Defining tympanostomy tube plugs

OBJECTIVES: To define the composition of tympanostomy tube plugs because selecting or developing effective solvents depends on such knowledge. STUDY DESIGN: Prospective, in vitro laboratory study. METHODS: Luminal contents of 105 plugged, microscopically removed tympanostomy tubes were expressed, pooled, acid hydrolyzed, and passed through a high-performance liquid chromatography column. Retention times were compared with high-performance liquid chromatography standards to develop free amino acid and monosaccharide profiles. Cerumen, blood, and chronic mucoid effusion (collected during myringotomy) were pooled and subjected to the same analysis. The elution profiles of each substance were compared to determine which substance most closely matched the plugs. RESULTS: High-performance liquid chromatography amino acid and monosaccharide analysis demonstrated greatest similarity between tympanostomy tube plugs and mucoid effusion. CONCLUSIONS: Tympanostomy tube plug composition is more similar to mucoid effusion than to blood or cerumen. Solvents to open plugged tympanostomy tubes should be directed against the components of mucoid effusion.     

Factors Affecting the Extrusion Rate of Ventilation Tubes

Objectives

The objective of this study was to determine the various factors that affect the extrusion rate of ventilation tubes (VTs), including the nature of the middle ear effusion.

Methods

A retrospective chart review of 82 pediatric patients (177 ears) who received VT insertion surgery under general anesthesia was carried out to evaluate the relationship between various factors and the VT extrusion rate. The factors we analyzed included age, gender, the adenoid size, the amount and content of the middle ear effusion after myringotomy, bleeding events, associated adenoidectomy and the findings of the tympanic membrane status, the tympanometry and the audiometry of the air bone gap.

Results

The mean extrusion time was 254 days (range, 11 to 809 days). The patients with no history of previous VT insertion had a longer extrusion time (mean, 279 days) than did the patients who had undergone previous VT insertion (mean, 203 days). The patients with serous effusion had the shortest extrusion time (mean, 190 days) as compared to those patients with glue (273 days) and pus (295 days) effusions. Other factors had no statistical significant relationship with the extrusion time.

Conclusion

The mean VT extrusion time was 254 days. The VT extrusion time was significantly related to the characteristics of the middle ear effusion and a history of previous VT insertion. Thus, the nature of middle ear effusion can provide a clinical clue to predict the VT extrusion time.     

鼓膜置管治疗成人渗出性中耳炎的长期观察

目的探讨鼓膜置管术对成人渗出性中耳炎治疗的长期结果.方法总结分析1996年6月至1999年6月治疗的42例成人渗出性中耳炎患者.男24例,女18例,左耳17例,右耳19例,双耳6例,共计48耳;年龄20～70岁,平均37岁;病程1个月至1年.通气管常规置入加冲洗治疗,8个月内取管,随访4-8年.结果症状全部消失29例;耳鸣6例,伴听力下降4例;时有耳堵塞感发作5例;鼓室积液复发2耳.鼓膜正常者28耳,鼓膜瘢痕、钙化10耳,鼓膜内陷8耳,鼓膜变薄、松弛2耳,鼓膜穿孔2耳.结论成人渗出性中耳炎行鼓膜置管治疗的远期效果良好,其并发症及后期的鼓膜改变较儿童期少.     

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.     

鼓室置管治疗分泌性中耳炎的影响因素

目的探讨用鼓室置管治疗分泌性中耳炎的影响因素。方法对72例（118耳）分泌性中耳炎患者的治疗效果和相关因素进行了研究。结果病程、留管时间及咽鼓管负压平衡功能对预后均有影响。结论提示积极改善咽鼓管功能并尽量留管半年以上对提高分泌性中耳炎的治愈率有着积极的意义。     

