Middle Ear Ventilation Research Articles

Effectiveness of adenoidectomy and laser tympanic membrane fenestration.

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. 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 Oto-LAM 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. 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. 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.

長期留置型パパレラＩＩ型チューブの使用経験

The use of long-term middle ear ventilation tubes (Paparella type II) was retrospectively analyzed in 66 ears with otitis media with effusion, in children treated at Kagawa Medical University Hospital between January 1990 and March 1998. The average intubation period was 23.9 months. The average pure tone air conduction threshold showed a remarkable improvement of between 32.7dBHL and 16.9dBHL. Otorrhea was observed in 25 ears (37.8%), obstruction in 2 ears (3.0%), granulation in 3 ears (4.5%) and permanent ear drum perforation in 11 ears (19.6%). No cholesteatma or adhesion of the ear drum was seen. Recurrence of otitis media with effusion was found in 9 of 45 ears (20.0%). In conclusion, Paparella type II tube can be placed for a long-term period and have a low rate of reccurence, but have a high rate of otorrhea and permanent ear drum perforation.

One-stage revision surgery for pediatric cholesteatoma: long-term results and comparison with primary surgery

Objective: Few studies report on revision surgery for pediatric cholesteatoma, even if most studies of primary surgery show high recurrence rates. We present independently evaluated long-term results of revision surgery and compare the results with those of primary surgery. Methods: The series consisted of 42 consecutive pediatric (age <16 years) cholesteatoma revision operations in the Helsinki University ENT Department. The primary and revision surgery was non-staged, all mastoids were obliterated and the bony ear canals were reconstructed. The preoperative, surgical and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.3 years and 87% attendance. Results: The recurrence rate for revision operations was 38%. A retraction process developed in 38% of the ears and 67% of these retractions turned into active cholesteatomas. There was a non-significant difference for these figures as compared with primary surgery. Postoperative discharge and poor middle ear ventilation were associated with recurrence. The following factors showed significant differences between primary and revision surgery: increased number of bare facial nerve in the revision group, lower recurrence rate for experienced surgeons (as for both groups together) and improved hearing results for ears without recurrence in the revision group. Conclusions: Recurrent disease after revision surgery appears either in the attic or in the mesotympanum, or develops from a retraction pocket in a similar manner as was seen in patients receiving primary surgery. Recurrence is associated with discharging and poorly ventilated ears. Pediatric cholesteatoma surgery should be done or be supervised by experienced surgeons. The present operation methods result in many recurrences after primary and revision surgery. New surgical methods are needed to create additional aeration pathways to the epitympanum in order to improve middle ear aeration and to prevent some of the retractions.

Laser-assisted Myringotomy for Otitis Media: A Feasibility Study with Short-term Followup

Intermediate-duration middle ear ventilation appears to be a good treatment option for selected children with otitis media. Laser-assisted myringotomy is one way to provide such ventilation. It can provide prompt pain relief and resolution of middle ear effusion and effusion-related hearing loss, and it can provide an opportunity for surveillance of antibiotic-resistant organisms. We performed laser-assisted myringotomy on 97 ears of 54 children over a 5-month period. All children had acute or recurrent otitis media or persistent middle ear effusions. Our experience suggests that laser-assisted myringotomy is a feasible treatment option for selected patients. Practitioner experience and patient and family considerations will contribute to the decision whether to use general or topical anesthesia.

A planimetric study of therapy-dependent development of temporal bone pneumatization in secretory otitis media.

The present study is based on the results of a planimetric investigation of temporal bone pneumatization in 43 children. Radiological and clinical follow-up studies 10 years after therapy for secretory otitis media indicate an adaptation in the size of pneumatization to an almost normal area. The increase shows that a myringotomy is sufficient in cases of serous effusion, whereas a mucous fluid requires long-term middle ear ventilation.

