Tympanostomy Tubes In Children Research Articles

Pediatric otitis media with effusion: current surgical approach

Otitis media with effusion (EOM), also called serous otitis media, is defined as the presence of fluid in the middle ear without signs of acute infection. EOM is a very common childhood disease. 90% of preschool children experience EOM, with an average of 4 episodes per year. There are 3 main factors in the etiology of EOM; impaired ventilation of the middle ear, infection and inflammation. Treatment of EOM is a combination of observation, medical and surgical therapies. The goals of treatment are to clear the middle ear fluid and restore normal middle ear pressure and hearing. In surgical treatment, myringotomy and tympanostomy tube placement are the main approaches. Shepard Grommet type temporary tube application is the most commonly used material. The current version of the "Tympanostomy Tubes in Children" guideline published by the American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) in 2013 was renewed in 2022. In this short review, we will explain the indications for surgical treatment of EOM-tympanostomy tube application with this guideline.

Outcomes of in-office versus operating room insertion of tympanostomy tubes in children

ObjectiveTympanostomy tube insertion in children is commonly performed under general anesthesia, but there has been increasing interest in office-based alternatives. Although initial research comparing in-office versus operating room (OR) insertion of tubes looks promising, there are scant data available on long-term outcomes. The objective of this study is to compare long-term outcomes of tympanostomy tubes placed in-office versus the OR, with emphasis on the duration of tube function. MethodsWe reviewed electronic medical records in an academic pediatric otolaryngology practice of children under age 13 years who had tubes placed in-office or the OR between 2010 and 2021. Differences in time to unilateral and bilateral tube occlusion/extrusion were compared by Kaplan-Meier survival analysis with log rank comparison. Cox regression modeling was performed to identify predictors of tube occlusion/extrusion. Results817 children were included (473 office tubes, 344 OR tubes). Tube placement was equally successful for both groups (98.3% for office and 98.9% for OR). Comparison of Kaplan-Meier plots for time to unilateral and bilateral tube occlusion/extrusion by location showed no significant difference (P = .842 for unilateral and P = .714 for bilateral). However, regression analysis indicated a strong interaction of location with operator status (resident vs attending). Median time to unilateral occlusion/extrusion and bilateral occlusion/extrusion was shorter for OR residents compared to OR attendings (15.0 vs 19.5 months, P = .002, and 22.1 vs 32.0 months, P = .030, respectively). There was no difference in the time to unilateral or bilateral tube occlusion/extrusion between the office attending and OR attending groups (16.8 vs 19.5 months, P = .057 for unilateral, and 23.0 vs 32.0 months, P = .320 for bilateral). There was no significant difference between groups in the need for tube removal, repeat tubes, tube medialization, or post-extrusion tympanic membrane perforation. ConclusionThe comparable long-term outcomes found for tubes inserted in-office versus the OR, including time to occlusion/extrusion, suggest that both settings are acceptable for the procedure, with choice based primarily on parental preference, clinician experience, and shared decision making with families.

Can ChatGPT Guide Parents on Tympanostomy Tube Insertion?

The emergence of ChatGPT, a state-of-the-art language model developed by OpenAI, has introduced a novel avenue for patients to seek medically related information. This technology holds significant promise in terms of accessibility and convenience. However, the use of ChatGPT as a source of accurate information enhancing patient education and engagement requires careful consideration. The objective of this study was to assess the accuracy and reliability of ChatGPT in providing information on the indications and management of complications post-tympanostomy, the most common pediatric procedure in otolaryngology. We prompted ChatGPT-3.5 with questions and compared its generated responses with the recommendations provided by the latest American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) "Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)". A total of 23 responses were generated by ChatGPT against the AAO-HNSF guidelines. Following a thorough review, it was determined that 22/23 (95.7%) responses exhibited a high level of reliability and accuracy, closely aligning with the gold standard. Our research study indicates that ChatGPT may be of assistance to parents in search of information regarding tympanostomy tube insertion and its clinical implications.