Sonotubometry findings in children at high risk from middle ear effusion

The functioning of the eustachian tube has an important role to play in the development of middle ear disease. It would be useful if a clinical test could assist in the identification of eustachian tube dysfunction, particularly if this is shown to be an indicator of persistent middle ear effusion. The aim of this study was to compare the results of sonotubometry using the MMS-10 instrument in children at high risk from middle ear effusion with a group of normal subjects. Forty-one subjects (age range 5–6 years) were allocated to one of two groups (experimental group, 21 subjects; control group 20 subjects) based on a questionnaire designed to identify subjects at high risk from middle ear effusion. The test protocol allowed each subject to swallow three times for each of two pure-tones (7 and 8 kHz) delivered by the nasal probe. Sonotubometry indicated opening of the eustachian tube on swallowing in around 80% of subjects. The incidence of positive findings varied greatly amongst subjects across both groups. In the control group, the mean increase in sound pressure level on swallowing was 11.5 dB (± 4.3) and 9.8 dB (± 2.5) for 7 and 8 kHz, respectively. The corresponding means for duration were 118 ms (± 47.9) and 137 ms (± 61.8). Sonotubometry failed to demonstrate a difference between the two groups of subjects. Hence, the clinical application of sonotubometry to identify subjects at high risk from middle ear effusion is not supported.     

What Your Colleagues Think of Tympanostomy Tubes—28 Years Later

Objective: Assess the changing opinions of otolaryngologists about tympanostomy tubes, including indications, tube material and shape and size, placement sites, and complications. Study Design: Crosssectional survey, compared to the same survey done 28 years earlier. Method: Questionnaires mailed to the 441 active fellows and 86 candidates of the Triological Society. Response rate 69.3%. Results: The preference for polyethylene has decreased from 75% to 13% of respondents. Preferred insertion sites are more anterior. The proportion of respondents who have seen a permanent perforation as a consequence has increased from 26% to 93%. The proportion of respondents who have seen a tube-attributable cholesteatoma has increased from 8% to 38%. The average tube duration has increased from 4 months to 18 months. Teflon and Silastic are now the materials most often used. As 28 years earlier, about 19% of patients get a subsequent tympanostomy tube. Anesthetics most commonly used now are general or topical phenol. Conclusion: The consensus on several aspects of tympanostomy tubes has changed during 28 years. Controversy continues about the indications for using tubes. Although not a not cure-all for otitis media, tympanostomy tubes have proved useful.     

Is facial pattern a predisposing factor for otitis media with effusion in children?

Abnormalities in craniofacial morphology are associated with Eustachian tube dysfunction and otitis media with effusion (OME).Aim: to evaluate the relationship between facial pattern and craniofacial growth direction, and OME in children with enlarged tonsils and adenoids (ETA).Methods: Clinical prospective survey in 79 children (41 male and 38 female), ranging from 4 to 10 years of age, with tonsil and adenoid enlargement (Brodsky's grades III and IV). Forty children presented with OME (study group) and 39 did not (control group). Cephalometric analysis was used to determine the facial pattern.Results: There was no correlation observed between facial pattern and OME (c 2 = 0.25 p = 0.88). Facial Axis was larger in the OME group (F(1.75) = 3.68 p = 0.05) and the Lower Anterior Facial height was smaller (F(1. 75) = 3.99 p = 0.05) in children with otitis media with effusion.Conclusions: There was no correlation between OME and facial pattern in children with ETA although a more horizontal facial growth direction, and a smaller lower anterior facial height was observed consistently among subjects in this group. This suggests that abnormal positioning of the eustachian tube influences the development of OME in children with ETA.     

The old-fashioned Politzer maneuver: a video clip demonstration

Politzer maneuver causes retrograde inflation of the middle ear by forcing air through the eustachian tube, and it has been proposed by many authors as the main nonsurgical treatment of middle ear effusion. To our knowledge, this is the first case in the literature in which air entering into a middle ear with effusion through a Politzer maneuver has been captured on video (www.laryngoscope.com).     

