Endoscopic Adenoidectomy in Children With Otitis Media With Effusion and Mild Hearing Loss

ObjectivesSurgical management of children with chronic otitis media with effusion (OME) includes tympanostomy tube insertion or adenoidectomy, alone or with myringotomy and tube insertion. The aim of this study was to compare the effectiveness of transoral microdebrider endoscopic-assisted adenoidectomy (TOMEA) and traditional adenoidectomy in the management of children with mild hearing loss due to OME and chronic adenoiditis.MethodsThis prospective, double-blind and controlled study involved 120 consecutive patients aged 4–12 years, who were randomised 1:1 to undergo TOMEA or traditional adenoidectomy under general anesthesia. All the patients underwent a complete otolaryngological examination, including nasopharyngeal fibre endoscopy (NFE), pneumatic otoscopy, otomicroscopy, tympanometry and supraliminar tonal audiometry, upon enrolment, and three and nine months postoperatively.ResultsThere were no statistically significant differences in age or gender distribution between the TOMEA group (mean age, 4.9±1.1 years; 53.3% males) and the traditional adenoidectomy group (mean age, 5.3±0.9 years; 56.7% males). Both procedures led to a significant improvement in choanal patency (P<0.01) and all of the otological and audiological parameters (P<0.01) 3 and 9 months postoperatively, although postoperative NFE showed that the mean percentage of residual choanal obstruction was significantly less in the TOMEA group (P=0.02). There was no significant between-group difference in the percentage of children with tympanic membrane changes, but the postoperative prevalence of children with a type B tympanogram was significantly lower in the TOMEA group after 3 (15.0% vs. 31.7%, P=0.05) and 9 months (18.3% vs. 38.3%, P=0.02), as was the percentage of children with mild conductive hearing loss (3.3% vs. 23.3%, P<0.01; and 8.3% vs. 28.3%, P<0.01).ConclusionAlthough both TOMEA and traditional adenoidectomy are effective in treating children with mild hearing loss due to adenoidal hypertrophy and OME, the former achieves the greater reduction in residual adenoidal hypertrophy and better audiological outcomes.     

management of otitis media with effusion

Otitis media with effusion is one of the most common diseases in children. Its treatment remains controversial. Clinical practice guidelines of OME allow watchful waiting for 3 months before treatment if the child with OME is not at risk for speech/language/or learning problems. Tympanostomy tube insertion is the preferred initial procedure when a child becomes a surgical candidate. Complementary or alternative medicine is not recommended as a treatment for OME. This paper provides a systematic review of management of OME, which we hope will be helpful for clinicians.     

豚鼠分泌性中耳炎模型的建立

目的 建立豚鼠分泌性中耳炎的动物模型。方法 20只豚鼠均分为对照组和造模组,造模组将0.1ml灭活的肺炎链球菌悬浮液注入豚鼠的鼓室内,5天后耳内窥镜下观察鼓室积液情况,检测反应阈,了解光镜下咽鼓管的组织形态变化。结果 20耳中有14耳出现鼓室积液,光锥消失。反应阈由14.00±3.08dB提高至45.00±5.67dB,光镜下咽鼓管的黏膜面有无结构的红染物覆盖,杯状细胞增多,胞质及胞核深染。结论 灭活的肺炎链球菌悬浮液注入豚鼠的鼓室内制造豚鼠分泌性中耳炎的动物模型切实可行。     

