Albumin-coated tympanostomy tubes: prospective, double-blind clinical study

OBJECTIVES: Coating an implant with albumin prevents adhesion of proteins, bacteria, and platelets and thus may lead to its improved and prolonged function. Previously, we have demonstrated the inhibition of binding of fibronectin, one of the most adhesive glycoproteins, on human serum albumin (HSA)-coated tympanostomy tubes and the durability of this binding inhibition in a 8-month trial. We have also demonstrated that the HSA coating inhibits the binding of Staphylococcus aureus and Pseudomonas aeruginosa to titanium plates. This prospective study evaluated the effect of albumin coating on tympanostomy tube sequelae and on the outcome of tympanostomized patients. STUDY DESIGN: Double-blind, prospective, randomized clinical trial. METHODS: Two otolaryngological centers in southern Finland enrolled 179 pediatric patients. Number of tube occlusions and otorrhea and tube ventilation time in the ears with HSA-coated titanium tympanostomy tubes were compared with the contralateral ear with its uncoated, otherwise identical titanium tube during a 9-month follow-up period. RESULTS: In HSA-coated tubes, average ventilation time was slightly longer and the number of early tube occlusions significantly less (P < .05). Moreover, in patients with perioperative bleeding, the coating prolonged average ventilation time of tympanostomy tubes significantly (P < .05). CONCLUSIONS: HSA coating reduces early tube occlusions by preventing adherence of blood and secretion.     

Durability of the binding inhibition of albumin coating on tympanostomy tubes

OBJECTIVE: Occlusion and prolonged otorrhea are typical problems associated with the use of middle-ear ventilation tubes. Albumin coating of ventilation tubes has been introduced to prevent tube occlusions by granulation tissue, blood clot, or pus. In this study, the durability of the binding inhibition (BI) of fibronectin was examined on the tube surface in albumin-coated tubes in different environments during an 8-month trial. METHODS: Human serum albumin (HSA) was used to coat silicone tympanostomy tubes. Fibronectin, a typical adhesive protein in serum and exudates, was used as a model representative of exudates of the ear. The durability of BI of this glue protein on the tube surface was tested in different time periods with radiolabelled fibronectin. Scanning electron microscopy (SEM) was performed on the tubes. RESULTS: The BI of fibronectin, achieved with the albumin coating, was still strong after 8 months of storage at +4 degrees C. A slight decline in BI was noted between the first and third months of storage at +37 degrees C. A significant difference between HSA-coated and uncoated tympanostomy tubes was noted in SEM. The uncoated surface generally appeared to be rougher than that of HSA-coated tubes when either titanium or silicone tubes were tested. CONCLUSIONS: Albumin coating markedly inhibits the binding of fibronectin on tube surfaces in vitro. A clear BI achieved by albumin coating on tube surfaces was shown to persist throughout an 8-month trial, although some reduction of the BI was seen over time. The result emphasizes the role of albumin coating in preventing the adherence of foreign material on tympanostomy tubes. No advantage was achieved by using a cross-linking chemical in the albumin coating.     

Phosphorylcholine-coated antibiotic tympanostomy tubes: are post-tube placement complications reduced?

OBJECTIVE: To determine if a phosphorylcholine (PC) antibacterial coating on standard Armstrong beveled tympanostomy tubes (TT) reduced the incidence of post-tube placement complications. METHODS: A prospective cohort aged 8-51 months received bilateral TTs for otitis media with effusion between July 2002 and February 2004 at a tertiary care pediatric hospital. Seventy children were randomized to receive a PC-coated TT in one ear and an uncoated TT in the other. Otologic examinations at prescribed intervals over two years post-operatively ascertained the status of sequelae. We analyzed the incidence of TT complications: otorrhea, premature extrusion, persistent tympanic membrane perforations, granulation tissue, and ventilation tube lumen obstruction. RESULTS: There was no statistical difference in the incidence of any of these sequelae between standard and PC-coated tympanostomy tubes (p>0.05) during the 24-month-follow-up period. Results after 13 months of follow-up may have been affected by patients lost to follow-up and therefore a smaller sample size as the study continued. CONCLUSIONS: This study found that there is no statistically significant difference in the incidence of complications between uncoated and PC-coated fluoroplastic Armstrong beveled TTs.     