Resolved effusion on myringotomy: A study of dry tap without general anesthesia

Objectives

Finding a resolution of middle ear effusion using myringotomy, or dry tap (DT), is relatively common, but its clinical outcome is confounded by general anesthesia (GA). The confounding effect of GA and a time delay can be removed because laser myringotomy can be completed under topical anesthesia, which is a routine procedure for otitis media with effusion (OME) before GA in our clinic. DT without GA would clarify the clinical outcome, and the percentage of recurrence for OME after DT would be clinically relevant. The objectives of the present study are (1) to clarify the clinical nature of DT without including the confounding effect of GA and a time delay and (2) to determine if OME recurs when a ventilation tube (VT) is not used for DT.

Methods

The control group consisted of 308 children who received an unilateral myringotomy due to a natural resolution in the contralateral ear. The experimental group consisted of 296 children who had a bilateral myringotomy, and a ventilation tube was not inserted for DTs after laser myringotomy under topical anesthesia. The rate of DT and the recurrence rate of OME without tube insertion was the main outcome measure.

Results

In the control group, which showed a natural resolution, the rate of DT was 16.9% (52/308) of patients, and DT was more common in non-B tympanometry, which only had a recurrence rate of 17.3% (9/52). In the study group, 3.7% of patients showed unilateral DT (UDT) with contralateral positive effusion, and 5.4% of patients showed bilateral DTs (BDTs). BDT showed a non-B tympanometry pattern and a low rate of recurrence (25.0%), which was similar to the control group. UDT showed a B-type tympanometry in 81.8% of the patients, and the recurrence rate was significantly higher (68.2%; 15/22) than the BDT and control patients. BDT or DT with signs of natural resolution showed a low rate of OME recurrence regardless of tympanometry, and thus, patients do not need a VT.

Conclusions

DT was not rare even without GA and the associated time delay, and DT was more common in the children that showed a natural resolution. However, microscopy and tympanometry was imperfect to predict dry tap, and thus, the surgeon needs to be prepared for individualized management of DT. UDT with B-type tympanometry and contralateral persistent effusion frequently recurred without tubes, and thus, VT for UDT appeared to be necessary.     

鼓膜置管术治疗分泌性中耳炎20例

目的探讨鼓膜置管术及鼓室药物灌洗治疗分泌性中耳炎的疗效。方法分泌性中耳炎20例均为经门诊行药物治疗、鼓膜穿刺、鼓室注药保守治疗2~3个月后无效,考虑主要为咽鼓管功能障碍所致。收入院行鼓膜置管术,并定期局部灌注药物冲洗,置管时间1~3个月后拔管。结果术后随访6~12个月,获得良好效果,总有效率100%,治愈率75%(15/20)。全部患者听力明显改善,纯音测听术后平均提高20~30dBHL。声导抗检查恢复为"A"型曲线15例,"A s"型曲线5例。拔管后鼓膜均自然愈合,无遗留鼓膜永久性穿孔、鼓膜萎缩、化脓性中耳炎等并发症。结论鼓膜置管术是治疗顽固性分泌性中耳炎的主要方法,其中术后的鼓室药物灌注冲洗尤其重要,同时要预防脱管、感染、鼓膜不愈合等并发症。     

Mucociliary function of the eustachian tube in the eustachian tube dysfunction

Background: Most of the tests to evaluate the eustachian tube (ET) function are focused on the ventilation function of the ET.

Aim: Here we evaluate mucociliary function of the ET in patients with ET dysfunction.

Materials and methods: Ten patients with ET dysfunction were enrolled into the study. Six patients had chronic tympanic membrane retraction and four patients had chronic middle ear effusion (MEE). All patients had intact tympanic membranes. Tympanometry and clinical examinations were done to all patients. Mucociliary function was evaluated with technetium labeled albumin and blue dye. Tympanometry and clinical examinations were done to six patients with chronic tympanic membrane retraction and four patients with chronic middle ear effusion (MEE). Mucociliary function of the ET was evaluated with technetium labeled albumin and blue dye placed into middle ear through an intact tympanic membrane and followed from nasopharynx ET orifice (blue dye) and with gamma camera (technetium).