分泌性中耳炎复发的相关因素分析

目的：探讨分泌性中耳炎（otitis media with effusion,OME）复发相关的影响因素。方法分析经鼓膜切开置管术治疗的255例慢性分泌性中耳炎患者的临床资料,其中取出通气管后一年内复发者85例,未复发者170例。对与分泌性中耳炎复发相关的可能因素包括年龄、性别、病程、吸烟环境、反复呼吸道感染、慢性鼻－鼻窦炎、鼻腔结构异常、腺样体肥大或鼻咽淋巴组织增生、乳突气化情况、既往置管手术史、中耳通气管留置时间等进行单因素分析及多因素 Logistic 回归分析。结果单因素分析发现,年龄、反复呼吸道感染（χ2＝22．546,P＝0．000）、慢性鼻－鼻窦炎（χ2＝5．211,P＝0．023）、腺样体肥大或鼻咽淋巴组织增生（χ2＝10．338,P＝0．002）、乳突气化不良（χ2＝15．196,P＝0．000）、通气管留置时间（3～6月）（χ2＝11．347,P＝0．001）对分泌性中耳炎复发的影响有统计学意义。Logistic回归分析显示,小龄、反复呼吸道感染（P＝0．001,OR＝2．992）、腺样体肥大或鼻咽淋巴组织增生（P＝0．021,OR＝2．198）、乳突气化不良（P＝0．000,OR＝3．433）、通气管留置时间（3～6 m）（P＝0．010,OR＝2．237）5个因素对分泌性中耳炎复发的影响有统计学意义。反复呼吸道感染对学龄前、学龄期儿童和青少年复发性分泌性中耳炎影响有显著意义,腺样体肥大或鼻咽淋巴组织增生对学龄前儿童O ME复发的影响有显著意义（P＜0．05）。结论小龄、反复呼吸道感染、慢性鼻－鼻窦炎、腺样体肥大或鼻咽淋巴组织增生、乳突气化不良、通气管留置时间较短可能是导致分泌性中耳炎复发的主要因素。反复呼吸道感染对学龄前、学龄期儿童和青少年的影响较成人更为显著,腺样体肥大对学龄前儿童的影响最为明显。     

The Role of Fibrinolysis in Adhesive Otitis Media(AOM)

Objective To study the effects of Batroxobin on otitis media with effusion(OME), an early stage of Ad-hesive Otitis Media(AOM), for the purpose of expanding our understanding of the role of fibrinolysis in the patho-genesis of AOM. Method Forty cases of OME(45 ears) were randomly selected to receive intratympanic adminis-tration of Dexamethasone at 5 mg/ml(Group 1 or G1), Batroxobin at 1 BU/ml(Group 2 or G2) or Batroxobin at 2 BU/ml (Group 3 or G3). Pre- and post-treatment changes in clinical symptoms, the Air conduction Hearing Threshold (AHT) in pure tone audiometry and average AHT over 0.25 to 2 kHz were compared. Results Data from 31 eases(33 ears) were available for analysis. AHTs among three groups were similar prior to treatment(P> 0.05). The rate of normal hearing following treatment in G3 was 70% or 7/10, higher than in G1 (41.7% or 5/12) and G2 (54.5% or 6/11)(P < 0.05). The rate of improvement following treatment was 81.8% or 9/11 and 80.0% or 8/10 in G2 and G3, respectively, higher than that in G1 (50.0% or 6/12)(P< 0.05). Conclusions Therapeu-tic effects of intratympanic injection of Batroxobin on OME is superior to traditionally used Dexamethasone. In ad-dition, higher concentration of Batroxobin appears to be superior to lower concentrations. These findings confirm that fibrinolysis plays a pivotal role in the pathogenesis of middle ear adhesion and that fibrinolytic medicine can prevent or reduce adhesion development in the middle ear.     

Effect of Nebulized Bovine Surfactant for Experimental Otitis Media with Effusion

Objectives

In this study, we evaluated the efficacy of nebulized bovine pulmonary surfactant on experimentally induced otitis media with effusion (OME) in guinea pigs.

Methods

Twenty guinea pigs were divided into three groups. Four untreated animals served as normal controls. Experimental OME was established in both ears of the remaining 16 animals by a transbullar injection of 10 µL of Pseudomonas aeruginosa lipopolysaccharide in saline. Thereafter, the guinea pigs received nebulized phosphate buffered saline (n=8) or nebulized bovine pulmonary surfactant (n=8). Nebulization was given daily for 7 days. On day 8, all the animals'' passive opening pressure (POP) of the Eustachian tube was measured and histopathological observations of the bulla were made by light microscopy.

Results

Nebulized bovine pulmonary surfactant significantly reduced the POP compared to that of saline nebulization. The bovine pulmonary surfactant improved the tubal patency and produced less histopathologcally-evident edematous bullar mucosa.

Conclusion

Nebulization of bovine pulmonary surfactant plays an important role in treating otitis media with effusion in guinea pigs. Our results suggest that the chosen nebulized bovine pulmonary surfactant can be of good clinical benefit for treating OME in the future.     

