Tympanic Membrane Fenestration Research Articles

Tympanostomy Tube Insertion Versus Myringotomy or Observation in Managing Otitis Media With Effusion Following Radiotherapy for Nasopharyngeal Carcinoma: An Updated Review.

Head and neck cancers, including nasopharyngeal carcinoma (NPC), are relatively common in Saudi Arabia. Radiotherapy is a standard treatment for NPC, but it can lead to side effects, including post-radiation otitis media with effusion (OME). Managing post-radiotherapy OME remains a topic of debate, with various interventions proposed. This study aims to review the efficacy of different methods to manage post-radiotherapy OME in NPC. This includes tympanostomy tube insertion, frequent myringotomies, and observation. A systematic review was carried out for articles published between 1975 and 2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Excluded from the analysis were articles that involved patients undergoing surgical treatment for nasopharyngeal cancer, studies that focused on patients with other head and neck cancers who developed OME after radiotherapy, research investigating the effectiveness of surgical procedures unrelated to tympanostomy tube insertion, studies written in non-English language, and case reports, reviews, or conference letters. A total of 450 studies were screened, of which six studies were included in the review, yielding 328 patients. The mean age ranged between 46 and 52 years. Follow-up varied from six months to 11 years. The intervention in all studies was tympanostomy tube insertion, and the controls were myringotomy, observation, or tympanic membrane fenestration with cauterization. The use of recurrent myringotomies for the treatment of OME in patients with NP post-radiotherapy is associated with improved chances for the resolution of effusion and decreased risk of complications when compared to tympanostomy tube insertion. Hence, we recommend following a step-wise approach when dealing with this group of patients, offering grommets for patients with persistent effusion or those who cannot tolerate frequent procedures.

The Treatment for Postirradiation Otitis Media With Effusion: A Study of Three Methods

To explore treatments for postirradiation otitis media with effusion (OME) in patients with nasopharyngeal carcinoma. This study is a prospective quasi-randomized clinical trial. Ninety-six patients (135 ears) with OME after the first course of radiotherapy for nasopharyngeal carcinoma were divided into three groups: simple auripuncture plus aspiration, tympanic membrane fenestration with cauterization, and myringotomy plus grommet insertion. Cure rates and incidences of complications were compared. Two deaths occurred. The other 94 patients (132 ears) finished a 2-year follow-up. In group 1, four ears (8.9%) were cured after the first treatment and 17 ears overall (37.8%) were cured by the end of the follow-up. Twenty ears (44.4%) had persistent fluid, two ears (4.4%) developed chronic suppurative otitis media, and five ears (11.1%) developed dry eardrum perforation. In group 2, seven ears (15.6%) were cured after the first treatment and 21 ears overall (46.7%) were cured by the end of the follow-up. Fourteen ears (31.1%) had persistent fluid, three ears (6.7%) developed chronic suppurative otitis media, and seven ears (15.6%) developed dry eardrum perforation. In group 3, eight ears (17.8%) were cured after the first treatment and 23 ears overall (51.1%) were cured by the end of the follow-up. Seven ears (15.6%) had persistent fluid, five ears (11.1%) developed chronic suppurative otitis media, three ears (6.7%) developed eardrum perforation with effusion, and five ears (11.1%) developed dry eardrum perforation. The methods each have advantages and disadvantages. We believe that a step by step approach should be used when choosing the treatment method for postirradiation OME. That is, first apply auripuncture plus aspiration, and then the other methods if this approach is inadequate. Enhanced local care after grommet insertion can effectively reduce the incidence of complications.

Duration of patency of laser-assisted tympanic membrane fenestration.

Laser-assisted tympanic membrane fenestration (LTMF) provides intermediate-duration middle ear ventilation, which benefits selected children with acute otitis media (AOM) and otitis media with effusion (OME). To evaluate clinical and technical factors that may affect duration of LTMF patency. Prospective clinical cohort effectiveness trial. Four tertiary care children's hospitals. Volunteer sample of 251 children (430 ears) followed up at 1, 2, 3, 4, 8, and 12 weeks; time to fenestration closure was evaluable in 201 ears, and assessment of cure at study conclusion was evaluable in 128 ears. Laser-assisted tympanic membrane fenestration for prospectively defined AOM or OME. The surgeon determined spot size, wattage, and concurrent adenoidectomy based on clinical judgment. Cure of AOM/OME with effusion at 90 days and duration of LTMF patency relative to spot size (1.8-2.8 mm), fenestration location on tympanic membrane, power (7-22 W), concurrent adenoidectomy, age, diagnosis (AOM vs OME), type of effusion, and preoperative tympanogram characteristics. Results are based on the number of ears that could be evaluated at each data collection interval. Fenestrations remained patent for 2 to 4 weeks (mean = 2.52, median = 2.0, SD = 1.4, n = 201); 97.4% were closed at 6-week follow-up. Spot sizes of 2.4 and 2.6 mm had a higher rate of patency than 2.0-mm spot size at 3 weeks following LTMF. Cure at 90 days was related to duration of patency for all patients combined and for patients treated for AOM and OME, but not for those undergoing adjunctive adenoidectomy. Cure at 90 days was related to larger spot size for all patients combined and those treated for AOM. Other investigated factors did not achieve statistical significance. Spot size of 2.4 mm or greater results in improved duration of LTMF patency, persisting for up to 3 weeks after LTMF, especially for treatment of AOM. Increased duration of LTMF patency correlates with greater incidence of cure of middle ear effusion at 90 days. Additional investigation is indicated to determine optimum spot size and optimum duration of patency for disease- severity-adjusted populations.