Results: Blue dye was observed in tubal orifice in six (6 of 10) patients during 30?min observation. Five of those patients (5 of 6) had tympanic membrane retraction and one patient (1 of 6) had MEE. Tracer activity decreased from middle ear in six (6 of 10) patients. Four of those patients had tympanic membrane retraction and two had MEE.

Conclusion: Mucociliary function of the ET seems to be better in patients with tympanic membrane retraction than patients with middle ear effusion.

Significance: Mucociliary function of the ET is an important function for middle ear aeration, blue dye test is easily available to be used also in clinical practice.     

Middle ear effusions: a consideration of factors involved in their aetiology,maintenance and treatment*

Although the treatment of chronic middle ear effusion in children by paracentesis and the insertion of a ventilator tube is popular, it is well recognized that this method does not always provide a cure. Failures are frequently attributed to premature extrusion of the tube. Success in designing a ‘long-stay tube’ will depend upon a better understanding of the pathogenesis of middle ear effusion. Some of the various factors considered responsible for the initiation and maintenance of middle ear effusion are discussed and the possible mechanisms of tube extrusion are considered.     

Validity of tympanometry in the diagnosis of middle ear effusion

A group of 266 children (515 ears), ranging in age from 5 months to 11 years, was studied. These children were candidates for the insertion of ventilation tubes, or adenoidectomy and/or tonsillectomy with myringotomy. Before surgery, tympanometry was performed. The surgical and tympanometric findings were compared afterwards. Two different tympanometers were used (GSI-27A and TYMP-85TT). This study showed a comparable validity of these two tympanometers. The sensitivity and specificity of tympanometry in the age group of 5 months to 2 years did not show a significant difference from that in the age group of 2–12 years. Otoscopy has limited value for the diagnosis of middle ear effusion in this age group.     

Clinical and audiological findings in children with acute otitis media

Conclusion: It is recommended to perform follow-up tympanometry and if necessary tonal audiometry in children who have normal plain otoscopy findings after recovering from acute otitis media (AOM). Children with Type B tympanogram, 3 months following the onset of AOM, are very likely to have a conductive hearing loss. Type B tympanogram is a much better indicator of effusion in the middle ear compared to plain otoscopy. Objective: This study was undertaken to investigate the frequency and duration of middle ear effusion in children following an episode of acute otitis media, to track changes in tonal audiometry and tympanometry findings in the post-AOM period, and recognize the optimal timing for performing both tests. Methods: In this study, 125 children aged 5–7 years with bilateral AOM were randomly selected and separately followed up for 3 months. The children underwent six ear, nose, and throat (ENT 1–6) examinations, six tympanometries (TM 1–6), and three tonal audiometries (TA 1–3). Evaluation of nasopharynx was done at the ENT 1 examination. Children who received ventilation tubes were followed for 21 month altogether. Results: At the first otoscopy, pathological findings were recorded in 250 ears/125 children (100.0%). The number of pathological otoscopy findings decreased at each subsequent examination. At ENT 6 all children had normal otoscopy findings. Type B tympanogram was detected in 49/250 (19.6%) ears at TM 6, performed 3 months following the onset of the disease. At the TA 1 conductive hearing impairment was recorded in 158/250 (63.2%) ears, at TA 2 in 66/250 (26.4%), and at TA 3 in 39/250 (15.6%). Most of them were associated with Type B tympanogram.     

When should retained Paparella type I tympanostomy tubes be removed in asymptomatic children?

Objectives

Tympanostomy tubes are routinely used for the treatment of otitis media with effusion (OME). There is no definite consensus on the optimal length of the intubation period and the timing of tube removal. This study was designed to determine the appropriate time for tympanostomy tube removal in asymptomatic patients of preschool age.