Office-based laser assisted tympanic membrane fenestration in adults and children: pilot data to support an alternative to traditional approaches to otitis media

Objectives: To determine the role of intermediate duration (∼3 weeks) middle ear ventilation using office-based laser assisted tympanic membrane fenestration in resolving an episode of otitis media with effusion in adults and children who otherwise would have been treated with insertion of pressure equalization tubes. Methods: A retrospective chart review of 92 patients (162 ears) was conducted to identify the utility and technical challenges associated with laser assisted tympanic membrane fenestration in an office setting. Clinical characteristics reviewed included: age, gender, duration of effusion, season performed, and hearing and health status of middle ear upon healing of the fenestration. Results: 69% of all patients were effusion free upon closure of the fenestration; 68% of those <3 years; 70% of those 3–7 years; and 70% of those 25–80 years. Some episodes recurred and at final follow-up 64% had normal middle ear structure and function (range of follow-up =1–18 months, mean 2.5 months, median 2.0). Shorter duration of effusion pre-fenestration was more often associated with return to normal middle ear structure and function ( P<0.01). Season performed, number of previous episodes of otitis media and pre-treatment tympanometry were not predictive of result. No significant complications were observed. Conclusions: The use of office-based laser assisted tympanic membrane fenestration is a reasonably safe and effective procedure for the treatment of otitis media in most adults and children. As a minimally invasive otologic procedure, laser assisted tympanic membrane fenestration has great potential to decrease the rates of both antibiotic usage and insertion of ear tubes.

鼓室換気チューブ留置術の評価 ＥＢＭの考えを用いた試み

Objective: To determine the efficacy and side effects of ventilation tube insertion in the treatment of otitis media with effusion in preschool children. Data sources: MEDLINE search [“human” in TG and “otitis media with effusion” in MESH] from 1966 through March 1999, and bibliographies of selected articles. Study selection: Articles were selected for seven outcomes; cure rates, hearing loss, language development, educational attainment, balance disturbances, histopathological sequelae, and side effects, by reviewers assessing study quality and suitability for inclusion. Four articles met inclusion criteria for the cure rates, 9 for hearing loss, 7 for language development, 0 for educational attainment, 6 for balance disturbances, and 1 for histopathological sequelae. There were no appropriate articles on side effcts. Data extraction: We abstracted quantitative data for each outcome measure. Data synthesis: In all data for 4 articles, cure rates in the treatment group were not higher compared with controls. Hearing loss was resolved within 6 months after ventilation tube insertion. Otitis media with effusion in children aged under 4 years did not seem to affect language development in children aged over 4 years. In regard to educational attainment, there were no appropriate trials for this study. According to several case-control studies, there was a relationship between otitis media with effusion in young children and balance disturbance. In regard to histopathological sequelae, ventilation tube insertion did not seem to reduce attic retraction and atelectasis. In regard to side effects, high incidences of otorrhea and tympanosclerosis were reported. The utility analyses of clinical decision analysis were thought to be necessary to determine the meanings of these sequelae. Conclusion: Although the data was insufficient to be conclusive evidence, we speculated that the effectiveness of ventilation tube insertion was very limited, that indications of ventilation tube insertion should be modified, and that large multi-center trials in domestic institutes should be conducted as soon as possible.Key words : meta-analysis, otitis media with effusion, middle ear ventilation, preschool child

Parental perceptions of grommet insertion in children with cleft palate.

Otitis media with effusion is almost universal in children with cleft palate and can delay speech, language and educational development by causing hearing loss. Grommet insertion at the time of cleft palate repair is common. There is debate about whether the benefits of grommets outweigh the risk of complications. A postal questionnaire was used to investigate parental perceptions of middle-ear ventilation via grommet insertion in children attending the multidisciplinary cleft palate clinic. These children's case notes were reviewed. Many children had speech and language delay, but parents thought this improved after grommet insertion. Overall parents were pleased with the results. This confirms that grommets have an important part to play in the management of children with cleft palate.

