Tube Otorrhea Research Articles

Cost Effectiveness of Treatments for Acute Tympanostomy Tube Otorrhea

Up to 60% of children with tympanostomy tubes develop otorrhea secondary to middle ear infection. In a prior Dutch study, researchers showed that

Biofilm formation on tympanostomy tubes depends on methicillin-resistant Staphylococcus aureus genetic lineage.

Bacterial biofilm formation has been implicated in the high incidence of persistent otorrhoea after tympanostomy tube insertion. The aim of the study was to investigate whether biofilm formation on tympanostomy tubes depends on the genetic profile of methicillin-resistant Staphylococcus aureus (MRSA) strains. Capacity of biofilm formation on fluoroplastic tympanostomy tubes (TTs) was tested on 30 MRSA strains. Identification and methicillin resistance were confirmed by PCR for nuc and mecA genes. Strains were genotypically characterised (SCCmec, agr and spa typing). Biofilm formation was tested in microtiter plate and on TTs. Tested MRSA strains were classified into SCCmec type I (36.7 %), III (23.3 %), IV (26.7 %) and V (13.3 %), agr type I (50 %), II (36.7 %) and III (13.3 %), and 5 clonal complexes (CCs). All tested MRSA strains showed ability to form biofilm on microtiter plate. Capacity of biofilm formation on TTs was as following: 13.3 % of strains belonged to the category of no biofilm producers, 50 % to the category of weak biofilm producers and 36.7 % to moderate biofilm producers. There was a statistically significant difference between CC, SCCmec and agr types and the category of biofilm production on TTs tubes (p < 0.001): CC5, SCCmecI type and agrII type with a moderate amount of biofilm, and CC8 and agrI type with a low amount of biofilm. Biofilm formation by MRSA on TTs is highly dependent on genetic characteristics of the strains. Therefore, MRSA genotyping may aid the determination of the possibility of biofilm-related post-tympanostomy tube otorrhea.

Management of refractory tympanostomy tube otorrhea with ear wicks.

Laryngoscope, 125:751–753, 2015

Does Tube Type Matter in Posttympanostomy Tube Otorrhea?

Objectives: The objective of this study was to review consecutive tympanostomy tube surgeries for the past 8 years, paying particular attention to the type of tube inserted at the time of surgery. Methods: Retrospective chart analysis of the last 3046 consecutive ears for tympanostomy tube surgery from 2005 to 2013. Results: Out of 3046 total ears reviewed, the total rate of otorrhea was 3.78% with 0.0% otorrhea in titanium tubes, 0.0% otorrhea in Sheehy activent tubes, 2.19% otorrhea in Donaldson tubes, 2.72% otorrhea in Sheehy collar button tubes, 3.28% otorrhea in Shepard tubes, 3.88% otorrhea in fluoroplastic tubes, 6.9% otorrhea in stainless steel tubes, 18.52% otorrhea in Goode tubes, and 25.0% otorrhea in triune tubes. Conclusions: Early posttympanostomy tube otorrhea is a frequent complication of tympanostomy tube insertion with a complication rate of 3.8%, and the type of tubes placed at time of surgery seems to make a difference in the incidence of posttympanostomy otorrhea.

Strategies to prevent biofilm-based tympanostomy tube infections

ObjectiveTo review the potential contributory role of biofilms to post-tympanstomy tube otorrhea and plugging as well as the available interventions currently utilized to prevent biofilm formation on tympanostomy tubes. Data sourcesA literature review was performed utilizing the MEDLINE/Pubmed database from 1980 to 2013. Review methodsElectronic database was searched with combinations of keywords “biofilm”, “tympanostomy tube”, “ventilation tube”, and “post-tympanostomy tube otorrhea”. ResultsTwo of the most common sequelae that occur after tympanostomy tube insertion are otorrhea and tube occlusion. There is an increased evidence supporting a role for biofilms in the pathogenesis of otitis media. In this review, we have shown a multitude of novel approaches for prevention of biofilm associated sequelae of otitis media with effusion. These interventions include (i) changing the inherent composition of the tube itself, (ii) coating the tubes with antibiotics, polymers, plant extracts, or other biofilm-resistant materials, (iii) tubal impregnation with antimicrobial compounds, and (iv) surface alterations of the tube by ion-bombardment or surface ionization. ConclusionCurrently, there is not one type of tympanostomy tube in which bacteria will not adhere. The challenges of treating chronic post-tympanostomy tube otorrhea and tube occlusion indicate the need for further research in optimization of tympanostomy tube design in addition to development of novel therapies.