Pediatric laser-assisted tympanostomy

OBJECTIVE: To evaluate effectiveness of laser-assisted tympanostomy in treatment of pediatric patients with chronic otitis media with effusion. STUDY DESIGN: Retrospective review of 23 pediatric patients who received office laser-assisted tympanostomy. METHODS: A CO2 laser attached to an operating microscope with a microscope laser adaptor device or the handheld Oto-LAM (Needham, MA) was used to perform all of the tympanostomies. The average diameter of tympanostomy was 2 mm; on average, 13.6 W was applied for 0.13 seconds. RESULTS: Laser-assisted tympanostomy was performed on 37 pediatric ears (patient age range, 2-16 y) for the diagnosis of chronic otitis media with effusion. Average follow-up time was 4.7 weeks. At the time of the follow-up examination, 46% of the ears had no evidence of fluid and required no further intervention. Forty-nine percent of the ears required placement of pressure equalization tubes. The average SRT improved from 30.8 dB preoperatively to 21.03 dB postoperatively. CONCLUSIONS: Laser-assisted tympanostomy appears to be an effective treatment for chronic otitis media with effusion in pediatric patients.     

Implications of laser assisted tympanostomy in adults.

OBJECTIVES: To assess outcome in adult individuals undergoing laser-assisted tympanostomy without ventilation tube placement. STUDY DESIGN: Case series with 2-month follow-up. SETTING: Faculty practice, research protocol, tertiary care academic medical center. PATIENTS AND METHOD: Laser-assisted tympanostomy was performed on a total of 142 ears (108 individuals). Indications included serous otitis media with effusion (66 ears/47 patients), functional eustachian tube dysfunction (48 ears/36 patients), acute otitis media (19 ears/16 patients), and endoscopic visualization of the middle ear (9 ears/9 patients). INTERVENTION: The laser-assisted tympanostomy procedure is performed with a CO2 laser under local anesthesia on an outpatient basis. MAIN OUTCOME MEASURES: Patency time of the tympanostomy, presence of fluid after the closure of the tympanostomy, tympanometry and tone audiometry findings, relief of symptoms. RESULTS: Middle ear disease was resolved after the closure of tympanostomy in 47.9% of patients with serous otitis media with effusion. In 79.1% of patients with functional eustachian tube dysfunction, symptoms were diminished. All patients with acute otitis media had a satisfactory outcome. Laser-assisted tympanostomy was found to be quite helpful in patients undergoing middle ear endoscopy. CONCLUSIONS: Laser-assisted tympanostomy without ventilation tubes provides a safe alternative surgical option in adult patients in certain cases. The selection criteria for this procedure are addressed in detail.     

Bacterial adherence to titanium surface coated with human serum albumin.

HYPOTHESIS: An albumin coating on titanium implants will inhibit bacterial adhesion on the implant surface. BACKGROUND: Bacterial, protein, and platelet adhesion on otologic implants and tympanostomy tubes is a major reason for implant sequelae and can eventually lead to implant removal. The role of albumin coating of the implant in prevention of protein adhesion on implant surface has already been tested by the authors. In the present study the authors examined the in vitro adherence of Staphylococcus aureus and Pseudomonas aeruginosa on an albumin-coated and uncoated titanium surface. METHODS: Human serum albumin (HSA)-coated and uncoated titanium surfaces were exposed to viable S. aureus and P. aeruginosa and, after washings, photographed by fluorescence microscopy to quantify the adhered bacteria, which was stained with acridine orange. RESULTS: Bacteria in the suspension adhered at a significantly lesser rate to the coated surfaces than to the uncoated surfaces, with overall bacterial adhesion dependent on bacterial concentration. Binding of S. aureus on HSA-coated surfaces was inhibited significantly (from 82 to 95% depending on concentration). Binding of P. aeruginosa was inhibited from 29 to 37%. CONCLUSION: Because albumin coating can reduce bacterial adherence on titanium surfaces in vitro, reduction is possible in bacterial contamination and infection of the HSA-coated titanium implant in vivo.     

