Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Tympanostomy Tubes Otitis media is the most common diagnosis in children, affecting two thirds of all children by the age of two years. Recurrent otitis media or otitis media with effusion may be treated with tympanostomy tubes, and approximately 700,000 children undergo this procedure each year. In an article that appeared in JAMA, Kleinman and colleagues studied the medical appropriateness of tympanostomy tube insertion in children under the age of 16. After developing clinical indicators, they retrospectively reviewed a large group of patients. They felt that preoperative indicators for tympanostomy insertion were inappropriate for 25% and equivocal for 33% of the patients reviewed. Despite several biases in the study, this paper received a lot of national attention, increasing parental concern about tympanostomy tubes. In addition, the increase in cost concerns related to health care reform has lead to increased scrutiny as well. Tympanostomy tubes are indicated for chronic otitis media with effusion, recurrent acute otitis media, tympanic membrane atelectasis, and complications of acute otitis media in children. A recent health care panel convened by the US government recommended tympanostomy tubes as a treatment option for otitis media with effusion that persists for three months with associated hearing loss. If the effusion persists four to six months despite other treatments, then tympanostomy tubes should be inserted at that time. Recurrent acute otitis media (5-6 episodes/year) with persistent middle ear effusion is best treated with tympanostomy tubes. Children with recurrent otitis media without persistent effusion may be treated with antibiotic prophylaxis or tympanostomy tubes. Children who fail antibiotic prophylaxis are candidates for tympanostomy tubes. No guidelines exist for preoperative audiologic testing in normal children undergoing tympanostomy tube insertion. Preoperative testing may identify undetected hearing loss and document hearing for medicolegal reasons. Manning et al reviewed the audiologic results of 600 children undergoing preoperative audiologic testing prior to tympanostomy tube insertion at Children's Medical Center in Dallas, Texas. They identified 6 patients (1%) with previously undetected sensorineural hearing loss. Each patient in this group had risk factors for hearing loss. Also, because the study was done in a tertiary children's hospital, the rate of hearing loss was higher than in the community. Despite these factors, they still recommended screening of all patients. A vast array of tympanostomy tubes have been designed. Tympanostomy tubes have been made out of Teflon, silicone, polyethylene, stainless steel, titanium, and even gold plated steel. Karlan et al performed a laboratory and clinical study comparing silicone and Teflon tubes and found the Teflon to be superior. Metal compounds such as stainless steel, titanium, and gold have been considered good compounds for tympanostomy tube construction. Several studies have failed to show a significant advantage over synthetic tubes. The shape and design of the tympanostomy tube is more important in determining its function. Large inner flanges increase the duration of middle ear ventilation. Tympanostomy tubes with a large inner diameter and short length are less likely to occlude but may allow easier passage of water. These characteristics must be considered during the selection of tympanostomy tubes. Tympanostomy tubes may be arbitrarily divided based on the duration of ventilation. Short term tubes are shaped like grommets or bobbins and have and the average duration of intubation is about 10 months. The tubes are easy to insert, have a low rate of obstruction, and low rate of permanent perforation. Long term ventilation tubes are typically T-shaped and have the opposite characteristics. The average duration of ventilation is around 30 months. Both groups of tubes have been modified to provide intermediate characteristics. Other operative factors may be important in tympanostomy tube insertion. In the past, several authors have felt that ear canal preparation was important prior to tympanostomy tube insertion. But Baldwin and Aland found no advantage with iodine preparation of the external canal prior to tympansotomy tube insertion. Myringotomy direction and location have been thought to influence the duration of middle ear ventilation and subsequent healing of the tympanic membrane. Although some authors have reported that intubation is longer when the tube is inserted in the anterior superior quadrant, a study by April et al found no difference between the anterior superior and anterior inferior quadrants. Likewise, myringotomy direction had no effect in a study by Guttenplan et al. Tympanostomy tubes may be inserted under local or general anesthesia. Some otolaryngologists have reported successful tympanostomy tube insertion using iontophoresis for local anesthesia in cooperative children over the age of six. Summerfield and White described insertion of tympanostomy tubes in 103 patients with an age range of 3-12 years using EMLA cream for local anesthesia. EMLA is a mixture of lignocaine and prilocaine in a high concentration that is absorbed across the epidermis providing local anesthesia. They were successful in 93.2% of the patients, with all failures occurring in children less than four years. Many children undergo the tympanostomy tube insertion under general anesthesia. Markowitz-Spence et al reviewed the anesthetic complications in a series of 510 children undergoing general anesthesia for tympanostomy tubes at the Children's Hospital of Buffalo. No complications were reported in 423 (82.3%). Minor complications without long-term sequelae occurred in the other patients. Postoperative topical antibiotic prophylaxis after tympanostomy tubes remains controversial. Many otolaryngologists use otic drops to prevent blockage of the tube by blood or discharge and to prevent postoperative otorrhea, despite the theoretical