Topical antibiotics are superior to oral antibiotics in children with acute tympanostomy tube otorrhea

Topical antibiotics are superior to oral antibiotics in children with acute tympanostomy tube otorrhea

Should water precautions be recommended for children with tympanostomy tubes?

Should water precautions be recommended for children with tympanostomy tubes?

Inhibition of Otopathogenic Biofilms by Organoselenium-Coated Tympanostomy Tubes

Tube occlusion and post-tympanostomy tube otorrhea (PTTO) are 2 major sequelae of tympanostomy tube placement. Plugging negates the function of the tympanostomy tubes and, along with chronic PTTO, can be financially burdensome owing to repeated surgical procedures and additional treatments. To investigate the effectiveness of an organoselenium (OSe) coating on Donaldson tympanostomy tubes in inhibiting biofilm formation on the tympanostomy tubes. In vitro microbiologic study; all experiments were performed in a Texas Tech University Health Sciences Center basic sciences laboratory. Inhibition of biofilm formation was investigated by incubating OSe-coated vs uncoated (control) tympanostomy tubes in a nutrient broth containing either Staphylococcus aureus (Sa) expressing green fluorescent protein (GFP), nontypeable Haemophilus influenzae (NTHi) expressing GFP, or Moraxella catarrhalis (Mc) for 48 hours at 37 °C. All biofilms were quantified via colony-forming unit (CFU) assays. The Sa and NTHi biofilms were visualized using confocal laser-scanning microscopy (CLSM) and analyzed using the COMSTAT program. The CFU assays, CLSM, and COMSTAT analysis revealed that compared with uncoated control tympanostomy tubes, OSe-coated tympanostomy tubes are able to inhibit Sa, NTHi, and Mc biofilm formation. The Sa and NTHi developed thick mature biofilms containing considerable biomass on uncoated tympanostomy tubes as determined by CLSM and COMSTAT analysis, while the OSe coating on the tympanostomy tubes drastically inhibited biofilm formation by Sa and NTHi. Quantitative CFU analysis revealed that this reduction in biofilm formation was significant, 6 logs for Sa (P < .001) and 4 logs for NTHi (P = .02). OSe coating also inhibited biofilm formation by Mc with a 4.5-log reduction (P < .001). The OSe coating is a potential long-lasting agent to prevent biofilm development on tympanostomy tubes by otopathogens.

AAO‐HNS Clinical Practice Guideline on Tympanostomy Tubes

Program Description:Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. This miniseminar will highlight key recommendations from the new AAO‐HNS guideline on tympanostomy tubes, developed by a multidisciplinary panel using methodology consistent with current Institute of Medicine standards. Emphasis is placed on surgical indications (otitis media with effusion and recurrent acute otitis media), caregiver education, management of tube otorrhea, use of water precautions, and special considerations for children who are at risk for developmental delays. The lively panel discussion will include case presentations and time for questions and answers.Educational Objectives:1) Recognize evidence‐based indications for tympanostomy tubes in children with otitis media with effusion and/or recurrent acute otitis media. 2) Identify children with otitis media with effusion who are at risk for developmental delays and might benefit from insertion of tympanostomy tubes. 3) Educate caregivers of children with tympanostomy tubes on the need for water precautions, management of tube otorrhea, and expectations for follow‐up and monitoring while the tubes remain in place.

