Tympanic membrane healing process and biocompatibility of an innovative absorbable ventilation tube.

OBJECTIVE: To investigate tympanic membrane healing process and biocompatibility of pressure-equalizing (PE) tubes, made of a novel biodegradable, absorbable material, in an animal model. BACKGROUND: Myringotomy and pressure-equalizing tube insertion is a frequent otologic procedure in children. However, results may vary because of the unpredictable extrusion rate of tubes. Furthermore, tubes that are no longer required need a surgical procedure to be removed. The ideal pressure-equalizing tube should remain in place for the time selected by the otologist, with no need for subsequent removal. This objective could be met with pressure-equalizing tubes made from a self-disintegrating material. METHODS: Pressure-equalizing tubes, made of poly-bis(ethylalanate)phosphazene, were inserted in 55 ears of 28 Hartley guinea pigs, with survival times of 10, 30, and 60 days after tube insertion. In vivo reactions between the poly-bis(ethylalanate)phosphazene pressure-equalizing tubes and the tympanic membrane were studied. Tympanic membranes, middle ears, and tubes were examined by scanning electron microscopy. RESULTS: There was neither infection nor inflammatory reaction to the tube in any animal. The healing process of tympanic membranes revealed neither residual perforation nor inward spread of skin epithelium into the middle ear cavity. At 30 days, 53% of the tubes had disintegrated. At 60 days, tubes were functioning in 25% of ears. CONCLUSION: These new poly-bis(ethylalanate)phosphazene pressure-equalizing tubes are promising. The healing process of tympanic membranes is excellent, with no complications. The tube disintegration rate can be controlled by varying the formulation of the polymer, obtaining tubes with predictable resorption rates, to adapt treatment to the needs of each single patient.     

Reliability of a tympanic thermometer in measuring temperatures in children after minor ear surgery

AIM: To evaluate the reliability of infrared tympanic thermometry in children who have undergone myringotomy with grommet insertion. METHOD: Forty children who had undergone myringotomy with at least one grommet insertion had the tympanic temperature of each ear and the axillary temperature measured on admission and 30 minutes post-operatively. RESULT: No difference was found between the pre- and post-operative temperatures measured by either method (p > 0.05, paired t-test, hypothesized difference of 0). CONCLUSION: Infrared tympanic thermometry is reliable in monitoring body temperature in children who have had minor ear surgery.     

Is aspiration of middle ear effusions prior to ventilation tube insertion really necessary?

A prospective double blind randomized trial of 55 children undergoing myringotomy and insertion of ventilation tubes for bilateral middle ear effusions was undertaken. The aim of the study was to assess the need for clearance of the middle ear by aspiration prior to the insertion of ventilation tubes. The day before surgery the children were assessed by clinical examination, pure tone audiometry and impedance audiometry. At the time of surgery each child underwent bilateral myringotomy, with aspiration of the right or left ear only on a randomly allocated basis. Standard ventilation tubes were then inserted. Postoperative evaluation up to three months following surgery showed no significant differences between the aspirated and the non-aspirated middle ears. We conclude that routine evacuation of the middle ear prior to ventilation tube insertion is not necessary.     

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.     

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.     