Need for Tympanostomy Tubes in Children With Recurrent Acute Otitis Media Without Middle Ear Effusion.

Children with recurrent acute otitis media (RAOM) presenting without middle ear effusion (MEE) do not meet indications for surgical intervention as outlined by Clinical Practice Guidelines (CPGs). The objective of this study was to determine which patients presenting with RAOM without MEE ultimately received tympanostomy tubes. Case series. Single academic pediatric otolaryngology clinic. Children (0-12 years) presenting with RAOM and no MEE were identified from October 2017 to December 2019. As per CPGs, no surgery was offered initially. Patients were given a semiurgent return appointment should they experience another suspected otitis media episode. If MEE was observed, tympanostomy tube insertion was offered. Patients were followed for 1-year following enrollment. One-hundred and twenty-four patients were included. The median age was 3.15 years old (interquartile range: 4.10). Seventy-five (60%) patients did not require additional follow-up and thus did not require tympanostomy tubes. Forty-nine (40%) patients were seen again; of these, 11 patients received tympanostomy tubes. Therefore, of patients presenting with no MEE, 91% did not require tympanostomy tubes. Patients who had surgery were younger on initial assessment than those who did not (mean difference 2.68 years, 95% confidence interval: 2.14-3.23). This study demonstrates the practical effect of adhering to CPGs for RAOM and suggests that many children may not require tympanostomy tube placement within the 1st year after the consultation if they did not initially present with MEE.

Tympanostomy tubes for children with acute otitis media.

A 30-month-old patient in our clinic has had 4 episodes of acute otitis media (AOM) in the past 6 months. Should I refer the child and family to an ear, nose, and throat surgeon to consider tympanostomy tube placement, or should we continue medical management with antibiotics? Acute otitis media is common among children in Canada, particularly those younger than 3 years of age. Recurrent AOM (3 or more episodes of AOM in a 6-month period or 4 or more episodes of AOM in a 12-month period) is also common in this age group. Routine immunization of infants and children in Canada with pneumococcal conjugate vaccines (initially the 7-valent PCV7 and more recently the 13-valent PCV13) considerably reduced the overall incidence of AOM. Tympanostomy tube placement decreases the incidence of AOM compared with medical management. However, the procedure is no longer superior to medical management after a 2-year period. Both tympanostomy tube placement and medical management are valid options for children with recurrent AOM, and shared decision making with caregivers is recommended.

Adenoidectomy may decrease the need for a third set of tympanostomy tubes in children

ObjectiveTo determine whether removing or retaining adenoids at the time of placement of a second set of ear tubes impacts the need for a third set of ear tubes later in childhood. Study designSingle-institution retrospective case series. SettingTertiary academic university hospital. MethodsWe identified pediatric subjects who had undergone a second ear tube placement between 1/1/17 and 9/1/19. Subjects were stratified into two groups: 1) adenoids removed at time of second tympanostomy tube insertion (TT+A) and 2) adenoids retained at time of second tympanostomy tube insertion (TT-A). A subset of children less than age 4 was also studied independently. The primary outcome was number of patients requiring a third set of tympanostomy tubes. ResultsA total of 136 subjects met inclusion and exclusion criteria. Among children less than 4 years of age (n = 99), the incidence of requiring a third set of tubes was significantly lower in the TT+A group <4 (12.8%; 6/47) compared to the TT-A group <4 (44.2%; 23/52) (p = 0.0008) with an odds ratio of 0.18 (95%CI 0.067–0.51) and number needed to treat of 3.2. ConclusionPerforming adenoidectomy in children less than 4 years of age at the second tympanostomy procedure was associated with a reduced incidence of requiring a third set of ear tubes.

Executive Summary of Clinical Practice Guideline on Tympanostomy Tubes in Children (Update).

Executive Summary of Clinical Practice Guideline on Tympanostomy Tubes in Children (Update).

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update).

Clinical Practice Guideline: Tympanostomy Tubes in Children (Update).

Plain Language Summary: Tympanostomy (Ear) Tubes in Children.