Management of Refractory Tympanostomy Tube Otorrhea with Ear Wicks

Objectives: Report our experience with ear wicks for the treatment of chronic tympanostomy tube otorrhea, failing to improve with oral and/or topical antibiotics. Methods: Retrospective review of 7 children with tympanostomy tubes and recurrent otorrhea failing medical management in 2012 at a tertiary care center. We describe the outcomes of patients after wick placement and Ciprodex ear drops. Results: The average age of patients in this study is 30 months (21-48months). The average age of tympanostomy tube insertion was 17 months (8-32 months). All patients had Armstrong grommet tubes placed. Three patients found effusions during time of insertion. All children failed previous topical and/or oral antibiotic treatment. An ear wick was placed during the clinic visit, and ciprodex drops were continued. Wicks were removed in approximately one week. Culture results showed 4 patients had Methicillin-resistant Staphylococcus aureus and 3 had Pseudomonas aeruginosa. After wick placement, 7/7 (100%) patients’ otorrhea resolved. One patient had recurrent otorrhea at further follow-up visit. Conclusions: Tympanostomy tube placement is one of the most common surgical procedures in children. Refractory otorrhea continues to be a complication that has a negative effect on patient quality of life and remains a challenge to treat. It can be difficult to adequately deliver topical therapy to young children. Placement of an ear wick improves topical delivery to the ear and may eradicate otorrhea in patients who failed prior topical and oral antibiotics.

Parent-reported otorrhea in children with tympanostomy tubes: incidence and predictors.

PurposeAlthough common in children with tympanostomy tubes, the current incidence of tympanostomy tube otorrhea (TTO) is uncertain. TTO is generally a sign of otitis media, when middle ear fluid drains through the tube. Predictors for otitis media are therefore suggested to have predictive value for the occurrence of TTO.ObjectiveTo determine the incidence of TTO and its predictors.MethodsWe performed a cohort study, using a parental web-based questionnaire to retrospectively collect data on TTO episodes and its potential predictors from children younger than 10 years of age with tympanostomy tubes.ResultsOf the 1,184 children included in analyses (total duration of time since tube placement was 768 person years with a mean of 7.8 months per child), 616 children (52%) experienced one or more episodes of TTO. 137 children (12%) had TTO within the calendar month of tube placement. 597 (50%) children had one or more acute TTO episodes (duration <4 weeks) and 46 children (4%) one or more chronic TTO episodes (duration ≥4 weeks). 146 children (12%) experienced recurrent TTO episodes. Accounting for time since tube placement, 67% of children developed one or more TTO episodes in the year following tube placement. Young age, recurrent acute otitis media being the indication for tube placement, a recent history of recurrent upper respiratory tract infections and the presence of older siblings were independently associated with the future occurrence of TTO, and can therefore be seen as predictors for TTO.ConclusionsOur survey confirms that otorrhea is a common sequela in children with tympanostomy tubes, which occurrence can be predicted by age, medical history and presence of older siblings.

Clinical Practice Guideline: Tympanostomy Tubes in Children

Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Resistance to complement-mediated killing and IgM binding to non-typeable Haemophilus influenzae is not altered when ascending from the nasopharynx to the middle ears in children with otitis media

We have previously found that non-typeable Haemophilus influenzae (NTHi) collected from the middle ear of children with otitis media (OM) exhibit increased levels of complement resistance compared to NTHi collected from the nasopharynx. However, it is unknown whether bacteria develop complement resistance in the middle ear, or whether resistance is present when residing in the nasopharynx. The objective of this study was to investigate whether the levels of complement resistance of isolates collected from the middle ear were similar to those of isolates from the nasopharynx with an identical MLST type. We included 62 children with recurrent acute OM, chronic OM with effusion or acute tympanostomy tube otorrhea. NTHi was simultaneously isolated from the nasopharynx and middle ear fluid. MLST, resistance to complement-mediated killing, IgG binding, IgM binding and phosphorylcholine expression was determined. In 41 children, NTHi isolated from the middle ear and nasopharynx showed to have an identical MLST type. Isolates collected from the middle ear showed a highly similar level of complement resistance and IgM binding with isolates collected from the nasopharynx, whereas this was not the case for IgG binding and phosphorylcholine incorporation into lipooligosaccharide. Resistance to complement-mediated killing and IgM binding of NTHi isolates with an identical MLST type collected from the middle ear and nasopharynx of children with OM was highly similar.