Infektionshäufigkeit und Keimspektrum nach Paukendrainage im Kindesalter Goldröhrchen vs. Silikonröhrchen

Otorrhea is the most common complication after tympanostomy tube insertions. In Germany there are currently two commonly used types of tympanostomy tubes: silicon tubes (ST) and gilded silver tubes (GT). Previously published in vitro studies by Tajima uncovered a positive correlation between the silicon concentration in culture fluid and the rate of growth of Staphylococcus aureus. Our study retrospectively evaluates the types of bacteria and rates of otorrhea after ST and GT insertions. The present study was undertaken to determine which of these tubes had a higher incidence of otorrhea and then whether silicon tubes stimulated the growth of certain types of bacteria, such as Staphylococcus aureus. In all, 186 ST and 59 GT were placed in 245 ears of 144 children. Both ST and GT were separated into three groups: first insertion of a tympanostomy tube, second implantation and insertion of a tympanostomy tube in an infected ear in the course of a mastoidectomy. No differences between ST and GT in causing otorrhea were found in the three groups. Nevertheless, ST in comparison to GT was associated with a higher incidence of infections with Pseudomonas aeruginosa. In contrast, a higher incidence of Staphylococcus aureus related to ST could not be proved. Twenty percent of the ears with mastoiditis were found to have Pseudomonas aeruginosa, but none of these ears implanted with a GT developed postoperative otorrhea. Our findings show that GT should be used when a ventilation tube is used during a mastoidectomy. Further, it is tenable to implant only GT because postoperative otorrhea in many cases is caused by insufficient water protection and water is frequently polluted with Pseudomonas aeruginosa.     

The feasibility of office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion: the duPont Hospital experience.

OBJECTIVE: To determine the feasibility of inserting tympanostomy tubes in children using office-based laser-assisted tympanic membrane fenestration. METHODS AND MATERIALS: Study consisted of a retrospective review of the charts of all children who underwent office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion from July 1, 1998 to August 31, 2000. Tetracaine eardrops were used for topical anesthesia. Fenestration was achieved with the OtoLAM flashscanner laser (ESC Sharplan, Yokneam, Israel). RESULTS: Of the 127 patients (185 ears) who underwent laser-assisted tympanic membrane fenestration, 61 ears underwent tympanostomy tube insertion. Ten ears were treated for otitis media with effusion, 43 for recurrent acute otitis media, and eight for acute otitis media not responding to antibiotics. Fifteen ears had purulent effusion, five had a serous effusion, and 23 had mucoid middle ear fluid. Eighteen ears had no middle ear fluid. At the first follow-up visit, all tested ears had hearing of 20 dB or better. Two children had tubes that were blocked. Blockage occurred in ears that required more than one laser firing to penetrate the tympanic membrane. Otorrhea was present in 13 ears (21%). Otorrhea occurred exclusively in ears with purulent or mucoid middle ear fluid. CONCLUSIONS: Office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion is a safe and effective alternative to tube placement in the operating room. The outcome compares favorably with previously published data.     

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.     

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.     

Failed tube extrusion is not a random event in children or their siblings

Objectives/Hypothesis: It has been assumed that prolonged retention of tympanostomy tubes was random, with an incidence of 4% to 12% per tube. We have noticed patterns of tube retention that suggested a genetic predilection. We undertook this study to validate or disprove this impression. Such information may shed light on the physiology of tube extrusion and may help better define the risks of tympanostomy tube placement. Study Design: Retrospective, single‐surgeon, statistical analysis. Methods: A computerized database of approximately 10,000 pediatric otolaryngology patients was queried. We identified all children treated by the senior author during a 6‐year period who underwent tube removal for failed extrusion 24 or more months after placement. Siblings with retained tubes and individuals requiring bilateral tube removal were further analyzed: 1) using the law of multiplication of independent factors, the chance of retaining tubes in both ears of an individual was compared with the observed rate of bilateral retention by calculating the difference in Poisson rates; 2) the rate of siblings who retained one or both tubes was compared with nonsiblings who retained one or both tubes using the Z test for independent proportions. Results: The observed rate of bilateral retention (228/6,000 = 0.038) far exceeded the theoretical rate (0.068² = 0.0046; P < .001). Siblings were more likely to retain tubes than nonsiblings (difference = 0.042; P = .085). This difference was more pronounced in unilateral (difference = 0.048; P = .014) than in bilateral retention (difference = 0.005; P = .856). Conclusions: Tympanostomy tube retention is not a random occurrence. Patterns of nonextrusion in individuals and siblings suggest a genetic mechanism. Implications for patient counseling and research are discussed.     