This plain language summary explains tympanostomy tubes, also known as ear tubes, to patients and families. The summary applies to children aged 6 months to 12 years with tympanostomy tubes or children being considered for tympanostomy tubes. It is based on the "Clinical Practice Guideline: Tympanostomy Tubes in Children (Update)," published in 2022 as a major update to the original guideline from 2013. This plain language summary is written explicitly for consumers, patients, and families as a companion publication to the full guideline, which provides greater detail for health care providers. A primary purpose is to facilitate insight and understanding that foster shared decision making regarding ear tubes. Guidelines and their recommendations may not apply to every child, but they do identify best practices and quality improvement opportunities that can help you and your child benefit most from ear tubes.

Trending Tubes: A Social Media Analysis of Tympanostomy Tubes in Children.

ObjectiveTo investigate the popular social media platforms Instagram and Facebook for public posts related to tympanostomy tubes in children, to discern attitudes and perceptions surrounding tympanostomy tubes, and to evaluate the content of social media posts related to tympanostomy tubes.Study DesignQualitative study.SettingInstagram and Facebook social media platforms.MethodsInstagram and Facebook were searched for public posts from 2018 and 2019 including the search terms “ear tubes,”“ear tube surgery,”“tympanostomy,” and “myringotomy.” Posts were excluded if they were unrelated to pediatric tympanostomy tubes or written in a non-English language. Relevant posts underwent subgroup analysis based on 6 domains: media type, perspective, topic, timeframe, popularity, and overall tone.ResultsOf 1862 public social media posts, the majority (78.2%) were made by the patient’s parents/caregivers and the rest by physicians (6.0%), hospitals (8.2%), and chiropractors (6.1%), with a few posts by the patients themselves (0.4%). The majority (79.3%) of posts portrayed tympanostomy tubes positively. Most negative posts were made by chiropractors (50.8%) and the patient’s parents/caregivers (42.9%). The most common themes of posts were reassurance regarding surgery (74.9%), advertisements (12.5%), apprehension (12.4%), and education (10.3%).ConclusionMost social media posts were made by parents/caregivers in the perioperative period, and there was a low percentage of educational posts. This information could be used by otolaryngologists to optimize their interactions with patients and parents and to potentially increase physician involvement and educational material related to tympanostomy tubes on social media.

Watchful waiting? Portuguese approach to otitis media with effusion

Introduction and objective: Otitis media with effusion (OME) is an important public health problem. Several clinical practice guidelines for diagnosis and treatment of OME are in place, including from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). This study aimed to evaluate the clinical practice of OME diagnosis and treatment among the Otolaryngology medical community working in Portugal. Material and methods: A questionnaire was developed based on AAO-HNS guidelines regarding placement of tympanostomy tubes in children. Each directive was transformed into a question, and further questions were added to improve the characterization of the population and its practices. Results: Answers provided agreed with “recommendations” and “recommendations against” enunciated in the guidelines. The exceptions were recommendations regarding the adoption of measures to prevent water from entering the external ear canal of children with tympanostomy tubes and the use of drugs. Questions asked outside guidelines scope revealed that 96.7% of doctors consider children’s age and 49.1% wait for the end of summer when deciding about surgery for tube placement, 68% recommend bathing in beaches, and 21.9% recommend mineral water treatment. Conclusion: These results suggest that Portuguese otolaryngologists act according to the latest international guidelines and consider factors like season, bathing in beaches, and mineral water treatment in surgical or treatment decisions.

Antibiotics for otitis media with effusion in children.

Otitis media with effusion (OME), one of the most common diseases in early childhood, is a self-limited illness1 with an estimated recurrence rate of 50% within 24 months2 . OME is characterized by an accumulation of fluid in the middle ear without symptoms or signs of acute infection.3 In most cases OME causes mild hearing impairment for a short period. OME in the pediatric population can lead to diminished hearing which in theory could hinder early learning. Some studies have shown an association with adult hearing loss as well.4 In one study, for instance, OME and recurrent otitis media before the age of 3 were weakly associated with worse classroom concentration, mathematical skills, oral performance and reading skills5 .