Editorial

FigureAs part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) recently published its list of “Five Things Physicians and Patients Should Question.” The goals of the campaign were to promote awareness of the overuse of tests and treatments and to improve the overall quality of American healthcare. The AAO-HNSF Patient Safety and Quality Improvement Committee was charged with leading an unbiased and equitable process to arrive at five conditions. The committee reviewed 20 initial items for consideration and then refined the list based on the amount of supporting clinical evidence and the frequency of use of the test, procedure, or treatment. Three of the final five items address diseases of the ear. 1. Don't order a computed tomography (CT) scan of the head/brain for sudden hearing loss. The support for this item comes from a recent AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2012;146[suppl 3]:S1-35).Figure: Michael E. McCormick, MDThe role of imaging in a patient with sudden sensorineural hearing loss (SSNHL) is to identify pathology that may be causing acute symptoms. SSNHL typically results from an abnormality of the cochlea, cochleovestibular nerve (CN VIII), or brainstem. While we are unable to accurately image the inside of the cochlea with current modalities, more central etiologies, such as the CN VIII and brainstem, are best evaluated by magnetic resonance imaging.Figure: Rahul K. Shah, MDTherefore, a routine CT scan of the head/brain adds no diagnostic yield to the workup of these patients in most clinical situations. Furthermore, CT scans expose the patient to potentially harmful radiation and intravenous contrast (Expert Opin Drug Metab Toxicol 2009;5[4]:403-416; Arch Intern Med 2009;169[22]:2078-2086). 2. Don't prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea. Ototopical antibiotic drops are typically 100 to 1,000 times more concentrated than oral preparations and do not need to undergo systemic metabolism and biodistribution (Drugs 1999;58[3]:509-531). As a consequence, topical preparations often can treat bacteria that oral antibiotics cannot. Using antibiotic eardrops instead of oral agents can also help prevent the development and spread of resistant bacteria (Pediatr Infect Dis J 2001;20[1]:102-103) and avoids the systemic side effects associated with oral therapy, such as vomiting, diarrhea, and rash.Figure. David: W. Roberson, MD3. Don't prescribe oral antibiotics for uncomplicated acute external otitis. Similar to the first recommendation, this item is supported by evidence from an AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2006;134[suppl 4]:S4-S23). The item applies primarily to healthy patients without complications or extension beyond the ear canal. In addition to the benefits of curbing overuse of oral antibiotics, there are multiple nonantibiotic preparations that are efficacious. Awareness of and general adherence to these simple recommendations by our health professional colleagues could potentially save an immeasurable amount of resources while improving the quality and perhaps outcomes of care in the United States.

Najczęstsze powikłania pooperacyjne w otolaryngologii w pediatrycznym szpitalnym oddziale ratunkowym

Postoperative complications in pediatric otolaryngology often present to the emergency department. Posttonsillectomy hemorrhage is a feared complication due to its lethal potential and should be managed in conjunction with an otolaryngologist. Physicians should possess and awareness of procedures that have been used in an emergent setting. Postoperative pain management options are discussed including acetaminophen, acetaminophen with codeine, and nonsteroidal anti-inflammatory drugs. Rare postadenoidectomy complications such as nasopharyngeal stenosis and Grisel syndrome are discussed. Tympanostomy tubes are the most common surgery in children, and the proper treatment of posttympanostomy tube otorrhea is discussed.

Choosing Wisely: Our List

In February 2013, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) released its list of 5 recommendations of diagnostic and therapeutic interventions that physicians and patients should question, as part of the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign. This commentary outlines the impetus for the AAO-HNSF to join the campaign, our list of 5 recommendations, how they were developed, and our future involvement with the campaign. The AAO-HNSF's 5 recommendations are (1) don't order a computed tomography (CT) scan of the head/brain for sudden hearing loss, (2) don't prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea, (3) don't prescribe oral antibiotics for uncomplicated acute external otitis, (4) don't routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis, and (5) don't obtain CT or magnetic resonance imaging in patients with a primary complaint of hoarseness prior to examining the larynx.