Audiological findings in large vestibular aqueduct syndrome

An enlarged vestibular aqueduct is a congenital disorder causing early onset and progressive hearing loss in children. This paper presents the audiological findings at first presentation and the audiological evolution in 10 consecutive cases presenting with hearing loss and showing a large vestibular aqueduct on imaging. The reported onset of the hearing loss is within the first few years of life. Most of the cases (80%) showed bilateral involvement. The sex ratio was 1. Patients presented on average at age 5 with a median hearing loss of 62 dB at the speech frequencies. The hearing loss was essentially asymmetrical with an interaural difference of 33 dB and it was a mixed type of hearing loss in 90% of the cases. The authors claim that the conductive component of this hearing loss is a pure cochlear conductive loss which may be pathognomonic for the disease. The presence of a conductive component in a child is easily misinterpreted as a middle ear ventilation problem or in case of good ventilation as an ossicular problem (type otosclerosis). In addition and in contrast to most literature data, the authors did not find evidence for stabilization of the hearing loss but they found a steady decrease of the hearing at an average rate of 4 dB/year.

Pediatric one-stage cholesteatoma surgery: long term results

The long-term results of pediatric cholesteatoma are dispersed and there is no consensus on operation methods and on factors affecting outcome of surgery. We analyzed the independently evaluated long-term results and possible reasons for recholesteatoma. Eighty-four consecutive pediatric (age <16 years) cholesteatoma operations were undertaken in the Helsinki University Central Hospital ENT Department. The operations were not staged; all mastoids were obliterated and bony ear canals reconstructed without open cavities. The pre- and perioperative and annual control data were recorded in a database. The last control was independently performed (J.S.) with an average follow-up of 4.8 years and 87% attendance. The total recholesteatoma rate was 29% (24/84), and it was not dependent on the size of cholesteatoma, mastoid status, cholesteatoma in the window niches or stapedial erosion. A retraction process developed in 25% (21/84) of the ears and 42% (9/21) of these turned into retraction pocket cholesteatomas as late as 13 years postoperatively. Retractions and postoperative discharge, especially in combination, predisposed to recholesteatoma. Of the healed ears, 37% became atelectatic. Hearing was maintained on the preoperative level. Reduced middle ear and attic ventilation led to retractions, and atelectasis and a tendency to discharge accelerated the process. Pitfalls in mastoid obliteration and attic reconstruction and the failure to create new ventilation routes were important reasons for recholesteatoma.

The surgical management of the pars tensa retraction pocket in the child — results following simple excision and ventilation tube insertion

Retraction pockets of the pars tensa formed due to poor mesotympanic ventilation can result in chronic infection, ossicular damage and even acquired cholesteatoma. A diversity in opinion exists as to the best surgical treatment of an established retraction pocket. This paper presents a consecutive prospective series of 39 ears managed over the last 4 years by means of simple excision and insertion of a middle ear ventilation tube. The retraction pockets were graded according to Sadé’s 1979 classification. There were 23 grade II and sixteen grade III retractions. All 39 pockets were successfully excised. Thirty-four of the perforations healed, with the remaining five failing to heal at the time of analysis. In 13 cases the pockets recurred, but in five of these cases the recurrence is minimal and has required no further surgical intervention. Of the eight remaining significant recurrences, four have undergone a repeat procedure with no further recurrence in three cases. Following initial surgery, 67% of the ears operated upon had either minimal or no recurrence. Following further surgery this figure increased to 75%. The air conduction threshold improved by an average of thirteen decibels in those ears that healed with no recurrence.

Thermal myringotomy for eustachian tube dysfunction in hyperbaric oxygen therapy

Otolaryngologists are frequently asked to manage eustachian tube dysfunction (ETD) in patients undergoing hyperbaric oxygen therapy (HBO). HBO patients with intractable ETD currently are treated by tympanostomy tube placement; typically, these tubes are indwelling far longer than is required by the duration of HBO. Also, tubes in this population are associated with higher complication rates of persistent perforation and otorrhea. We investigated the use of thermal myringotomy as an alternative to tympanostomy tube placement in this clinical setting. Potentially, thermal myringotomy avoids the risks and complications associated with indwelling tympanostomy tubes and would be a temporally more appropriate treatment during short- and intermediate-term HBO. In this study 13 patients undergoing HBO who would have required tympanostomy tube placement instead underwent bilateral thermal myringotomies. At the fifth postoperative week, 96% of myringotomies were patent; this duration is adequate for most HBO courses. No patient required a second myringotomy for premature closure. The persistent perforation rate was 15% (at the end of 6 months), which compares favorably with the rate observed with tympanostomy tubes in this unique population of poor wound healers. Only 1 patient had otorrhea; this resolved with dry ear precautions. This study demonstrates thermal myringotomy to be an effective technique for middle ear ventilation in patients undergoing HBO in whom ETD develops. (Otolaryngol Head Neck Surg 1999;121:185-9.)