Repeat tympanostomy tubes in children with Down syndrome

ObjectivesChildren with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS. MethodsA retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI. Results277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15–3.51, p = .014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74–0.95, p = .004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448–1.872, p = .809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99–3.90, p = .054). ConclusionChildren with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population.

Otolaryngologists' Attitudes toward In-Office Pediatric Tympanostomy Tube Placement without General Anesthesia.

Our objectives were to assess attitudes regarding office-based insertion of tympanostomy tubes without general anesthesia, to identify barriers that would discourage in-office procedures, and to highlight opportunities that would potentially facilitate this approach in the future. Cross-sectional survey administered to members of the American Society of Pediatric Otolaryngology (ASPO) from March to April 2020 using the Research Electronic Data Capture (Redcap), internet-based data capture platform. The brief, 10-item survey required 3 minutes to complete and used a 5-point Likert scale for primary questions. Respondents included 172 fellowship trained, pediatric otolaryngologists with 14 median years of clinical practice and 25 median tympanostomy tube insertions per month (75% >40 per month). Although tubes, in any setting, were most often inserted in children under age 2 years (95% "often" or "very often") and in those aged 3 to 5 years (93%), the likelihoods of doing this in-office for these age groups were only 8% and 6% respectively. For children aged 6 to 12 years, likelihood of in-office insertion was only 15%. Frequent barriers noted were safety concerns, emotional trauma, physical pain, and inability to suction. Opportunities to facilitate this approach include improved topical anesthesia, availability of conscious sedation, conclusive research on adverse effects of general anesthesia, and availability of an automated tube insertion device. Office-based insertion of tympanostomy tubes in children without general anesthesia is performed by a small minority of respondents, but there are discernible barriers and opportunities to promote future uptake. Our results should facilitate ongoing discussion and innovation to better accommodate the preferences of families whose children are candidates for tympanostomy tubes.

Formations of Host Fibers and Bacteria in Human Temporal Bones With Otitis Media.

In temporal bones with otitis media, fibrin and neutrophil extracellular traps (NETs) form a fibrous network with bacteria, which is involved in growth of bacterial clusters/biofilms and chronicity of disease. NETs and fibrin are important in host defense against pathogens; however, their role in otitis media is not well understood. Eight human temporal bones with serous otitis media, 30 with serous-purulent otitis media, 7 with mucoid otitis media, 23 with mucoid-purulent otitis media (OM), 30 with purulent OM, and 30 with chronic otitis media were selected based on histopathologic findings. Fibrous material with bacteria was detected with hematoxylin-eosin, Gram-Weigert, and propidium iodide stains; and its composition was analyzed with immunohistochemistry. Extensive formations of fibrous material with bacteria were observed in 30% of temporal bones with serous-purulent otitis media, 29% with mucoid otitis media, 50% with mucoid-purulent OM, 57% with purulent OM, and 67% of temporal bones with histological evidence of chronic otitis media. Some of these formations showed large bacterial clusters or biofilms. Immunohistochemical analysis showed that fibrous structures were composed of fibrin or NETs. Formations of fibrous material with bacteria were detected in human temporal bones with different types of otitis media. Inflammatory cells were observed mostly in areas with low presence of fibrous structures. The network of fibrous material seems to prevent clearance of bacteria by phagocytic cells and thus influences growth of bacterial clusters or biofilms. Fibrin and NETs may be important for the recurrences and chronicity of disease, and contribute to clogging of tympanostomy tubes in children.

In-office insertion tympanostomy tubes in children using single-pass device.

