia including nitrous oxide and halothane on 109 children undergoing myringotomy with pressure equalization tube insertion. A total of 213 preoperative tympanograms were compared with their intraoperative counterparts and the presence or absence of middle ear effusion at myringotomy. When preoperative tympanograms were consistent with pneumatized middle ears, intraoperative findings demonstrated a mean middle ear pressure increase of +147 daPa. When preoperative tympanometry suggested middle ear effusion, less than 1% demonstrated intraoperative tympanometric changes and/or findings at surgery that would support anesthesia clearing middle ear effusion. Preoperative tympanometric data were poor predictors of the presence or absence of effusion at myringotomy. The relationship between inhalation anesthetics (i.e., nitrous oxide and halothane) and middle ear fluids, and the reliability of tympanometry to predict middle ear effusion are discussed.     

An assessment of the validity of tympanometry compared to myringotomy performed under a nitrous oxide-free general anaesthetic

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a ‘gold-standard’ of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5–15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a ‘gold standard’ of myringotomy performed after a nitrous oxide-free general anaesthetic.     

Adenoidectomy With Laser or Incisional Myringotomy for Otitis Media With Effusion

Objective To compare the effectiveness of CO₂ laser myringotomy to incisional myringotomy at the time of adenoidectomy for refractory otitis media with effusion (OME). Study Design Controlled retrospective consecutive case series. Methods All children undergoing myringotomy and adenoidectomy for OME in the spring of 1999 had 1.7‐mm‐diameter perforations created in their tympanic membranes using a CO₂ laser and conventional microslad. Their ears were evaluated at first postoperative visit (mean, 16.65 days after surgery) by a validated otoscopist to determine the presence or absence of perforations and middle ear effusions. These patients were compared with historical controls comprising all children undergoing incisional myringotomy and adenoidectomy in 1998. A χ² analysis was performed to compare the results of these two myringotomy techniques. Results Twenty‐three children (39 ears) underwent laser myringotomy and adenoidectomy in 1999, compared with 26 children (48 ears) who underwent incisional myringotomy and adenoidectomy in 1998. In the laser myringotomy group, 8 of the 39 ears had a persistent opening at first follow‐up; 4 of the 39 ears showed evidence of effusion. In the incisional myringotomy group, all 48 ears had healed; 7 of these ears showed evidence of effusion. Conclusion Myringotomies created using the CO₂ laser are more likely to be patent at first postoperative visit than those made with incisional technique (P < .01). However, this prolonged middle ear ventilation does not significantly decrease the prevalence of effusion (P > .1).     

A planimetric study of temporal bone pneumatization

The present study is based on the results of planimetric measurements of temporal bone pneumatization in 60 children. Radiological and clinical follow-up studies show that a myringotomy is sufficient therapy for cases of serous effusions. In contrast, mucous effusion require long-term middle ear ventilation with tympanostomy tubes to get approximately the same increase in temporal bone pneumatization.     

Does the type of middle ear aspirate have any prognostic significance in otitis media with effusion in children?

Two hundred and twenty-two children with chronic, bilateral middle ear effusions were assessed during a 2 year follow-up period. At initial myringotomy the middle ear aspirate was found to be serous in 44 children and mucoid in 178 children. Evaluation at 1 and 2 years post-operatively showed no difference in otoscopic fluid clearance or mean hearing threshold at either follow-up time in relation to either type of fluid. There was no greater need for ventilation tube reinsertion in either group during the overall follow-up period. There was found to be no significant difference between the children with serous or mucoid effusions in relation to a range of pre-operative and operative variables. The study suggests that outcome in terms of fluid clearance and hearing thresholds is independent of the fluid type and there appears no greater need for revision ventilation tube insertion in relation to the findings at myringotomy. The type of effusion found on aspiration prior to ventilation tube insertion has no prognostic value. Children with serous fluid should be managed in an identical manner to those in which the fluid is thicker and mucoid in character.     

Nasopharyngeal carcinoma and middle ear effusion: natural history and the effect of ventilation tubes

Middle ear effusion is a common occurrence in nasopharyngeal carcinoma, and is often treated by myringotomy and ventilation tube insertion. However, this can be complicated by a high rate of otorrhoea after radiotherapy. The natural history and management of middle ear effusion was examined in this retrospective study of 81 patients. An effusion was noted in 52% of patients at presentation and developed in 26% of patients after radiotherapy. At the end of the observation period there was no difference in the rate of resolution of effusions in patients with ventilation tubes insertion compared with patients with no tube insertion. A significantly greater incidence of otorrhoea and persistent perforation was found in patients with tubes (P= 0.0497). When otorrhoea occurred it was often persistent and troublesome, and so conservative management of effusions in patients with nasopharyngeal cancer should be considered.     