Laser-assisted tympanic membrane fenestration

Otitis media is one of the most common medical conditions treated by physicians in the United States, especially in children. Antibiotics have been a mainstay of treatment for this condition for decades. However, in recent years, with the evolution of antibiotic-resistant organisms and increased costs of prescription drugs, alternative therapies have been sought. Surgical techniques, most often tympanostomy tube placement, are frequently necessary and usually require a general anesthesia. An alternative procedure, laser-assisted tympanic membrane fenestration (LTMF), uses middle ear ventilation to treat recalcitrant middle ear effusions and access infected middle ear fluid for culture. Antibiotic choice can then be culture-driven in the acute otitis patient, and tympanostomy tubes may often be avoided for children with chronic otitis media with effusion.

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.

Office-based CO2 laser-assisted tympanic membrane fenestration addressing otitis media with effusion.

To use the CO2 laser-assisted tympanic membrane fenestration in office settings, under local anesthesia, as the sole treatment for patients with chronic otitis media with effusion (OME). This new treatment ensures artificial ventilation of the middle ear for several weeks, and provides an intermediate solution between ordinary lancet-made tympanocentesis and transtympanic ventilation tube insertion. The operative technique is already well codified, and preliminary studies have demonstrated that tympanic membrane fenestration does not expose patients to any major hazard. We treated 30 ears in 21 children and 29 ears in 24 adults. All patients had presented with OME persistent for more than 3 months. The laser tympanostomy was performed under local anesthesia, as an outpatient procedure, using a CO2 flash-scanning laser in conjunction with a handpiece (OTOLAM). Using a power of 12 W to 17 W, a single laser pulse usually sufficed to create a 2-mm-diameter circular perforation in the anteroinferior quadrant of the eardrum. The tympanic membrane fenestration allows avoiding ventilation tube insertion in 63% of children and 75% of adults. The CO2 laser-assisted tympanic membrane fenestration seems a valid therapeutic option addressing OME. This study should be pursued on a larger scale to define more precisely the indications of the laser tympanostomy.

Alternative indications for laser-assisted tympanic membrane fenestration.

To assess the utility of the CO(2) Flashscanner laser for treatment of selected middle ear diseases other than otitis media with effusion (OME) and acute otitis media (AOM). A retrospective review of the records of 144 patients treated with the OtoLAM((R)) device, a Flashscanner laser, between July 1, 1998, and February 29, 2000. Patients treated for AOM or OME were excluded. Data are presented on 11 patients (17 ears). Four indications were identified: Elimination of middle ear fluid before auditory brainstem response with or without otoacoustic emission testing (ABR +/- OAE), barotrauma, eustachian tube obstruction, tympanocentesis when a culture of middle ear fluid was deemed necessary. All tympanic membranes (TM) healed. Fenestration of the TM can be accomplished for both diagnostic and therapeutic purposes. Laser assisted tympanic membrane fenestration seems to be effective in the management of middle ear fluid before ABR +/- OAE, barotrauma, eustachian tube dysfunction, and for tympanocentesis.

Optimizing effectiveness of laser tympanic membrane fenestration in chronic otitis media with effusion: Clinical and technical considerations

Objective: To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME). Setting: Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent. Methods: An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF. Outcome Measures: Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing. Results: At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years ( P<0.04), who had shorter durations of effusion ( P<0.009), and who experienced longer duration of fenestration patency (FP) ( P<0.009) correlated to improved outcomes. Conclusions: The use of LTMF to create 2–3 weeks of middle ear ventilation in patients with chronic OME (middle ear effusion (MEE) for 3 months or greater) is effective in 66% of 95 (58%) of ears evaluable at 90 days follow-up. This study provides basic information needed to optimize the use of LTMF today and enhance research efforts in the future.

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.

レーザーを使用した中耳手術

Although modern laser systems offer excellent hematostatic ability and accurate cutting, the use of the laser in ear microsurgery has not become widespread other than in stapes surgery, mainly due to cost ineffectiveness and lack of recognition of the laser as an essential tool. However, the refinement of laser technology such as the flashscanner has brought attention to the use of lasers in the treatment of secretory otitis media. Laser assisted tympanic membrane fenestration is discussed with a review of the literature. In addition, a description of the tecnique used for laser assisted tympanoplasty, which we perform for resecting tympanosclerotic lesions in chronic otitis media or extirpating cholesteatoma medial to the ossicles, is reported.

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.

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration.

To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting. Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements. The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.