Safety and efficacy of mitomycin C in prolonged middle ear ventilation

Safety and efficacy of mitomycin C in prolonged middle ear ventilation

Long-term results of pediatric primary one-stage cholesteatoma surgery

The long-term results of surgical treatment for pediatric cholesteatoma are variable and there is no consensus on operation methods and on factors affecting outcome of surgery. We analyzed the independently evaluated long-term results and possible reasons for recurrence of cholesteatoma. A total of 84 consecutive pediatric (age <16 years) cholesteatoma operations in the Helsinki University Central Hospital ENT Department. The operations were not staged, and all mastoids were obliterated and bony ear canals reconstructed without open cavities. The pre- and postoperative and annual control data were recorded in a database. The last control was independently performed (JS) with an average follow-up of 4.8 years and 87% attendance. The total recurrence rate was 29% (24/84), and it was not dependent on the size of cholesteatoma, mastoid status, cholesteatoma in the window niches or stapedial erosion. A retraction process developed in 25% (21/84) of the ears and 42% (9/21) of these turned into retraction pocket cholesteatomas as late as 13 years postoperatively. Retractions and postoperative discharge, especially in combination, predisposed to recurrence. Of the healed ears, 37% became atelectatic. Hearing was maintained on the preoperative level. Reduced middle ear and attic ventilation led to retractions, and atelectasis and a tendency to discharge accelerated the process. Pitfalls in mastoid obliteration and attic reconstruction and the failure to create new ventilation routes were important reasons for recurrence of cholesteatoma.

Avian species differences in susceptibility to noise exposure

Previous studies of hair cell regeneration and hearing recovery in birds after acoustic overstimulation have involved relatively few species. Studies of the effects of acoustic overexposure typically report high variability. Though it is impossible to tell, the data so far also suggest there may be considerable species differences in the degree of damage and the time course and extent of recovery. To examine this issue, we exposed four species of birds (quail, budgerigars, canaries, and zebra finches) to identical conditions of acoustic overstimulation and systematically analyzed changes in hearing sensitivity, basilar papilla morphology, and hair cell number. Quail and budgerigars showed the greatest susceptibility to threshold shift and hair cell loss after overstimulation with either pure tone or bandpass noise, while identical types of overstimulation in canaries and zebra finches resulted in much less of a threshold shift and a smaller, more diffuse hair cell loss. All four species showed some recovery of threshold sensitivity and hair cell number over time. Canary and zebra finch hearing and hair cell number recovered to within normal limits while quail and budgerigars continued to have an approximately 20 dB threshold shift and incomplete recovery of hair cell number. In a final experiment, birds were exposed to identical wide-band noise overstimulation under conditions of artificial middle ear ventilation. Hair cell loss was substantially increased in both budgerigars and canaries suggesting that middle ear air pressure regulation and correlated changes in middle ear transfer function are one factor influencing susceptibility to acoustic overstimulation in small birds.

The use of eardrops in an ENT department.

A survey of the pattern of usage of ototopical preparations in out-patients of the ENT department of a Dutch University Hospital has been performed. Data on clinical presentation and previous treatment of the patient, otoscopic results, prescribed current treatment and, if available, results of microbiological examination were collected. One-hundred and twenty-one evaluable patients were prospectively included. For 20% of the patients it concerned a first manifestation of the symptoms, 35% had a recurrence after a period free of symptoms and in 37% it concerned patients with persisting symptoms despite treatment. Forty-five percent of the patients' ears concerned had an intact tympanic membrane, in 25% a perforation was present and in 12% middle ear ventilation tubes were in situ. Thirty-five percent had already received previous treatment with ear drops. The species most often isolated was Staphylococcus aureus, followed by Pseudomonas aeruginosa. A wide range of products were prescribed. While previous treatment occurred with combination preparations, for current prescriptions, ofloxacin was most often used. Most patients received 2 to 3 drops 3 times a day for 7 to 10 days, which is in accordance with recommendations in the literature. Potentially ototoxic substances are regularly used in daily practice. Ofloxacin is widely used even thought it is not registered for this indication in the Netherlands and the development of resistance has to be taken into account. A new policy based on this survey is proposed, which will reduce the number of different preparations used and will eliminate ofloxacin from first the treatment.