鼓膜激光打孔治疗分泌性中耳炎20例

目的 评价鼓膜激光打孔治疗分泌性中耳炎的疗效。 方法 分泌型中耳炎患者20例(25耳),行鼓膜激光打孔,并配合口服抗生素、激素及黏液促排剂等药物综合治疗。 结果 20例(25耳)中17耳鼓膜激光打孔1次痊愈,4耳激光打孔2次痊愈,4耳打孔失败后行鼓膜置管痊愈,打孔有效率为84%(21/25)。 结论 鼓膜激光打孔治疗分泌性中耳炎疗效确切,操作简单,可反复操作,是一种较好的治疗方式。     

New method for coating tympanostomy tubes to prevent tube occlusions

OBJECTIVE: tympanostomy tube insertion is currently the most common surgical procedure requiring general anesthesia performed on children. Occlusion of the tube and prolonged otorrhea through the tube are typical problems associated with the use of middle-ear ventilation tubes. In this study, a new method for coating ventilation tubes is introduced that prevents occlusion of the tube lumen by granulation tissue, blood clot or pus. METHODS: human serum albumin (HSA) was used to coat standard tympanostomy tubes of different materials. Fibronectin, a typical protein in serum and exudates and one of the most adhesive glycoproteins, was used as a model representative of exudates of the ear. RESULTS: when compared with the binding on uncoated tubes, the binding of fibronectin on HSA-coated tubes was inhibited from 59 to 85%, depending on the tube material used. CONCLUSIONS: HSA-coating markedly reduced the binding of fibronectin on tube surfaces in vitro. The study shows the potential role of HSA-coating in preventing the adherence of foreign material to tympanostomy tubes and reducing tube occlusions.     

Evaluation of the Polytetrafluoroethylene-Membrane Ventilation Tube

In an effort to evaluate the safety and efficacy of the currently available polytetrafluoroethylene (PTFE)-membrane ventilation tube, in a group of 41 children, the experimental tube was inserted into one ear and a conventional tympanostomy tube was placed in the other ear. The membrane tubes, except in a few instances, were inserted into ears without effusion. After the procedure the children were forbidden to swim and their ears were protected during bathing. In addition to pneumatic otoscopy, a specially designed tympanometric test—which determined if the membrane tube was functioning—was used to assess the operation of the new device postoperatively. In many of the children, Eustachian tube function studies were also performed on the ears with the conventional tympanostomy tubes. The study was aborted early in the clinical trial period due to the early findings: only 10 of 41 (24%) of the membrane tubes continued to function, the remainder having become occluded; whereas 35 of 41 (85%) of the conventional tympanostomy tubes were found to be still functioning during the same period of observation. Twelve of the 41 membrane tubes had to be removed prematurely and replaced with conventional tympanostomy tubes due to recurrence of middle ear effusion. Scanning electron microscopic studies of the removed tubes revealed blockage of the membrane pores. From the extraordinarily high failure rate of the PTFE-membrane ventilation tube in this study, it is evident that the experimental tube should not replace the conventional tympanostomy tube at this time. The selection of the PTFE covering-membrane on this tube was ill advised, but the rationale of a semipermeable-membrane ventilation tube has merit. However, should another membrane ventilation tube be designed, its routine use must await controlled clinical trials to determine safety and efficacy in humans.     

