Surgical indications and outcomes of tympanostomy tube removal

OBJECTIVE: To evaluate factors affecting perforation healing in children with surgical removal of retained tympanostomy tubes. METHODS: We conducted a retrospective chart review of 82 pediatric patients (111 ears) who underwent surgical tube removal at a tertiary care pediatric hospital from 1/1/1999 to 12/31/2001. Patients included 47 males and 35 females with an age range of 2-15 years (average age, 6.8 years and median, 6 years). The length of intubation ranged from 12 months to 108 months (average, 44.6 months). The indications for removal included: prolonged intubation (61.3%), otorrhea or recurrent infection (21.6%), obstruction (7.2%), tube in middle ear (6.3%), enlarging perforation (2.7%), and in preparation for future cochlear implant surgery (9.9%). Interventions included removal of tympanostomy tubes and techniques for encouraging perforation closure. Seventy-six percent of the ears had a technique used to encourage healing. These techniques included freshen edges (11.8%), Gelfoam or Gelfilm (14.1%), Gelfoam and/or Gelfilm with freshened edges (50.6%). The main outcome measure was perforation healing. Chi-square statistical analysis were used to determine the statistical significant of observations. RESULTS: Overall closure rate for all patients available for follow up was 87.0%, regardless of technique used to encourage healing. There was no statistically significant difference between the average intubation time in ears that healed (44 months), versus those with persistent perforation after removal (42 months). There was no statistical significant difference in closure rate based on patient age. When tubes were removed for prolonged intubation, 87.0% closed. If the indication was otorrhea or recurrent infections, 93.0% healed. CONCLUSIONS: The overwhelming majority of patients who undergo surgical removal of tubes will show complete tympanic membrane healing independent of technique at time of removal, duration of intubation, patient age, or indication for removal.     

A comparison of audiometric performance and complications of T tubes and Shepard grommets

Since T tubes were introduced in 1972 their use in cases of chronic Eustachian-tubal insufficiency has been reported on several occasions, (Goode, 1973, 1983; Rothera and Grant, 1985). T tubes remain in-situ for longer than grommets, and they are frequently used in cases where multiple grommet insertions have failed to provide adequate middle ear ventilation. They have also been used when prolonged Eustachian-tubal insufficiency is anticipated, for instance in children with cleft palate. Shepard grommets continue to be the most commonly used type of ventilating tube for short-term use and a significant proportion of children with glue ear require repeated insertions. In an attempt to reduce the need for repeated myringotomy, and also to reduce the need for adenoidectomy in children with glue ear, it has been the recent practice of one Consultant (K.S.M.) to use T tubes routinely in all cases of glue ear. This study analyses the audiometric performance and complications of 32 children (60 ears) who underwent myringotomy and insertion of T tubes for glue ear. In all cases no previous treatment for glue ear had been undertaken. The results are compared with those of a control group who underwent myringotomy with insertion of Shepard grommets and adenoidectomy as a first-line treatment.     

Goode T-tubes: do the benefits of their use outweigh their complications?

In this retrospective study of 130 ears over a 5-year period, the effect of intubation with the Goode T-tube was evaluated. The tubes improved the hearing in 86% of ears with a conductive loss secondary to a middle ear effusion to an average 5 dB airbone gap. They improved the early stage retracted tympanic membrane but had no effect on the established postero-superior retraction pocket. They were successful in treating barotrauma. The main complication with their use was otorrhoea which occurred in 28% of ears, and persistent perforation occurring in 6% of the ears. Seventy-seven per cent of tubes were in place after 36 months. Extrusion was significantly related to infection in the ear, and also to the presence of glue on insertion but there was no correlation between the number of previous grommets or the age of the patient. The Goode T-tube is advocated for use in middle ear effusion refractory to conventional grommet insertion or that due to cleft palate.     

Transtympanic ventilator tubes in the treatment of seromucous otitis. Indications and results.

400 patients with bilateral secretory otitis media (SOM) were treated with ventilating tubes (VT) in a prospectiv study. The ear drums were normal on both sides before VTs treatment thus allowing ear drum changes and complications during VT treatment to be recorded. 618 VT were placed in the ear drum after suction of the fluid. In 182 patients unilateral myringotomy with suction of fluid were done and VT placed in the contralateral ear. Adenoidectomy with myringotomy, with an obstructing adenoid, gave 30% better chance. 10 different VTs were used. The most frequent pathology found in the ear drum after one period of VT treatment was tympanosclerosis. In the ears only treated with myringotomy tympanosclerosis occurred in 1%. 3 factors seemed to give more tympanosclerosis: metal (stainless steel or titanium), polyethylene and prolonged stay-time in the ear drum. Chronic perforations of the ear drum occurred with great variations between the different tubes. The Goode modified T-tube caused perforations in 17%. In the other VTs the perforations occurred in 2.1%. Chronic perforation together with tympanosclerosis will happen more often when the VT is made of polyethylene compared to silicone or fluoroplastic (p < 05). 90% of the perforations were located at the site of the VT. The ideal VT will stay in for 8-18 months at an average and it can be shown to improve middle ear function better than only waiting or myringotomy. Long-term VTs should not be used at the first VT procedures.     

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.     

Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.     