Otitis media with effusion: a disability or not?

Otitis media with effusion (OME) is a disease most commonly affecting the paediatric population. However, it is a condition that is also seen in adults and does lead to significant morbidity. We studied the effect of surgical treatment of OME in an adult population and found that the subjective relief of symptoms exceeded the objective audiometric gain. In children where subjective symptoms are perhaps more difficult to assess the clinician needs to beware of underestimating the effect of a hearing loss.     

Effect of Tumor Necrosis Factor‐α on Experimental Otitis Media With Effusion

Objectives/Hypothesis Up to the present, many reports have demonstrated that local immune response is associated with maintenance and persistence of effusion in the middle ear cavity. Resulting retention of inflammatory cells and mediators in the middle ear results in ongoing effusion. The purpose of this study was to clarify the role of tumor necrosis factor in experimental otitis media with effusion, which was induced by transtympanic injection of tumor necrosis factor in the rats. Study Design Four groups were designed in two e‐periments. The purpose of e‐periment 1 was to confirm that transtympanic injection of TNF‐α produces the middle ear effusion. In experiment 2, TNFsolRI was used to evaluate the possibility as an inhibitor in otitis media with effusion. Methods The histopathological changes were observed under light microscope, and the changes in microvascular permeability were examined using Evans blue vital dye technique. Results Middle ear effusion was developed in 70% of specimens, and histopathological changes, such as subepithelial edema and marked infiltration of neutrophils, were present in 100% at 24 hours after administration of tumor necrosis factor‐α through transtympanic approach. Extravasation of Evans blue dye was found in all specimens injected by tumor necrosis factor‐α, which was qualified using a fluorescence microscope and quantified using a spectrophotometer. These histopathological findings and changes in microvascular permeability were significantly reduced by tumor necrosis factor soluble receptor type I. Conclusions Neutrophil infiltration, subepithelial edema, increased microvascular permeability, and resultant effusion were indirectly proved to be induced by tumor necrosis factor‐α. We hope that this study may contribute to understanding the role of tumor necrosis factor‐α in otitis media with effusion and clarifying the future role of tumor necrosis factor soluble receptor type I in preventing otitis media with effusion.     

鼓室积液的激光显微外科治疗

目的 探讨鼓室积液的激光显微外科治疗方法。方法 应用以色列Sharplan-30C CO2激光器对62例99耳鼓室积液患者进行鼓膜造孔术。结果 单纯鼓膜造孔术18耳，鼓膜造孔维持时间平均2.5周，纯音气导语频区听力较术前平均提高16dBHL；鼓膜造孔同时置通气管81耳，术后跟踪随访3个月以上，纯音气导听力语频区较术前平均提高18.4dBHL。结论 CO2激光治疗鼓室积液为激光在 耳科手术中的典型应用，符合外科手术微创原则，安全性好，非接触式，准确性高，无血操作，术罢清晰，方法简便。     

Management for the Children with Otitis Media with Effusion in the Tertiary Hospital

Objectives

Recently, new evidence-based recommendations have been introduced for diagnosing and managing otitis media with effusion (OME) in children. However, there are some difficulties to follow the general guidelines in the tertiary hospitals. The purpose is to evaluate the efficiency of antibiotics or antihistamines for treatment of children with OME in the tertiary hospital with a randomized prospective clinical study.

Methods

Eighty-four children with OME who had been diagnosed in the tertiary hospital were randomized to receive 5 different medications for 2 weeks. We prescribed antibiotics (amoxicillin-clavulanate syrup) in Group I (n=16), antibiotics/steroids (prednisolone) in Group II (n=18), antibiotics/antihistamines (ebastine) in Group III (n=15), antibiotics/steroids/antihistamines in Group IV (n=17), and mucolytics (ivy leaf extract) in Group V (n=17) for control. We followed-up children every 2 weeks and evaluated the state of OME at 3 months.

Results

Thirty six (42.9%) of 84 children were resolved within average 6.9 weeks after the treatments. Thirty-six (42.9%) were treated with ventilation tube insertion and 12 patients (14.3%) were observed. There was no difference in the resolution rates of OME among the five different protocols (P>0.05). There was no difference in the resolution rates among groups who used steroids, antihistamines, steroids and antihistamines, or other medications to manage 42 children with allergies (P>0.05).