Laser myringotomy in otitis media with effusion: long-term follow-up

Otitis media with effusion is a leading cause of conductive hearing loss in children. Myringotomy and insertion of tympanostomy tubes is the accepted form of treatment. Recently, several studies utilizing laser myringotomy have been published, but few of them present late results. The objective of this study was to compare late results of the treatment with laser and classical myringotomy. A clinical effectiveness trial was conducted in three groups of children: (1) 37 children treated with laser myringotomy (ML), (2) 29 children treated with laser myringotomy and the insertion of tympanostomy tubes (ML+V) and (3) 43 children treated with classical myringotomy and the insertion of tympanostomy tubes (MC+V). All types of surgery were performed under general anesthesia because adenoidectomy and/or tonsillectomy was done at the same time. The results of treatment were assessed on the basis of the otoscopic examination (recurrences of effusion, condition of the tympanic membrane, and audiological examination (pure-tone audiometry, tympanometry and DPOAE). The minimum follow-up period was 1 year. The recurrence rate was lowest in the ML+V (11%) group, and highest in the ML group (36%). The difference between ML+V and MC+V was not significant. Permanent changes in the tympanic membrane were observed in 8% of the ears after ML, 19% after ML+V and 31% after MC+V. The difference was significant between the ML and MC+V groups. PTA was significantly higher in the MC+V group than in the control group of otologically healthy children. Mean amplitudes of DPOAE, measured in treated children with normal tympanometry results, were significantly lower than in the control group, but within the normal range. The use of CO₂ laser during myringotomy has no negative effect on the function of the cochlea. Healing of the tympanic membrane after laser myringotomy was uneventful with a low percentage of permanent sequelae.     

Does the use of radiofrequency myringotomy for insertion of a ventilation tube reduce the incidence of myringosclerosis?

The aim of the present study was to determine the rate of myringosclerosis after radiofrequency (RF) myringotomy and ventilation tube (VT) insertion and compare it with that after the incisional myringotomy and VT insertion. Thirty children (60 ears), 2–16 years old (mean age 7.06 ± 2.77 years) who were planned to undergo surgical intervention for bilateral otitis media with effusion (OME), were included in this study. The children were treated by RF myringotomy of the right ear, incisional myringotomy of the left ear, and insertion of VTs into both ears. Both ears were examined intraoperatively for bleeding, and patients were evaluated for myringosclerosis formation with otomicroscopy at the end of the ninth month. Myringosclerosis was observed in 22 of the 60 ears. The overall incidence was 36.6 %. Fifteen (50 %) left ears showed myringosclerosis by otomicroscopy, and seven (23.3 %) right ears showed myringosclerosis. The rate of myringosclerosis of the right ear was significantly lower than that of the left ear (p < 0.05). In addition, intraoperative tympanic membrane bleeding was observed in 24 (40 %) of the 60 ears: 21 (70 %) left ears and three (10 %) right ears were perforated by RF. The tympanic membrane bleeding rate of the right ear was significantly lower than that of the left ear (p < 0.01). The present study is the first to determine the myringosclerosis rate after RF myringotomy and VT insertion. Our results indicate that VT insertion with RF myringotomy decreased the incidence of myringosclerosis.     

Perforation rates after ventilation tube insertion: does the positioning of the tube matter?

A prospective study was performed of children undergoing bilateral ventilation tube insertion. One hundred and twenty-one children aged between 9 months and 10 years 3 months were admitted for surgery for secretory otitis media (glue ear). Each child had a ventilation tube inserted anteriorly in the tympanic membrane of one ear and posteriorly in the tympanic membrane of the other. They underwent regular clinical and audiological assessment until extrusion of the ventilation tubes occurred. Perforations were noted in 2.75% of tympanic membranes (4.6% of the children). The rate with posteriorly placed ventilation tubes was higher than with the anteriorly placed ventilation tubes (3.7% compared with 1.8%) though this is not statistically significant.     

Avoidance of postoperative blockage of ventilation tubes

While most of the complications of ventilation tubes are widely described in the literature, little is mentioned about postoperative blockage of these tubes. Generally, this blockage is caused by viscid secretion or a blood clot. This study was conducted to assess the effect of using a vasoconstrictor solution to cover the tympanic membrane after ventilation tube insertion to ensure hemostasis in the immediate postoperative period and to decongest the mucosa of the middle ear and the eustachian tube. Xylometazoline hydrochloride (Otrivin^r? Nasal Drops 0.1% or Pediatric Nasal Drops 0.05%) was introduced into 60 ears in 32 patients undergoing myringotomy and ventilation tube insertion. The control group, consisting of 76 ears in 40 patients, underwent only myringotomy and ventilation tube insertion. In a follow-up period of 3 months, postoperative tube obstruction occurred 10.5% of the patients in the control group. No case of blocked tube occurred in the patients who received xylometazoline.     