Draining Ears and Tympanostomy Tubes

Posttympanostomy tube otorrhea also known as acute otitis media with tympanostomy tubes (AOMT) occurs in 15% to 80% of children with tympanostomy tubes. Its management is fairly standardized among pediatric ear, nose, and throat (ENT) physicians owing to recommendations published by the American Academy of Otolaryngology-Head and Neck Surgery. Pediatric emergency medicine (EM) physicians have no such guidelines. This study aimed to compare management of AOMT by pediatric ENT and EM physicians. A 27-question online survey was disseminated via SurveyMonkey.com using e-mail addresses of ENT and EM physicians via organization directories and professional listserves. A total of 175 and 174 responses were received from EM and ENT physicians, respectively. Higher proportion of EM physicians used oral antibiotics to treat AOMT (54% [n = 94] vs 9% [n = 16], P < 0.001). Virtually all ENT physicians used topical antibiotics, compared with 87% of EM physicians. Only 6% (n = 10) of EM physicians used suction to clean ear canals (aural toilet) before instilling topical antibiotics, compared with 81% (n = 138) of ENT physicians. Most ENT physicians (80% [n = 138]) instructed patients to keep the treated ear up for 10 to 60 seconds after instilling the drops and to use the tragal pump technique to direct the medication down the ear canal and through the tube (92% [n = 157]). Only 56% (n = 98) and 24% (n = 41) of EM physicians did the same. There are large differences between ENT and EM physicians with respect to: the use of systemic antibiotics, techniques of using ototopical antibiotics, methods of aural toilet in treating AOMT, and directions given to patients.

Recurrent Post-Tympanostomy Tube Otorrhea Secondary to Aerobic Endospore-Forming Bacilli: A Case Report and Brief Literature Review

We report a unique case in which a 57-year-old man with an 8-year history of late recurrent post-tympanostomy tube otorrhea (PTTO) was found to harbor Bacillus subtilis, an aerobic endospore-forming bacillus that is typically resistant to chemical and physical agents because of its unique life cycle. Removal of the patient's tympanostomy tube resulted in complete resolution of his long-standing otorrhea. We also review the etiologies of and treatment strategies for early, late, chronic, and recurrent PTTO. We conclude that regardless of the etiology, a patient with persistent or recurrent PTTO should consider undergoing removal of the ventilation tube.

Role of Bacterial Biofilm in Refractory Post Tympanostomy Tube Otorrhea

Role of Bacterial Biofilm in Refractory Post Tympanostomy Tube Otorrhea

Methicillin-resistant Staphylococcus aureus (MRSA) pediatric tympanostomy tube otorrhea

ObjectivesTo describe our experience and clinical outcomes with the management of pediatric tympanostomy tube otorrhea secondary to methicillin-resistant Staphylococcus aureus (MRSA). MethodsRetrospective review of pediatric patients (age <18) diagnosed with culture-positive MRSA tympanostomy tube otorrhea. ResultsMRSA positive ear cultures in the presence of tympanostomy tubes were identified in 41 patients (6.3%). The average age was 2.9years old. In all cases, culture results indicated sensitivity to trimethoprim/sulfamethoxazole and gentamicin; resistance to fluoroquinolones and clindamycin occurred in 87.8% and 61.0% of cases, respectively. Fluoroquinolone and sulfacetamide ototopical medications were found to be associated with successful otorrhea resolution (p=0.005 and 0.009, respectively). Adjunctive therapy with oral antibiotics, bactrim and clindamycin (p=0.172 and 0.877, respectively), did not improve resolution rates with medical treatment. Tympanostomy tube removal was more successful than medical therapy alone (p<0.0001). ConclusionAppropriately treated recurrent or recalcitrant tympanostomy tube-related otorrhea should raise the suspicion for MRSA-related tympanostomy tube otorrhea. Fluoroquinolone ototopical medication should be considered for initial therapy. Sulfacetamide ototopical medication can be considered for failures. The adjunctive use of oral antibiotics, bactrim and clindamycin, and aminoglycoside ototopical medications did not improve clinical outcomes for medical therapy alone. We believe that some consideration be given to removal of the tympanostomy tube with or without replacement, after an initial treatment period with fluoroquinolone and/or sulfacetamide otopical medications. Our findings seem to suggest an improved rate with tympanostomy tube removal over medical therapy alone (p<0.0001). No standard management guidelines currently exist.