ObjectivesInsertion of tympanostomy tubes (TT) is generally accomplished in children in the operating room under general anesthesia. We report on 229 children treated in‐office with a novel device.MethodsInvestigators participated in an IRB‐approved, prospective, single arm, multisite investigation of in‐office TT placement in awake children. Topical anesthetic was applied, and protective restraint was used. TT placement was performed with a single‐pass TT insertion device. Safety was assessed by monitoring procedural events.ResultsFour hundred and forty‐four ears were treated in 229 children at 10 sites. Children were in age groups 6‐24 months (n = 211, mean = 13 months) and 5‐12 years (n = 18, mean = 8.3 years). Two hundred and fifteen children received bilateral TT placement, and 14 received unilateral placement. Overall, 226/229 (98.7%) children had successful TT placement in the office (209/211 in 6‐24 months and 17/18 in 5‐12 years). Three children were rescheduled for the operating room due to anatomical challenges or patient movement. Median procedure time for bilateral cases in both age groups was 4:53. Two minor adverse events (AEs) were reported in one patient. Per independent assessment of 30 procedure videos by clinicians, TT placement was tolerated acceptably by all children.ConclusionIn‐office TT placement in awake young children using topical anesthetic, enabled by a single pass delivery device, was safe, successful and well tolerated. The American Academy of Otolaryngology (AAO) recently released a Position Statement supporting in‐office TT placement in appropriate children. These results affirm an in‐office alternative for clinicians and parents who have concerns with the risk, inconvenience and cost of surgery in an operating room under general anesthesia.Level of Evidence: 2c.Clinical Trials Registration Number: NCT03544138.

Tympanostomy Tube Controversies and Issues: State-of-the-Art Review.

To review current pragmatic issues and controversies related to tympanostomy tubes in children, in the context of current best research evidence plus expert opinion to provide nuance, address uncertainties, and fill evidence gaps. Each issue or controversy is followed by the relevant current best evidence, expert insight and opinion, and recommendations for action. The role of expert opinion and experience in forming conclusions is inversely related to the quality, consistency, and adequacy of published evidence. Conclusions are combined with opportunities for shared decision-making with caregivers to recommend pragmatic actions for clinicians in everyday settings. The issues and controversies discussed include (1) appropriate tube indications, (2) rationale for not recommending tubes for recurrent acute otitis media without persistent middle ear effusion, (3) role of tubes in at-risk children with otitis media with effusion, (4) role of new, automated tube insertion devices, (5) appropriateness and feasibility of in-office tube insertion in awake children, (6) managing methicillin-resistant Staphylococcus aureus acute tube otorrhea, and (7) managing recurrent or persistent tube otorrhea. Despite a substantial, and constantly growing, volume of high-level evidence on managing children with tympanostomy tubes, there will always be gaps, uncertainties, and controversies that benefit from clinician experience and expert opinion. In that regard, the issues discussed in this review article will hopefully aid clinicians in everyday, pragmatic management decisions.

Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study.

The "Clinical Practice Guideline: Tympanostomy Tubes in Children" published in 2013 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation encourages that an "educational video, or other teaching aid, should be developed to illustrate how parents/caregivers" may manage postoperative complications such as tube otorrhea; however, the current literature is devoid of such patient safety and quality improvement measures. Our objective was to develop an effective educational model to assist parents and caregivers in understanding the signs and symptoms of tympanostomy tube (TT) otorrhea and how to independently institute the appropriate otologic treatment. A 3.5 × 2-inch instructional card was designed to illustrate TT otorrhea and describe the subsequent steps necessary to obtain and institute the appropriate medical therapy. This was distributed to caregivers of all patients undergoing TT placement in September 2016; patients undergoing TT placement in May 2016 served as the preintervention control cohort. Group comparisons were made before and after implementation of the educational model by number of telephone calls our clinic triaged regarding untreated TT otorrhea, as documented within the electronic medical record. A total of 30 sets of TT were placed in September 2016, compared to 27 sets of TT in May 2016. Postoperatively, a run chart revealed a significant shift (ie, 7 consecutive points) in the number of telephone calls received (16-5 calls) after establishment of the proposed educational model. This clinical experience demonstrates the utility of patient-driven management of TT otorrhea through ancillary educational material. Given the superiority of topical otic therapy, continued translation efforts are needed for continued focus on practice implementation and dissemination.

