Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.     

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.     

Titanium grommets: a trial to assess function and extrusion rates

Titanium grommets have been promoted as having the advantage of a slower extrusion rate than other types of ventilation tube. A prospective trial was therefore designed to compare the function and extrusion rates of these grommets with those of the widely used Shepard design of Teflon grommet in a single group of patients. Thirty-one children had one type of grommet inserted in one ear and the other type in the opposite ear. After eight months there were significantly more Titanium grommets still functioning (p less than 0.05) but after 12 and after 16 months there was no significant difference in the extrusion rates of the two types of grommet. There was a higher incidence of infection with granulation tissue formation around the Titanium grommet. Accordingly it is concluded that the extra expense of the Titanium grommet is not justified, particularly as the long-term effects of these grommets on the tympanic membrane are not known.     

Long‐term Paparella II grommet use in the management of persistent childhood otitis media: a 5‐year follow‐up study

• ? A comprehensive 5‐year follow‐up study of Paparella grommet use in UK.
• ? Study group consists of children previously treated with short‐term grommets and with persistent glue ear.
• ? Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study.
• ? Infection and perforation rates increased with the duration of grommet in‐situ and this was especially marked after 36 months.
• ? We advise the elective removal of these long‐term grommets after 3 years of function to reduce compication rate.

     

Tympanosclerosis, grommets and shear stresses

This paper deals with grommet induced tympanosclerosis. In the first part, patients from a controlled trial of the treatment of bilateral glue ear using unilateral grommet insertion are reviewed 15 years later. Tympanosclerosis due to grommet insertion is summated using computer graphics. Two areas of maximal tympanosclerosis are found, anteriorly and posteriorly midway between the annulus and the umbo. These maximal areas join inferiorly in the classical horse shoe shape. In an attempt to identify reasons for this distribution, the structure of the lamina propria is reviewed, and the changes that occur in tympanosclerosis considered. With this in mind, the tympanic membrane is modelled using finite element methodology to determine the areas of maximal shear stresses. These are found to be in the same position as tympanosclerosis. Such stresses would be increased by the weight of a grommet in situ. These stresses will damage the fibrils interconnecting between the fibrous layers of the lamina propria and this may lead to tympanosclerosis. This raises the question of whether a lighter grommet would decrease the incidence of grommet-induced tympanosclerosis.     

Sex and grommet operations

Sex differences in patients having grommet operations in Scotland were analysed to provide further evidence on whether girls should be managed differently from boys. In children treated at less than one year, 64% were boys, but this proportion declined with age and, after the age of 13 years, became less than 50%. The median age at treatment and the repeat operation rate were similar for both sexes. Different management according to the sex of the patient does therefore not appear to be justified.     

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.     

外耳道吹氧法治疗胶耳的疗效观察

目的 :探讨一种新的治疗胶耳以及其他耳病的方法。方法 :对 2 2例 2 8耳胶耳患者在行鼓膜置管后 ,行外耳道吹氧治疗 ,并与同期用常规方法治疗的 19例 2 0耳胶耳进行比较 ;此外还比较了乳突根治术后用外耳道吹氧法治疗对干耳的影响。结果 :胶耳吹氧组平均恢复时间为 1.2 0± 0 .4 2d ,胶耳对照组则为 3.5 0± 0 .87d ,两组比较 ,差异有显著性意义 (P <0 .0 5 )。乳突术后吹氧组平均干耳时间为 3.92± 0 .77周 ,乳突术后对照组则为 5 .82± 2 .0 3周 ,两组比较 ,差异有显著性意义 (P <0 .0 5 )。结论 :外耳道吹氧法是一种治疗胶耳的较好方法 ,还可用于乳突开放术后 ,以缩短干耳时间 ,值得推广。     

The nasopharynx and adenoid in children with glue ear compared with normal controls

This study was designed to demonstrate whether any differences could be detected in the nasopharyngeal soft tissue size and postnasal space airway in children with glue ear compared with controls. Lateral cephalometric radiographs of 34 children with bilateral glue ear confirmed by paracentesis were compared with those of normal children matched for age and sex. There was no difference in the measurement of adenoid depth between the 2 groups. However, it was found that the palatal airway size was significantly smaller in children with bilateral glue ear than in normal children. Reduction in the palatal airway to 4 mm or less is found in most cases with bilateral glue ear, but only in 15% of normal controls.     