Effectiveness of laser-assisted myringotomy for otitis media in children

OBJECTIVE: To evaluate the effectiveness of OtoScan CO2 laser-assisted myringotomy (OtoLAM ESC/Sharplan) for acute otitis media and chronic otitis media with effusion (COME) in children. STUDY DESIGN: Retrospective review of 47 children with refractory acute otitis media (RAOM) or COME more than 3 months in duration in a pediatric otolaryngology practice. METHODS: Laser-assisted myringotomy was performed on 47 patients (79 ears) using the OtoLAM device. There were 28 children (ages 0.50-3 years) with RAOM and 19 children (ages 0.58-15 years) with COME. RESULTS: A total of 57.4% of procedures were considered treatment failures. Failures occurred in 53.6% of patients with RAOM on average +/-SD 3.89 +/- 2.16 weeks after the procedure and in 63.2% of patients with COME on average +/-SD 7.25 +/- 5.57 weeks after the procedure. Age, sex, microorganism isolated, myringotomy size, wattage, and laterality did not predict outcome. Ventilation tube insertion was performed in 27 (57.4%) patients. Two patients have persistent tympanic membrane perforations at 2 years. CONCLUSIONS: Laser-assisted myringotomy in children with RAOM and COME was associated with a high incidence of recurrence or persistence of disease and with perforation of the tympanic membrane. Recommendations for use of the OtoLAM should include discussion of high failure rates and the strong likelihood of subsequent ventilation tube insertion. The OtoLAM remains an option for office-based ventilation of the middle ear for families and patients where general anesthesia is a concern.     

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.     

Subannular ventilation tubes: retrospective study

OBJECTIVE: To evaluate the efficiency of a subannular tube insertion technique in a group of pediatric patients with adhesive otitis or severe atelectasis of the tympanic membrane. DESIGN: Retrospective nonrandomized case series. Setting: Tertiary referral centre. MAIN OUTCOME MEASURES: The main outcomes of this study are tube duration according to the type of tube used, the complication rate, and the audiometric gain associated with this procedure. RESULTS: The study group consisted of 190 patients (316 tubes) aged between 3 and 19 years (average 9 years old) and operated on between 1993 and 1999 by four pediatric otolaryngologists. The average follow-up was 53 months. The tubes remained in place for an average of 21.8 months, with fluoroplastic tubes lasting 17.8 months and Goode T tubes lasting 23.8 months. When used in children between 5 and 9 years of age and in cases of adhesive otitis, Goode T tubes showed statistically significantly better results than fluoroplastic tubes. The complications of this technique were otorrhea (17.7%), perforation (7.9%), a plugged tube (7.0%), and cholesteatoma (1.6%). The 5- to 9-year-old group and the reintervention group of patients showed statistically higher complication rates compared with all other groups. Sixty-four patients (128 tubes) were eligible for audiogram analysis, which showed a gain of 13.4 dB (speech reception threshold). CONCLUSIONS: The technique of subannular tube insertion is a safe and effective method for long-term middle ear ventilation in cases of adhesive otitis or severely atelectatic tympanic membrane or for patients with pathology related to dysfunction of the eustachian tube. It offers an alternative to repeated short-term tube insertions for otitis media with effusion or recurrent acute otitis media.     

Iatrogenic cholesteatoma in children with OME in a training program

PURPOSE: To report the occurrence of cholesteatoma following myringotomy and insertion of ventilating tube (VT) in a residency training program. MATERIALS AND METHODS: Nine hundred and eighty-four children who were operated for grommet insertion with or without adenotonsillectomy during the year 1999-2003 were included in the study. Children were divided into two groups: group 1 (648 children) operated by residents and group 2 (305 children) operated by consultant. All procedures were carried out under general anesthesia using Ziess operating microscope. Shah ventilating tubes were used in most cases and Goody T tube in some others. RESULTS: Nine ears developed cholesteatoma, six with perforation and three with pearl cholesteatoma cyst and intact tympanic membrane. The rate of iatrogenic cholesteatoma occurrence was 0.62% when done by residents (group 1) and 0.33% when operated by consultants (group 2). The overall prevalence was 0.48%. CONCLUSION: Iatrogenic cholesteatoma occuring as a complication following VT insertion is not uncommon. It occurs more often following surgery done by inexperienced surgeons. Excessive manipulation may cause meatal wall and drum surface epithelium injury. This epithelium might be pushed with the VT into the middle ear.     