A 14-year prospective follow-up study of children treated early in life with tympanostomy tubes: Part 1: Clinical outcomes

OBJECTIVE: To determine 14-year otological outcomes in young children treated with early insertion of ventilation tubes (VTs) for recurrent acute otitis media or otitis media with effusion (OME). DESIGN: Prospective 14-year follow-up. SETTING: Central Hospital of Central Finland, a tertiary care hospital.Patients Three hundred five consecutive infants and young children aged 5 to 16 months with otitis media were enrolled for early initial tympanostomy tube insertion. The final study group comprised 237 patients (77.7%) attending the 14-year checkup. MAIN OUTCOME MEASURES: At the 14-year checkups, abnormal otological findings were recorded and results compared with those of the 5-year checkups. RESULTS: From 5 to 14 years' follow-up, the number of healed ears increased from 156 (65.8%) to 177 (74.7%), while the number healed of ears with abnormal outcomes decreased from 81 (34.2%) to 60 (25.3%). Of 156 healed ears, 142 (91.0%) remained healed, and 35 (43.2%) of 81 ears with abnormal outcomes healed. The proportion of abnormal outcomes was higher among ears with OME (P = .02) and with 3 or more VT insertions (P<.001). Repeated tympanostomy tube insertion was performed in 141 ears (59.5%), more often in those with OME (P = .003), and ear surgery was performed in 9 ears (3.8%), 8 with OME. CONCLUSIONS: Early VT treatment is recommended for young children with recurrent acute otitis media or persistent OME. Parents should be informed of the long follow-up, of the possible need for repeated VT insertion, and of potential sequelae that sometimes necessitate surgical intervention. Patients healed after 5 years do not need further follow-up.     

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.     

Direct evidence of bacterial biofilms in otitis media

OBJECTIVES/HYPOTHESIS: Bacteriologic studies of otitis media with effusion (OME) using highly sensitive techniques of molecular biology such as the polymerase chain reaction have demonstrated that traditional culturing methods are inadequate to detect many viable bacteria present in OME. The presence of pathogens attached to the middle-ear mucosa as a bacterial biofilm, rather than as free-floating organisms in a middle-ear effusion, has previously been suggested to explain these observations. The suggestion has been speculative, however, because no visual evidence of such biofilms on middle-ear mucosa has heretofore been collected. The hypotheses motivating the current study were: 1) biofilms of nontypable Hemophilus influenzae will form on the middle-ear mucosa of chinchillas in an experimental model of OME, 2) these biofilms will exhibit changes in density or structure over time, and 3) biofilms are also present on tympanostomy tubes in children with refractory post-tympanostomy otorrhea. The objective of this study was to collect visual evidence of the formation of bacterial biofilms in these situations. STUDY DESIGN: Laboratory study of bacteriology in an animal model and on medical devices removed from pediatric patients. METHODS: Experimental otitis media was induced in chinchillas by transbullar injection of nontypable H. influenzae. Animals were killed in a time series and the surface of the middle-ear mucosa was examined by scanning electron microscopy (SEM) for the presence of bacterial biofilms. Adult and fetal chinchilla uninfected controls were similarly examined for comparison. In addition, tympanostomy tubes that had been placed in children's ears to treat OME and removed after onset of refractory otorrhea or other problems were examined by SEM and by confocal scanning laser microscopy for bacterial biofilms, and compared with unused control tubes. RESULTS: Bacterial biofilms were visually detected by SEM on the middle-ear mucosa of multiple chinchillas in which H. influenzae otitis media had been induced. Qualitative evaluation indicated that the density and thickness of the biofilm might increase until at least 96 hours after injection. The appearance of the middle-ear mucosa of experimental animals contrasted with that of uninjected control animals. Robust bacterial biofilms were also visually detected on tympanostomy tubes removed from children's ears for clinical reasons, in contrast with unused control tubes. CONCLUSIONS: Bacterial biofilms form on the middle-ear mucosa of chinchillas in experimentally induced H. influenzae otitis media and can form on tympanostomy tubes placed in children's ears. Such biofilms can be directly observed by microscopy. These results reinforce the hypothesis that the bacterial aggregates called biofilms, resistant to treatment by antibiotics and to detection by standard culture techniques, may play a major etiologic role in OME and in one of its frequent complications, post-tympanostomy otorrhea.     