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.     

Glue under pressure: a bad prognostic sign for recurrence of otitis media with effusion.

One hundred and thirteen children with bilateral otitis media with effusion (OME) underwent myringotomy and insertion of Shah grommets. They were classified into three groups according to the presence or absence of 'glue under pressure' unilaterally or bilaterally. The follow up period ranging between 18 and 32 months determined the comparative rate of recurrence of OME and the number of grommet reinsertions. This study shows a significantly higher incidence of recurrent OME, requiring grommet reinsertion, in ears with glue under pressure (60 per cent) compared to those with glue not under pressure (7.4 per cent). Thus it was possible to identify a subset of children with OME who have a poorer prognosis for recurrence and who should be treated with long-stay grommets in the first instance.     

Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects

Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pessure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.     

Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects.

Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pressure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.     

The use of perioperative Sofradex eardrops in preventing tympanostomy tube blockage: a prospective double-blinded randomized-controlled trial

Around 11-12% of tympanostomy tubes are reported to become blocked by middle ear secretions or blood immediately following surgery, and so no longer function. Many otologists routinely instil an antibiotic and steroid-containing solution at the time of surgery in the belief that this may reduce this complication. The aim of the study was to investigate the efficacy of instilling the antibiotic and steroid-containing solution Sofradex at the time of grommet insertion in preventing grommet blockage. Double-blind randomized-controlled trial, comparing rates of grommet blockage in ears treated with Sofradex drops against control (no drops) in patients undergoing bilateral grommet insertion. Sixty-one pairs of results were obtained. There was a significant difference between the rates of grommet blockage in the two groups. Grommets with Sofradex drops instilled perioperatively were nine times less likely to be blocked than controls [1.6%versus 13.1%, odds ratio (Sofradex/control) = 9.06, 95% confidence interval (CI): 1.04-78.82, P = 0.05]. There was no association between grommet blockage and perioperative bleeding or the nature and presence of middle ear secretions. Sofradex eardrops are effective in reducing the rate of grommet blockage when instilled perioperatively.     

Does passive smoking affect the outcome of grommet insertion in children?

Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.     

Prognostic factors in otitis media with effusion

To determine which factors were associated with recurrence of otitis media with effusion following grommet insertion, the casenotes of 323 children who had a total of 485 operations for grommet insertion were reviewed. The incidence of repeat surgery was higher in those aged between four and six years, in those having grommet insertion between the months of July and October and in those cases in which the grommet was extruded within six months. Recurrence was not related to sex of the patient, month of listing for surgery, adenoidectomy, tonsillectomy, length of time on the waiting list or past history of previous grommet insertion.     

Effect of middle ear effusion on distortion product otoacoustic emission

OBJECTIVES: It is well documented that children, particularly between the ages of about 2 and 6 years, exhibit a high prevalence and incidence of otitis media. Distortion product otoacoustic emissions (DPOAEs) offer great potential for clinical testing of cochlear function in children. The aim of the present study was to determine the influence of middle ear effusion and physical properties of the effusion on the recording of DPOAE. METHODS: Nineteen children (38 ears) undergoing myringotomy and/or tympanostomy tube insertion for secretory otitis media were studied. Pre-operative and post-operative first day DPOAE signal to noise ratios were compared. The results were analyzed by paired samples test and ANOVA statistical methods. RESULTS: We were found significant differences between pre-operative and post-operative first day DPOAE signal to noise at 1, 1.5, 2 and 4kHz. In addition, comparison of the pre-operative DPOAE signal to noise ratio and per-operative middle ear findings are shown significant differences between glue (thick mucous) and the other three groups (mucous, serous and no-effusion groups) at 2 and 4kHz, and between glue and no effusion group at 8kHz. Also post-operative DPOAE signal to noise ratio in relation to per-operative middle ear findings were significantly different at 2, 4 and 8kHz. The most increase of emissions at the post-operative first day was seen in ears with glue effusion at 1 and 2kHz. CONCLUSIONS: Otitis media with effusion can be monitored by DPOAE measurement pre-operatively and post-operatively. In the pre-operative evaluation, glue effusion may cause a reduction in the emissions at 2, 4 and 8kHz more than the other kind effusions.     