Conclusion

In the tertiary hospital, the cure rate of children with OME was not as high as well-known, and antibiotics or anti-allergic medications were not more effective than control. We may, therefore, need any other guidelines which are different from the previous evidence-based recommendations, including early operation in the tertiary hospitals.     

腭裂与分泌性中耳炎

目的探讨腭裂与分泌性中耳炎的关系,了解腭裂修复术及鼓室置管术手术前后的听力学变化.方法对203(406耳)例腭裂患者进行年龄分组,采用声导抗,纯音测听或听性脑干反应(ABR)检查判断中耳功能.21例腭裂伴分泌性中耳炎患者在作腭裂修复术的同时,行鼓室置管术,术前术后作听力学检测.结果203例腭裂患者,中耳功能障碍的发病率为68.5%,6岁前可高达80%.21例腭裂伴分泌性中耳炎患者术后随访1～3年,听力明显改善,平均听力比术前提高17dB(P＜0.01).结论腭裂与分泌性中耳炎的发病明显有关,年龄越小,发病率越高.腭裂伴有分泌性中耳炎的患者,应早期行鼓室置管术,方能改善听力,有助于正常语言的发育.     

Effectiveness of adenoidectomy and laser tympanic membrane fenestration

Objective Adenoidectomy alone or with tonsillectomy (A±T) is an effective surgical intervention in the management of otitis media in children, especially when it is performed in conjunction with insertion of pressure equalization tubes (PETs). Otorrhea and persistent tympanic membrane (TM) perforation are frequent complications. This study evaluates the effectiveness of intermediate duration middle ear ventilation using laser tympanic membrane fenestration (LTMF) without tube insertion and as an adjunct to adenoidectomy in resolving middle ear disease within the first 90 days after surgery. Study Design This pilot study was a multicenter, prospective clinical cohort trial. Institutional review board approval and informed consent were obtained. The study involved four tertiary care pediatric otolaryngology departments. Fifty children (96 ears) were treated with LTMF in conjunction with A±T from June 1, 1998, through March 30, 1999. Ages ranged from 9 months to 12 years. Patients undergoing A±T who would have been recommended for PET insertion instead underwent middle ear ventilation with LTMF using the OtoLAM? device (ESC/Sharplan, Yokneam, Israel). Patients were seen at 30, 60, and 90 days postoperatively. Resolution of otitis media with effusion was determined by clinical examination, which included pneumatic otoscopy, audiometry, and tympanometry. Results Of the treated ears, 88%, 86%, and 83% had clinical resolution of middle ear disease at 30, 60, and 90 days, respectively. Preoperatively, 45% (n = 85) of ears had normal hearing; 92% (n = 49) had normal hearing at 90 days. Eighty‐nine percent (n = 92) had type C2 or B tympanograms preoperatively, and 12% (n = 60) had type C2 or B at 90 days. Conclusion Laser tympanic membrane fenestration in conjunction with adenoidectomy was effective in restoring normal middle ear function at 90 days post‐treatment in greater than 80% of children who otherwise may have had placement of PETs.     

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

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

Dry tap at myringotomy: a three-year study of 1688 children undergoing myringotomy

One thousand six hundred and eighty-eight children undergoing myringotomy were studied to determine the rate of ‘dry taps’ and factors associated with a dry middle ear at operation. The percentage of bilateral dry taps was 16%. The dry tap rate was significantly higher in the following groups: older children, those with an A, C1 or C2 tympanogram at the time of listing, milder hearing loss, a preceding history of recurrent acute otitis media and operation performed during the summer or autumn. There was no significant relationship between the dry tap rate and the time on the waiting list, the gender of the child or the order in which right or left myringotomies were performed. Careful preoperative reassessment of any child with a type A, C1 or C2 tympanogram should be made to prevent unnecessary surgery. Separating those listed for treatment of recurrent acute otitis media from those with OME would prevent these being included in the overall dry tap rate.     