Vitamin e-coated tympanostomy tube insertion decreases the quantity of free radicals in tympanic membrane

OBJECTIVE: Tympanosclerosis is a common sequela of ventilation tube treatment of otitis media with effusion causing hearing disability. It is associated with an increased production of free radicals (also known as reactive oxygen species) after myringotomy. Vitamin E is a scavenger of different free radicals by working as an antioxidant. The aim of the present study was to evaluate the effect of vitamin E-coated tympanostomy tube insertion at quantity of free radicals in rat tympanic membrane. METHODS: This prospective, controlled animal study consisted of male Sprague-Dawley rats divided into two groups of 10 animals each. Ordinary silcone tubes were applied to the right ears of the first group and vitamin E-coated silcone tubes were applied to the right ears of the second group. The left ears were used as controls. Then, the animals were killed and chemiluminescence measurements were made for tympanic membranes. RESULTS: Reactive oxygen species levels (ROS) were significantly increased in right ears of the first group when compared with the control ears (P < .0001), and the levels were statistically significant decreased in right ears of the second group as compared with the operated ears of the first group (P < .0001). The free radical levels of right and left ears in the second group were similar. CONCLUSIONS: Our results indicate that vitamin E-coated tube insertion decreases the quantity of reactive oxygen species in tympanic membrane after myringotomy and tympanostomy tube insertion.     

两种鼓室硬化造模方法的比较

目的 应用鼓膜切开法和鼓室接种细菌法构建鼓室硬化动物模型,观察两种方法造模后其鼓膜和鼓室粘膜的组织形态学变化.方法 40只SD大鼠分为4组,每组10只:A1组双耳鼓膜不作处理,作为正常对照;A2组双耳鼓膜紧张部后下象限作2 mm的切口;B1组双侧鼓室不作处理,作为正常对照;B2组双侧鼓室接种1×108 CFU/ml肺炎链球菌0.1 ml.分别于鼓膜切开后第2周及鼓室接种肺炎链球菌后第1、2、4、6、8周时观察各组大鼠鼓膜情况,比较鼓室硬化发生率;分别于造模后第2周和第8周取材行听泡连续切片HE染色,观察鼓膜及鼓室粘膜的组织形态学变化.结果 A2组14耳发生鼓膜钙化(14/20,70%);B2组死亡一只,6耳发生鼓膜钙化(6/18,33.33%),两组的鼓膜及鼓室粘膜均可观察到炎症细胞浸润及纤维组织增生,但B2组的改变更显著.两对照组(A1和B1组)既未发生鼓膜钙化,也未出现组织形态学改变.结论 两种鼓室硬化造模方法均切实可行,但鼓膜切开法操作更简单,成模周期更短,成模率更高.     

腭裂与中耳功能障碍的相关性

目的：探讨腭裂手术对患者中耳功能的影响，为早期改善患者中耳功能提供依据。方法：对112例(224耳)腭裂患者进行年龄分组,采用声导抗、纯音测听或听性脑干反应检查。65例腭裂伴分泌性中耳炎患者在作腭裂修复术的同时,行鼓室置管术,术前术后作听力学检测，术前对鼓室分泌物作细菌培养。结果：腭裂患者常伴有不同程度的中耳功能障碍，腭裂修复术能明显改善患者中耳功能(P＜0.05)。鼓室分泌物Ｇ+、Ｇ-细菌培养阳性率为22.86%、23.53%,且多为低毒性条件致病菌。结论：腭裂患者常有中耳功能障碍,应重视其早期预防与治疗，早期修复腭裂有助于咽鼓管功能恢复。     