Day-case paediatric mastoid surgery

OBJECTIVE: Children have traditionally been kept in hospital overnight after mastoid surgery, but evidence from the US in adults suggests that a substantial number of patients may be suitable for discharge on the day of surgery. We sought to ascertain the proportion of our children having mastoid operations between February 1994 and December 2000 who were suitable for same-day discharge. We also evaluated some of the factors that prevented discharge the same day. METHODS: A standard proforma was used to record relevant data in 35 children (mean age 10 years 6 months) undergoing consecutive mastoid operations at Mayday University Hospital, London, UK. Operative findings, duration of anaesthesia and time back on ward were recorded as well as details regarding admission, follow-up findings and complications. A bed was booked preoperatively but there was intent to discharge the patient if feasible. RESULTS: Nine out of twelve patients (75%) operated between 1998 and 2000 were suitable for discharge on the day of surgery. The pre-1998 discharge rate was 20%. Only one of the former group of patients underwent a modified radical mastoidectomy in comparison with ten such procedures pre-1998. There was a significant relationship between extent of surgery and in-patient admission. The outcomes of day-case mastoid surgery, in terms of complications rates and overall success rates, were comparable with surgery performed on an in-patient basis. Using correlation analysis, no relationship could be found between duration of anaesthesia and time of arrival back on the ward and in-patient admission. CONCLUSION: Children can undergo mastoid procedures safely and effectively on a day-case basis but should still have a bed booked pre-operatively as the majority will require admission. The main factor related to admission was the mastoid procedure performed. With improvements in surgical and anaesthetic techniques and other advances, operations such as atticotomy may become standard day-case procedures in paediatric patients.     

中耳胆固醇肉芽肿的诊断与手术治疗

目的探讨中耳胆固醇肉芽肿的诊断与手术治疗方法。方法分析14例（15耳）经手术并病理证实的中耳胆固醇肉芽肿患者的病例资料。其中,行完壁式乳突根治加鼓室探查加中耳置管术6耳;完壁式乳突根治加听骨链重建6耳;改良乳突根治加鼓室成形3耳。结果1耳改良乳突根治加鼓室成形术后仍间断溢液;1耳中耳置管术后2周通气管脱落,中耳积液复发,需通气管重新置入半年病情缓解后取出。所有病例术后随访0．5～3年,14耳术后语频听力提高15dBHL以上,1耳术后听力无改变。结论中耳胆固醇肉芽肿应及早手术治疗。根据病变的程度、部位及范围,采取不同的手术方法。原则是彻底清除病变,建立咽鼓管、鼓室、鼓窦、乳突的通气系统。     

The use of perioperative Sofradex® eardrops in preventing tympanostomy tube blockage: a prospective double‐blinded randomized‐controlled trial

Around 11–12% of tympanostomy tubes are reported to become blocked by middle ear secretions or blood immediately following surgery, and so no longer function. Many otologists routinely instil an antibiotic and steroid‐containing solution at the time of surgery in the belief that this may reduce this complication. The aim of the study was to investigate the efficacy of instilling the antibiotic and steroid‐containing solution Sofradex^® at the time of grommet insertion in preventing grommet blockage. Double‐blind randomized‐controlled trial, comparing rates of grommet blockage in ears treated with Sofradex^® drops against control (no drops) in patients undergoing bilateral grommet insertion. Sixty‐one pairs of results were obtained. There was a significant difference between the rates of grommet blockage in the two groups. Grommets with Sofradex^® drops instilled perioperatively were nine times less likely to be blocked than controls [1.6%versus 13.1%, odds ratio (Sofradex^®/control) = 9.06, 95% confidence interval (CI): 1.04–78.82, P = 0.05]. There was no association between grommet blockage and perioperative bleeding or the nature and presence of middle ear secretions. Sofradex^® eardrops are effective in reducing the rate of grommet blockage when instilled perioperatively.