Trimethoprim-sulfamethoxazole plus topical antibiotics as therapy for acute otitis media with otorrhea caused by community-acquired methicillin-resistant Staphylococcus aureus in children

OBJECTIVE: To report our experience in identification and treatment of acute otitis media (AOM) with otorrhea secondary to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), which is seen in children at increasing rates. DESIGN: Clinical and laboratory records were retrospectively reviewed between January 2003 and December 2003. SETTING: Primary pediatric clinic. PATIENTS: Six pediatric patients who had AOM with otorrhea caused by CA-MRSA. MAIN OUTCOME MEASURES: Clinical resolution of AOM with otorrhea. RESULTS: All patients had acute-onset otorrhea associated with their AOM. Five patients had tympanostomy tubes and 1 had perforation of the tympanic membrane. None of the patients were responding to treatment with oral antibiotics (amoxicillin sodium-clavulanate potassium, cefpodoxime proxetil, and cefprozil) or fluoroquinolone ear drops (ofloxacin, ciprofloxacin). Specimens were obtained from the ears for cultures, and MRSA was present in the cultures. The organisms were resistant to levofloxacin and erythromycin in all patients and resistant to clindamycin hydrochloride in 2 patients. The cultures were sensitive to trimethoprim-sulfamethoxazole, gentamicin sulfate, rifampin, and vancomycin hydrochloride. All patients were treated successfully with oral trimethoprim-sulfamethoxazole and ear drops (gentamicin sulfate or polymyxin B sulfate-neomycin sulfate-hydrocortisone [Cortisporin]). CONCLUSIONS: The rising rate of CA-MRSA as a cause for many pediatric infections is a major concern. It is very important to obtain cultures from patients with nonresponsive or persistent otorrhea with AOM to look for MRSA and determine the sensitivity of the pathogen to antibacterial therapy. Trimethoprim-sulfamethoxazole is a good choice for initial, empirical therapy when combined with a topical agent for AOM with otorrhea if CA-MRSA is suspected. Further studies are needed to determine whether there is a link between the overuse of topical fluoroquinolones in pediatric patients and the recent rising rate of CA-MRSA.     

Synchronous fat plug myringoplasty and tympanostomy tube removal in the management of refractory otorrhoea in younger patients

OBJECTIVE: Tympanostomy tubes are associated with many complications, the most common being recurrent otorrhoea, in many cases resistant to medical treatment. With the associated vestibulo-cochlear toxicity of many topical antibiotics, their use is dose limited. Removal of the tympanostomy tube has been shown to cure the otorrhoea, however, it is associated with a high persistent perforation rate of 10-28%. A synchronous fat plug myringoplasty was performed with tube removal in an attempt to reduce the residual perforation rate. METHODS: A retrospective study of 13 consecutive children, nine male and four female, mean age 9.1 years (median=9, range 2-15), with a total of 15 ears (left=6, right=9) had either Shah Tubes (n=5), Shepard Tubes (n=1) or Shah Long Term Tubes (n=9) in-situ for middle ear effusions. The tubes were removed for recurrent otorrhoea. The tubes had been in-situ for a mean of 38.8 months (median=31, range 9-84 months). All ears had recurrent infections, with a variable response to topical antibiotics. All were under the care of one specialist, who performed all the procedures. At the time of tube removal, a standard fat graft myringoplasty was done. RESULTS: The procedure was successful in 15 of the 15 ears, and all perforations had closed by 3 weeks. Pure tone audiometry improved in 11 ears, remained the same in two and worsened in two (0-10 and 11-15 dBA, respectively). There were no complications arising from the procedure. Mean follow up was 13.7 months (median=9, range 3-31). None of the patients have re-perforated, but two have required re-ventilation of their middle ear for middle effusions, and one of these two has also undergone subsequent adeno-tonsillectomy. CONCLUSIONS: Our experience in this small series shows that the removal of a tympanostomy tube for recurrent otorrhoea can be successfully managed with a fat plug myringoplasty, with the benefit of a reduction in the persistent perforation rate following tympanostomy tube removal. It is a simple technique that requires little extra operating time with no significant morbidity.