Resistance to biofilm formation on otologic implant materials.

New materials and coatings are now being developed to resist permanent bacterial contamination of implanted medical devices. This study exposed several styles of middle ear ventilation tube materials and coatings to high concentrations of Pseudomonas and Staphylococcus. Electron microscopy was then used to evaluate these tubes' resistance to bacterial biofilm formations. Ionized, processed silicone tubes were the only tubes resistant to Pseudomonas adhesion. Tubes that were made of fluoroplastic or that were ionized processed were very resistant to Staphylococcus contamination when compared with untreated silicone or silver oxide-treated silicone. This study suggests that ionized, coated fluoroplastic would be a highly effective tube material in preventing bacterial biofilm contamination of implanted ventilation tubes.

Resistance to biofilm formation on otologic implant materials

New materials and coatings are now being developed to resist permanent bacterial contamination of implanted medical devices. This study exposed several styles of middle ear ventilation tube materials and coatings to high concentrations of Pseudomonas and Staphylococcus . Electron microscopy was then used to evaluate these tubes’ resistance to bacterial biofilm formations. Ionized, processed silicone tubes were the only tubes resistant to Pseudomonas adhesion. Tubes that were made of fluoroplastic or that were ionized processed were very resistant to Staphylococcus contamination when compared with untreated silicone or silver oxide–treated silicone. This study suggests that ionized, coated fluoroplastic would be a highly effective tube material in preventing bacterial biofilm contamination of implanted ventilation tubes. (Otolaryngol Head Neck Surg 1998;118:444-51.)

Middle ear laser office ventilation (LOV) with a CO2 laser flashscanner.

Laser assisted ventilation of the middle ear with a defocused laser beam has been performed on adults in an office setting without anesthesia. The purpose of this study was to evaluate the efficacy and safety of a highly controlled, char-free CO2 flashscanner technology for the ventilation of the middle ear in young children, at this stage under general anesthesia, and later without anesthesia. A CO2 flashscanning laser, in conjunction with a micromanipulator, was used on 21 SOM patients ages 3-7 years old, with followup at 2 months. Operating time is approximately 5 minutes. Postoperative results show average patency of 2-3 weeks without adverse effects. Of the treated patients, 53% did not require a second treatment, whereas 47% still suffered from otitis media and needed a second treatment. The CO2 flashscanner laser technology is effective and safe for middle ear ventilation and provides excellent control of the perforation diameter. It is already being performed in an office setting with sedation on a limited basis with very promising preliminary results. Based on the current study and on 70 additional cases with longer interval followup, we anticipate the office technique to become widely used in the future.

Pathophysiological and therapeutic considerations of otitis media with effusion from viewpoint of middle ear ventilation

Using nitrous oxide, we examined the gas exchange function through the middle ear mucosa in ears with otitis media with effusion (OME) in children, and found the function to be impaired in 50% of them. The size of the mastoid was significantly smaller in ears with negative gas exchange function than those with positive function, and the presence or absence of the function was even more significantly correlated with the presence or absence of aeration in the middle ear. Furthermore, the presence or absence of aeration in ears with OME was found to be significantly correlated with their prognosis (response of OME to antibiotics treatment) and also with the presence or absence of eardrum mobility examined by a pneumatic otoscope. Finally, after myringotomy and removal of effusion, the gas exchange function recovered in most of the ears with impaired function. These results indicate that the eardrum mobility test may serve as an appropriate indicator for the surgical treatment for OME.