Incidence of perforation with Goode T-tube

Two groups of patients from the same era were retrospectively studied in Cincinnati and Chicago. In Cincinnati two subgroups were studied. The first group received myringotomy with insertion of a 'T'-shaped ventilating tube (75 patients, 140 ears, 147 insertions). Fifty-eight ears still had the tube in place, 31 had healed after spontaneous extrusion, 17 had healed after removal of the tube, 20 had persistent perforation after the tube was gone, 2 had a cholesteatoma, and 4 patients (7 ears) were lost to follow-up. The second set received myringotomy and insertion of a small grommet (Donaldson tube, 71 patients, 140 ears, 164 insertions) tympanostomy tube. None could be documented to still have the tube in place, 156 ears healed after spontaneous extrusion, none required removal, 3 ears had a persistent perforation after the tube was gone, none had cholesteatoma, and 5 patients (5 ears) were lost to follow-up. The perforation rate for the T-tube is 13.6% and for the grommet is 1.8% (P = 0.0005). In Chicago, 93 patients who received the Goode T style tube (175 ears, 175 insertions) prior to March, 1986 were evaluated. The degree of retraction of the tympanic membrane preoperatively was recorded. No ears still had the tube in place, 145 had healed after spontaneous extrusion or removal of the tube, 30 had persistent perforation 12 months after the tube was gone, 4 had a cholesteatoma, and 8 patients (15 ears) were lost to follow-up. The rate of perforation is 18.8% which is not statistically different from the Cincinnati rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Comparison of the Goode T-tube with the Armstrong tube in children with chronic otitis media with effusion

Treatment of otitis media with effusion is focused on reaeration of the middle ear cavity. In achieving long-term aeration, the insertion of ventilation tubes that have a long duration of stay can be beneficial. The results are presented of a trial in which the Goode T-tube was compared with the Armstrong tube. Fifteen children were treated between 1981 and 1986 with a T-tube in one ear and a conventional tube in the other. The results are different with regard to duration of stay in the tympanic membrane. Re-insertions were necessary in 47 per cent in the Armstrong group and in 20 per cent in the T-tube group. Otorrhoea occurred in 20 per cent of the Armstrong and 13 per cent of the T-tube intubated ears. A persistent perforation was present in 6 per cent of the ears in both groups. It is concluded that the Goode T-tube is indicated primarily in cases when long-term ventilation is needed.     

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.     

A clinical evaluation of gold-plated tubes for middle-ear ventilation

Gold-plated tympanostomy tubes have been recently marketed as possessing qualities making them ideal for middle-ear ventilation. The performance of these tubes was compared with that of similarly designed Teflon tubes in a controlled, prospective study. Twenty-eight children underwent bilateral myringotomy and tube placement. One ear was randomly chosen for intubation with a gold-plated tube, and a Teflon tube was inserted into the other ear. Patients were examined monthly for 12 months and evaluated for otorrhea, tube occlusion, and early tube extrusion. Although the incidence of otorrhea and tube occlusion were higher for the gold-plated tube, these differences were not statistically significant. The gold-plated tube had a significantly higher rate of early extrusion than the Teflon tube. Based on these findings, there appears to be no advantage to using gold-plated tubes for middle-ear ventilation.     

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.     

Permanent t-tube insertion in two patients with Hurler's syndrome

Hearing loss in mucopolysaccharidosis is usually both conductive and sensorineural. The conductive component is attributable to serous otitis media secondary to dysfunction of the eustachian tube and chronic thickening of the mucosa of the middle ear. The conductive component may persist after myringotomy and insertion of short-term or long-term ventilation tubes. In Hurler's syndrome, death usually occurs in the first decade of life. In our study, we present two cases, a three-year-old girl and a four-year-old boy, who were diagnosed with Hurler's syndrome. Both children have a history of otitis media with effusion requiring repeated short-term ventilation tube insertions that were unsuccessful. Permanent t-tubes were inserted in both cases. Results showed an approximate 20 dB improvement in hearing sensitivity postoperatively for each patient.     

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.     

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.     

Untreated persistent middle ear effusion

Seventy-nine children have been followed with persistent middle ear effusion (MEE). They were scheduled for myringotomy and insertion of ventilating tubes (VT). Several factors delayed elective surgery for two-and-a-half years in a closed population. After that period, the children were again examined otomicroscopically and hearing tests were performed. MEE persisted in 69 per cent of the ears, but was absent in 31 per cent. Atelectasis appeared in 26 per cent of the ears; in only a very few cases did severe atelectasis develop. Complications following delay of myringotomy and introduction of VT are minor.     

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.     

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。     

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.     

Pediatric tympanoplasty: effect of contralateral ear status on outcomes

OBJECTIVE: To assess the prognostic value of different variables on the outcome of pediatric type I tympanoplasty. DESIGN: Retrospective review of medical records. SETTING: An otolaryngology department in a large urban tertiary care medical center. PATIENTS: We reviewed 72 ears in 60 patients who had undergone a type I tympanoplasty from 1987 to 2000. Patient ages ranged from 3 to 18 years. INTERVENTIONS: Type I tympanoplasty. MAIN OUTCOME MEASURES: We identified the following 3 criteria for success: (1) healing of the neotympanic graft; (2) healing of the graft with a postoperative air-bone gap of no greater than 20 dB; and (3) healing of the graft with aeration of the middle ear space. RESULTS: Healing occurred in 59 (82%) of the 72 neotympanic grafts; 39 (83%) of the 47 healed ears for which a postoperative audiogram was available had an air-bone gap of no greater than 20 dB; and 49 (83%) of the 59 healed ears had a normally aerated middle ear space. A statistically significant difference in the rate of graft healing was identified for large perforations (76%), as well as for creation of an aerated middle ear space, when there was evidence of ongoing contralateral eustachian tube dysfunction (ie, otitis media with effusion or negative middle ear pressure, but not a perforation). CONCLUSIONS: Pediatric type I tympanoplasty can offer reasonably good chances for postoperative graft healing, serviceable hearing, and creation of an air-containing middle ear space if performed in carefully selected patients. Caution should be exercised in performing tympanoplasty in children with evidence of ongoing eustachian tube dysfunction, as evidenced by otitis media with effusion and negative middle ear pressure, but not perforations, in the contralateral ear.