Ultrasonic detection of middle ear effusion: a preliminary study

OBJECTIVE: To assess the ability to detect and characterize middle ear effusion in children using A-mode ultrasonography. DESIGN: Prospective nonblinded comparison study. SETTING: Tertiary children's hospital. PATIENTS: Forty children (74 ears) scheduled to undergo bilateral myringotomy with pressure equalization tube placement. INTERVENTIONS: Before myringotomy, ultrasound examination of the tympanic membrane and middle ear space was performed on each ear. Afterward, myringotomy was performed and the type of effusion (serous, mucoid, or purulent) was recorded. Pressure equalization tubes were then placed. MAIN OUTCOME MEASURE: Comparison of ultrasound findings with the visual assessment of the type of middle ear effusion present. RESULTS: Of the 74 ears tested, 45 (61%) had effusion on direct inspection. The effusion was purulent in 8 ears (18%), serous in 9 ears (20%), and mucoid in 28 ears (62%). Ultrasound identified the presence or absence of effusion in 71 cases (96%) (P = .04). Ultrasound distinguished between serous and mucoid effusion with 100% accuracy (P = .04). The probe did not distinguish between mucoid and purulent effusion. CONCLUSIONS: Ultrasonography is an accurate method of diagnosing middle ear effusion in children. Moreover, it can distinguish thin from mucoid fluid. Further refinements in probe design may further improve the sensitivity of fluid detection and allow differentiation of sterile vs infectious effusion.     

Detection of Helicobacter pylori in children with otitis media with effusion: a preliminary report

OBJECTIVE: To determine the presence of Helicobacter pylori in the middle ear effusion of patients with otitis media with effusion (OME) by polymerase chain reaction (PCR). STUDY DESIGN: A prospective study in patients with OME. METHODS: The study was performed in 38 patients with OME who were admitted to the ENT Clinic, Firat University from June 2003 to April 2004. In all cases, a myringotomy operation (with or without placement of a ventilation tube) was carried out. The effusion samples aspirated from the middle ear were analyzed with PCR assay. RESULTS: A total of 55 aspiration samples collected from 38 children ranging in age from 2 to 12 were included in the study. Fifteen of the subjects were girls, and 23 were boys. In 17 patients, both ears demonstrated effusions, whereas in 21 patients, only one ear had effusions. Nine (16.3%) of 55 the middle ear effusion samples were shown to be H. pylori positive by PCR. CONCLUSIONS: H. pylori was detected in the middle ear effusion of some patients with OME. These results may have interesting implications for a possible role of H. pylori in OME. In addition, these results suggest that further studies are needed to investigate the role of H. pylori in the etiology of OME.     

Long-term ventilation of the middle ear using a subannular tympanotomy technique: a follow-up study

The results of a nine-year series of patients who underwent long-term middle ear ventilation using a tympanotomy technique are presented. The original series of 26 cases was published in 1995. The same series has now expanded to 37 cases, which form the basis of this follow-up study. In contrast to the original series we found a high spontaneous extrusion rate (68 per cent) and in 27 per cent of cases complications necessitated removal of the subannular T tube. In favour of the technique was a low perforation rate after extrusion or removal (eight per cent). Although only nine per cent underwent re-ventilation this is unlikely to represent resolution of the middle ear effusion in the remaining cases. We conclude that the adverse effects of the subannular tympanotomy technique for long-term ventilation of the middle ear outweigh the benefits when compared with the traditional technique of placing a T tube through a myringotomy incision.     

General Anesthesia With and Without Nitrous Oxide (N2O) and the Weight of Middle Ear Effusion in Children Undergoing Adenoidectomy and Tympanostomy

This study was designed to explore the effect of nitrous oxide (N₂O) on the amount of middle ear effusion. Seventy-six children referred for adenoidectomy or tympanostomy tube placement were divided into two groups in the basis of the method of anesthesia. One group of 39 children was ventilated with a mixture of 30% oxygen and 70% nitrous oxide, while the other group of 37 patients was ventilated with a mixture of oxygen and air. The amounts of middle ear effusion obtained in myringotomy were weighed and compared between these groups. Preoperative and perioperative tympanograms were performed. Ventilation with nitrous oxide caused a distinct rise in middle ear pressure. The amount of the middle ear effusion, however, remained the same in the two groups. It is concluded that the operating surgeon can rely on the myringotomy finding even when nitrous oxide anesthesia is used.