小白鼠实验性分泌性中耳炎粘附分子的表达

目的 研究粘附分子表达与分泌性中耳炎的关系。方法 采用灭活未分类流感嗜血杆菌制备小白鼠分泌性中耳炎模型，了解中耳粘膜的病理改变，检测其对白细胞粘附分子表达的影响。结果 实验组小白鼠粘附分子Mac-1和L-selectin的表达明显增加，伴有相应中耳粘膜病理改变。结论 死亡的细菌可能作为一种抗原，导致中耳粘膜的炎症反应及中耳渗出，粘附分子Mac-1及L-selectin的表达与炎症反应密切相关。     

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.     

咽鼓管测压对儿童分泌性中耳炎疗效评估的价值

目的 探讨儿童分泌性中耳炎(otitis media with effusion,OME)治疗前后咽鼓管测压(tubomanometry,TMM)对预测OME预后的价值.方法 66例(98耳)OME患儿(中耳炎组,其中单耳34例,双耳32例)分别在治疗前及正规药物治疗后1月内进行声导抗和TMM测试,记录鼓室导抗图类型及咽鼓管评分(eustachian tube scores,ETS)值,并比较二者之间关系,以单耳患者的正常耳(34耳)作为正常对照组.结果 治疗前,中耳炎组ETS平均值(2.27±1.98分)低于正常对照组(5.14±0.98分)(P＜0.01),鼓室导抗图B型耳的ETS平均值(1.70±1.68分)低于C型耳(3.02±2.11分)(P＜0.01).治疗后中耳炎组ETS平均值(3.62±1.85分)显著高于治疗前(P＜0.05),但治疗后鼓室导抗图B型耳的ETS平均值(3.58±1.69分)与C型耳(3.98±1.45分)差异无统计学意义(P＞0.05),B型耳的ETS提高值(1.84±1.7分)高于C型耳(0.72±0.03分)(P＜0.05).无论B型耳还是C型耳,有效组治疗前后ETS平均值及治疗前后ETS差值均高于无效组(P＜0.01).结论 儿童分泌性中耳炎患耳治疗后ETS值提高,咽鼓管功能改善;治疗前鼓室导抗图B型耳的ETS值较C型耳低,治疗后B型耳的ETS提高值高于C型耳;TMM可为临床评估儿童OME预后提供一定参考.     

鼓室置管治疗儿童分泌性中耳炎疗效观察

目的 探讨鼓室置管治疗儿童分泌性中耳炎(SOM)的疗效和并发症。方法 回顾性分析了我科1997年～2001年经鼓室置管治疗的45例(78耳)儿童SOM的临床资料。结果 45例随访1-2年，85％耳(35例，66耳)听力明显改善，鼓室导抗图恢复成A型。结论 积极改善咽鼓管功能并适当延长留管时间，防止过早脱管对提高儿童SOM的治愈率有着积极的意义。     

难治性分泌性中耳炎术后听力影响因素分析

目的探讨难治性分泌性中耳炎采用乳突轮廓化并行鼓膜置管和单纯鼓膜置管术后,患者听力的改变及其有无差异,并对影响术后听力改变的可能因素进行分析。方法回顾性分析2001年3月～2011年6月收治的难治性分泌性中耳炎患者52例（86耳）,其中20例（33耳）行乳突轮廓化联合鼓膜置管治疗,32例（53耳）仅行鼓膜置管治疗,所有患者均在鼓膜置管术后3~6个月拔管。分析影响术后听力改变的可能因素,涵盖性别、年龄、鼓室黏膜、乳突轮廓化、中耳积液性质、脱管史、耳溢液史、留管时间等。结果乳突轮廓化联合鼓膜置管组术后听力提高30耳（90.9%）;单纯鼓膜置管组术后听力提高38耳（71.7%）。两组相比有显著性差异（χ2=4.535,P=0.033）。对影响难治性分泌性中耳炎患者术后听力的可能因素行多因素统计学分析,提示患耳脱管史（OR=13.425,P＜0.05）、中耳CT结果（OR=0.057, P＜0.05）是影响术后听力的主要因素。结论患耳脱管史和中耳CT结果是影响难治性分泌性中耳炎患者术后听力的重要因素,尤其对于中耳CT提示病变范围较广时,应在鼓膜置管基础上清除中耳鼓室、鼓窦和乳突病变,扩大中耳鼓室、乳突气房容积,改善中耳腔持续负压状态,并建立乳突、鼓室至鼓膜置管通畅引流,对提高听力防止并发症有积极治疗作用。