Myringotomy Delays the Tympanic Membrane Recovery in Acute Otitis Media: A Study in the Rat Model

Background/Hypothesis Acute otitis media is a major cause of visits to pediatric health care providers. Myringotomy in uncomplicated acute otitis media is debatable today. The study addressed this problem through the otomicroscopic and histopathological observations of the events occurring in the tympanic membrane during the first week after myringotomy. Study Design Randomized study in an experimental animal model. Methods Under anesthesia, the left middle ear of 36 Sprague‐Dawley rats was inoculated with Streptococcus pneumoniae type 3. Forty‐eight hours later, at day 0, four animals were immediately killed and the remaining animals were randomly assigned into a myringotomy group (n = 16, myringotomy on the left ear) and a non‐myringotomy group (n = 16, otomicroscopy without myringotomy). Otomicroscopy and killings were performed in series of four animals from each group at days 1, 2, 4, and 7 after myringotomy. Tympanic membranes were collected after fixation and processed for light and electron microscopy. Results All inoculated ears showed a manifest acute otitis media at day 0. An intense infiltration by inflammatory cells and edema distorted severely the tympanic membrane structure. These findings decreased the following days. However, inflammation as evaluated by the thickness and the cytoarchitecture of the tympanic membrane layers, recovered significantly faster in the membranes in the non‐myringotomy group. At day 7, all tympanic membranes in the myringotomy group were closed by a hypertrophic keratinizing epithelium and a remodeling connective tissue layer, whereas the animals in the non‐myringotomy group had a residual edema in the lamina propria. Conclusions The present infectious model induced an intense inflammatory reaction within the entire structure of the tympanic membrane. Myringotomy provoked a delayed recovery from the inflammatory process within the tympanic membrane. Therefore, if applicable to human conditions, the use of myringotomy in the management of acute otitis media should be restricted to selected cases of acute otitis media.     

分泌性中耳炎临床疗效观察

目的随访分泌性中耳炎患者经单纯鼓膜切开、鼓膜切开冲洗灌药后的恢复情况，探讨有效的治疗方法。方法对2006年1月-2008年12月因分泌性中耳炎住院手术治疗的病人共168例进行随访，实际回应预约随访者40例（67耳）。术后随访时间为6个月-3年，通过手术前后I临床表现、纯音测听、声导抗及鼓膜改善情况评估各组疗效。结果单纯鼓膜切开组与鼓膜切开冲洗灌药组的有效率分别是55.56％和74.19％，两组之间无统计学差异。结论单纯鼓膜切开和鼓膜切开冲洗灌药是治疗分泌性中耳炎的有效方法。     

Effect of the status after ear surgery and ear pathology on the results of infrared tympanic thermometry

Most publications that deal with infrared tympanic thermometry (ITT) have performed a comparison between the established temperature measurements and ITT. However, to date an understanding of the influence of pathological ear findings on ITT test results is incomplete. Therefore, in the present study ITT was performed in healthy adults ( n =21), adult patients with monaural central perforation ( n =31) or strong scar formations ( n =24) of the tympanic membrane and 18 adult patients after monaural canal wall down surgery. Right and left ear and oral temperature were measured three times by one investigator in a room with a constant temperature of 20–22°C. Between every measurement there was a free time interval of 2 min. In healthy adults (36.50°C vs. 36.51°C) patients with monaural central perforation of the tympanic membrane (36.41°C vs. 36.34°C) and with monaural strong scar formations in the tympanic membrane (36.39°C vs. 36.45°C), no significant difference between the right and left ear could be proved. In contrast to this, a significantly higher temperature in the surgically treated ear compared to the healthy side (36.97°C vs. 36.31°C; P <0.001) occurred in patients with a status of after monaural canal wall down surgery. In summary, it could be demonstrated that, in contrast to minor ear surgery, major ear surgery such as canal wall down has a significant influence on the results of ITT. If a patients history gives reference to previous ear surgery, an otoscopic examination is necessary in order to exclude the presence of an after-canal-wall-down surgery status and thus to avoid false ITT test results.     

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.