Methods

A retrospective study was conducted in 336 patients (478 ears) under the age of 7 years old who underwent tympanostomy tube insertion or removal from January 2006 to September 2010 at our institution. The information gathered from chart review included patients’ age at the time of tube insertion, duration of intubation, and the presence of complications, such as tube site infection and persistent tympanic membrane perforation. Logistic regression, chi-square test and Fisher's exact test were used to determine the statistical significance of observations.

Results

The spontaneous extrusion rate of tympanostomy tubes was about 90% at 18 months and showed a plateau after 18 months. The OME recurrence rate decreased after 12 months of intubation, and complications such as tube site infection and persistent tympanic membrane perforation increased after 15 months of intubation.

Conclusion

Tympanostomy tubes removed before 12 months showed a high possibility of recurrence. Removal after 15 months showed an increased possibility of complications. Spontaneous extrusion seldom occurred after 18 months. From these findings, we concluded that asymptomatically retained tympanostomy tubes are recommended to remove when a tube is retained for more than 18 months.     

Eustachian tube closing failure in children with persistent middle ear effusion

One important role of the Eustachian tube is to protect the middle ear from the extensive physiological pressure variations that take place in the nasopharynx, for example on sniffing. In a previous investigation in 50 children with persistent middle ear effusion a surprisingly high percentage of ears were evacuated by sniffing. The present study was undertaken in a second series of children, and results were found to be reproducible. In total 156 ears in 100 children have been investigated. In 63% of ears (73% of subjects) evacuation of the middle ear took place on sniffing. Results show that Eustachian tube malfunction in these subjects is characterized by a reduced protective function; a condition denoted "Eustachian tube closing failure".     

Water precautions and tympanostomy tubes: a randomized, controlled trial

OBJECTIVES/HYPOTHESIS: The objective was to determine whether there is an increased incidence of otorrhea in young children with tympanostomy tubes who swim and bathe without water precautions as compared with children who use water precautions in the form of ear plugs. STUDY DESIGN: Prospective, randomized, investigator-blinded, controlled trial. METHODS: Two hundred one children (age range, 6 mo-6 y) who had undergone bilateral myringotomy and tube insertion were randomly assigned into one of two groups: swimming and bathing with or without ear plugs. Children were seen monthly for 1 year and whenever there was intercurrent otorrhea. RESULTS: Ninety children with and 82 children without ear plugs returned for at least one follow-up visit. Mean (SD) duration of follow-up was 9.4 (4.1) months for the children with ear plugs and 9.1 (4.4) months for the children without ear plugs. Forty-two children (47%) who wore ear plugs developed at least one episode of otorrhea, as compared with 46 (56%) who did not use ear plugs (logistic regression adjusting for stratification variables, P = .21). The mean (SD) rate of otorrhea per month was 0.07 (0.31) for the children who wore ear plugs as compared with 0.10 (0.31) for the children who did not wear ear plugs (Poisson regression adjusting for stratification variables, P = .05). CONCLUSION: There is a small but statistically significant increase in the rate of otorrhea in young children who swim and bathe without the use of ear plugs as compared with children who use ear plugs. Because the clinical impact of using ear plugs is small, their routine use may be unnecessary.     

The effect of anaesthesia on tympanograms of children undergoing grommet insertion

A prospective study was designed to assess the effect of anaesthesia, including nitrous oxide, on tympanometric results of children undergoing myringotomy and possible grommet insertion. 155 patients (310 ears) were examined with a pneumatic otoscope and had tympanograms performed within 1 hour of operation. The patients were then anaesthetized by a combination of intravenous and gaseous anaesthetic. Immediately before myringotomy, a tympanogram was repeated. In 13% of patients predicted to have fluid at admission, there was a change in their tympanogram after induction of anaesthesia, suggesting clearance of fluid. At myringotomy, these ears were dry. We surmise that there was displacement of fluid from the middle ear by nitrous oxide during the early stages of anaesthesia. Thus we feel that, if an otologist confidently expects to find an effusion at myringotomy, the presence of a dry tap should not change his management plan.