risk of ototoxicity. Garcia et al performed a meta analysis of the five previous studies on the use of antibiotic drops and found a reduction in otorrhea by 85 %. They recommend continued use of topical antimicrobial prophylaxis in high risk cases with mucoid or purulent effusions. For routine cases without effusion and normal middle ear mucosa, they do not advocate routine use. Water may pass through a tympanostomy tube and cause a middle ear infection. Consequently, most otolaryngologists instruct parents to take precautions to avoid water exposure. This usually includes the use of ear plugs during bathing or water sports, while others forbid water sports. Paradoxically, children with ear tubes who swim do not have an increased rate of otorrhea, as shown in nine different studies. For middle ear contamination to occur through a tympanostomy tube, water must reach the tympanic membrane and then cross the tympanostomy tube into the middle ear. Middle ear contamination with bath water is much more irritating than other solutions. Studies suggest that middle ear contamination without immersion underware occurs rarely. Occasionally, a tympanostomy tube will persistent beyond the desired period of middle ear ventilation. The otolaryngologist must then decide at what time to remove the tube. Based on an increased rate of complications in tubes that persist for three years or longer, most tubes are removed at 2-3 years. No other tests or criteria exist to determine when they should be removed. Tympanostomy tubes may have significant complications. Meclelland reviewed his series of 307 patients under the age of 10 years who had been treated with tympanostomy tubes and followed for a minimum of 1 year. The most common complication was otorrhea in 34.5% of patients. This include postoperative and delayed otorrhea with chronic otorrhea occurring in 5.5% of patients. Tympanic membrane perforation occurred in 6.2% of patients, but only 2.8% had chronic perforation that required surgical closure. Persistent tympanostomy tube and cholesteatoma occurred in 0.2 % of patients. Several other studies have been done on the overall rate of complications, showing similar rates. Long term complications following myringotomy and tubes was reported by Ben-Ami et al for Afula, Israel. They retrospectively reviewed and examined 64 patients 10 years after having myringotomy and tubes. In their review, 77.9% of patients were treated with one procedure, and the remainder required multiple procedures. Two patients had perforations on follow-up. Myringosclerosis was found in 42.3% of tympanic membranes with only 17.8% of the patients having myringosclerosis in the area of the previous tympanostomy tube. Only two patients (1.9%) developed long term otorrhea. Otorrhea, the most common complication, occurs in around 20% of all patients with tympanostomy tubes. Postoperative otorrhea is most likely related to the presence of purulent fluid or inflamed middle ear mucosa. Delayed otorrhea occurs due to another episode of acute otitis media, which may result from either external contamination through the tube or from nasopharyngeal reflux. Management of post tympanostomy otorrhea usually begins with ototopical agents and antibiotics. If this fails to clear the infection, then a culture is taken to identify any resistant organisms and guide further therapy. Sometimes if all therapy fails, removal of the tympanostomy tube is required. Chronic tympanic membrane perforation remains problematic with tympanostomy tubes. The rate of perforation varies widely in reported series and is heavily influenced by tympanostomy tube type and duration of intubation. In a number of studies, the rate of chronic perforation with short term grommet type tube is less than 5%, while with long term tympanostomy tubes the rate of perforation is around 15-20%. The longer the period of intubation, the greater the risk of persistent perforation. This factor should be considered during selection of tympanostomy tubes. Tympanosclerosis, or more accurately myringosclerosis, occurs in around 40-50% of children with tympanostomy tubes. The incidence of tympanosclerosis in chronic otitis media not treated with tympanostomy tubes is around 10%. The etiology of the tympanosclerosis is unclear and is related to both the disease process and the tympanostomy tube. In several studies the myringosclerosis does not cause an appreciable difference in hearing. The development of cholesteatoma with tympanostomy tubes is a relatively rare occurrence, reported in less than 1% in most series. Cholesteatoma may result from squamous debris being trapped in the middle ear around the tympanostomy tube. In some series, patients developed cholesteatoma in the attic area away from the tube site. In conclusion, tympanostomy tubes are an important tool in the treatment of chronic otitis media in children. Successful management requires the use of appropriate indications and the proper selection of tube type. Case Presentation A 10-month-old female infant was referred to the Otolaryngology Clinic for recurrent otitis media for which she had been treated six times with antibiotics. Each episode responded to antibiotics, but she would develop another episode shortly after completion of antibiotic therapy. She was not routinely exposed to cigarette smoke, and was not in day care. The remainder of her history was normal. Her physical examination was remarkable for bilateral middle ear effusions. After discussing treatment options with the family, they elected to proceed with insertion of tympanostomy tubes. Preoperative audiologic evaluation was normal. She underwent bilateral myringotomies with tympanostomy tube insertion under general anesthesia. 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Weigel MT, Parker MY, Goldsmith MM, Postma DS, Pillsbury HC. A prospective randomized study of four commonly used tympanostomy tubes. Laryngoscope 1989;99:252-256. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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