Dornase Alfa Ototoxic Effects in Animals and Efficacy in the Treatment of Clogged Tympanostomy Tubes in Children

Many treatments for clogged tympanostomy tubes (TTs) have been proposed, but none have met scientific rigor for safety and efficacy, including the popular empirical use of ototopical antibiotic drops. Dornase alfa, a recombinant molecule with the unique property of cleaving DNA, may be ideal in treating clogged TTs because both middle-ear effusion and the plug are abundant with DNA. To investigate the ototoxic effects of dornase alfa in a chinchilla model and its efficacy in a clinical trial in children with clogged TTs. The safety profiles of dornase alfa (full-strength and 1:10 strength) were evaluated in chinchilla middle ears using serial auditory brainstem response. The efficacy of ototopical dornase alfa (full-strength) was evaluated in children with clogged TTs in a prospective, single-blind randomized clinical trial. The animal study included 21 chinchillas and was conducted at Loma Linda University, Loma Linda, California, and the clinical trial was conducted at Children's Hospital Colorado, Aurora. A total of 40 children (50 ears with tubes) were enrolled. In the animal study, chinchillas were assigned to 3 groups: controls (saline), full-strength dornase alfa, or 1:10 dornase alfa dilution. Children were randomly assigned to receive either topical dornase alfa or ofloxacin for clogged TT, 5 drops each ear twice a day for 7 days. Animal study: Auditory brainstem responses. Randomized trial of children participants: The primary outcome was patency of TT at day 14 assessed by otoscopy and tympanometry. The chinchilla study showed similar auditory brainstem response degradation during a 6-hour period between the control (n = 5) and treatment groups (n = 21). In the clinical trial, a total of 40 clogged TTs (in 33 children, including 25 boys [76%]; mean age, 4.3 years; median [range] age, 3.4 [1.0-14.3] years) were analyzed. The number of unclogged TTs was higher in the dornase alfa group (13 [59%]) compared with the ofloxacin group (8 [44%]), with a difference of 15% (odds ratio, 1.8; 95% CI, 0.54-6.72). The chinchilla model suggests that dornase alfa is likely nonototoxic. The pilot clinical trial failed to show efficacy of dornase alfa to unclog TTs. With the difference seen between the treatment groups, a sample size estimate could be calculated for a future large-scale trial. ClinicalTrials.gov identifier: NCT00419380.

Multiple surgeries in pediatric otolaryngology patients and associated anesthesia risks

ObjectivesTo determine the risk of healthy children undergoing tympanostomy tubes of an additional surgery prior to age three and associated risk factors. MethodsA retrospective chart review of pediatric patients at a tertiary metropolitan children's hospital who underwent tympanostomy tube insertion procedure before age of three from January 2010 through March 2015. We determined patient demographics, indication for tympanostomy tube insertion, as well as information about additional procedures requiring general anesthesia before the age of three years. A prospective telephone interview was also performed on a portion of the study population to assess if there were additional surgeries before the age of three that did not occur at our institution. ResultsIn our institution there was a 13% risk of getting an additional surgery after tympanostomy tubes in children who are otherwise healthy. The most common second procedure was an otolaryngologic procedure in 77.8% of the cases. Children with a diagnosis of recurrent acute otitis media had a threefold greater chance of getting an additional surgery than those with a diagnosis of chronic otitis media with effusion. Patients that identified as Black or African American were 3.2 times more likely to have additional surgery. With every year increase at age of surgery, the odds of an additional surgery decreased by 77%. ConclusionsIn healthy children undergoing tympanostomy tube insertion at our institution, the incidence of additional procedures under general anesthesia (GA) is low at 13%. Although there is evidence of possible deleterious effects of anesthesia on the developing brain, it is generally accepted that one short (≤1 h) anesthetic exposure under the age of three has not been associated with adverse neurodevelopmental outcomes. As a specialty that regularly performs procedures on young children, we need to be aware of the possible effects of anesthetic agents on our patients. However, this study shows that the exposure risk is low and should help reassure patient's families.