© Borgis - New Medicine 2/2002, s. 71-72
Małgorzata Dębska, Anna Bielicka, Mieczysław Chmielik
Ventilating tube insertion in the treatment of otitis media with effusion in children
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw, Poland
Head: prof. Mieczysław Chmielik, M.D.
The authors present methods of surgical treatment of otitis media with effusion in children. The advantages and complications of ventilating tube insertion are given particullar attention.
A uniform scheme for treatment of otitis media with effusion in children is difficult, and it is not always possible due to the complicated aetiology and differing progression of this disease. The choice of treatment method depends on disease duration, degree of hearing loss, the appearance of the tympanic membrane in otoscopy, and the type and amount of residual secretion in the middle ear.
In laryngological literature there are different methods of treatment of otitis media with effusion, viz:
– medical treatment (anti-inflammatory drugs, antihistamines, anti-exudative drugs, nasal decongestants, mucolytic drugs),
– polterization, tubal insufflation by Valsalva´s method,
– biostimulating laser,
– Eustachian catheterization,
– immunotherapeutic treatment,
– restoration of an upper respiratory tract patency,
– tytmpanopunction or tympanostomy with a suction of residual secretion from the middle ear,
– permanent drainage of the tympanic cavity (ventilating tubes) (2).
In the event of middle ear effusion, the need to remove the inflammatory focus from the nose, nasopharynx, or paranasal sinuses should be considered. Conservative therapy of otitis media with effusion should not last longer than three months. After this period, surgical treatment should be performed. This treatment consists of the restoration of upper respiratory tract patency in patients with adenoids, nasal septum deviation, or nasal polyps. Simultaneously, tympanopunction with suction of any residual secretion from the middle ear may be performed, or may be performed as an independent surgical procedure. When allergic rhinitis coexists with otitis media with effusion, consultation with an allergologist, leading to antiallergic treatment, will be needed.
The most frequent cause of otitis media with effusion is adenoids, and therefore tympanostomy is usually performed alongside surgical procedures leading to restoration of patency of the auditory tube, such as adenoidectomy, adenotonsillotomy and, exceptionally, tonsillectomy.
Tympanostomy should be performed as a consequence of:
– short-lasting conductive hearing loss with a type B tympanometry curve,
– conductive hearing loss below 30-35 dB,
– presence of otoscopic changes characteristic of otitis media with effusion,
– type B tympanometry curve co-existing with sensorineural hearing loss (2).
If, in spite of surgical treatment, otitis media with effusion recurs, the next stage of treatment is the insertion of a ventilating tube. This allows reduction of pressure differences between the middle and exterior ear, and allows a decrease in secretion from the tympanic cavity and the mastoid process cells through the Eustachian tube. Normal ventilation of the middle ear by a ventilating tube allows permanent regression of pathological changes in the middle ear. Ventilating tube insertion should, however not be the first and only method of treatment of otitis media with effusion in children.
Ventilating tube placement is indicated in the following cases:
– conductive hearing loss lasting over 6 months,
– tympanic membrane atrophy, retraction pouches, or adhesions,
– thick mucous secretion in the middle ear,
– recurrent acute otitis media,
– facial skeletal abnormalities causing nasal obstruction and Eustachian tube dysfunction (2).
Methods of treatment should be adjusted to the individual in all cases. If the doctor decides, that, in a small patient, there are indications for surgical treatment at the onset of secretion and while this is still fluid adenoidectomy or adenotonsillotomy should be performed (6, 10, 16). In the case of the secretion in the middle ear being thick and observed for a longer period, an adenoidectomy should be performed together with tympanopunction and aspiration of secretions from the middle ear. After aspiration, the tympanic cavity is irrigated with physiological saline, and steroids are applied topically.
In laryngological literature are good descriptions of the results of treatment of otitis media with effusion (closure of cochlear reserve below 20 dB) after adenoidectomy or adenotonsillotomy, without tympanopunction//tympanostomy. This treatment has given satisfactory results in between 50 and 90% of patients (3, 4, 6, 10, 16). Similar results have been achieved by performing either adenoidectomy or adenotonsillotomy with tympanopunction/tympanostomy (good results in 75-85% of patients) (4) and by ventilating tube insertion only (80-87%) (1, 4, 11, 12, 14). There have been no reports concerning any essential differences between ventilating tube placement and adenoidectomy (adenotonsillotomy) or/and tympanostomy, taking into consideration results of treatment, in a two-year period of observation (1, 6, 8, 10, 16). However, in children who were treated with a ventilating tube only in a period of observation lasting 2-3 years or longer, an exudation in the middle ear recurs in 10-15% cases; described changes are more frequent (deposits, scar formation, perforations, retraction pouches) in otoscopic examination, than in children after adenoidectomy (adenotonsillotomy) (4).
In cases when symptoms of otitis media with effusion recur, nasal and nasopharyngeal patency should be examined again, and, if a nasal or nasopharyngeal obstruction is recognised, nasal patency should be restore by surgical or conservative treatment. Simultaneously, a ventilating tube insertion should be performed (12). Ventilating tubes remain in the tympanic membrane for several days to over one year (14, 17). This depends mainly on the tympanic membrane´s condition at insertion, and on the type of ventilating tube. Thin, atrophic tympanic membranes with many retractions rapidly reject tubes. Ventilating tubes remain longer in thickened tympanic membranes. Tubes with a collar, or the T type of ventilating tube may hold in the membrane for as much as two years (15). They are indicated in children with permanent Eustachian tube dysfunction. A ventilating tube need not usually be removed before spontaneous elimination. In cases of purulent secretion from the middle ear and the presence of ventilating tube the treatment is routine (antibacterial treatment).
Ventilating tube insertion may cause the generation of cicatricial changes (8, 9), tympanic membrane atrophy (5, 9, 13), retraction pouches (9, 13), calcification of the tympanic membrane, hyaline deposits (9) and tympanic membrane retraction (8, 9, 13). These conditions are favourable for bacterial infection of the middle ear with otorrhoea (in 5% of cases) (7), cholesteatoma generation (0-5%) (5, 13, 17), tympanosclerosis (5, 13), permanent tympanic membrane perforation (1-4%) (4, 7, 9, 11, 17), or granulation tissue generation (11). Changes visible under otoscopic examination are more frequent after long-standing drainage. It is difficult to determine the degree of dependence of the above-mentioned complications on ventilating tube presence, and on the primary cause of otitis media with effusion. We should remember that ventilating tubes are not inserted in healthy ears (17).
In spite of the complications, a ventilating tube is recommended in patients with permanent Eustachian tube dysfunction, for example with palatoschisis and in some patients with secretory otitis media recurrences (8). In the literature are reports on laser tympanostomy. This procedure allows the making of a foramen in the tympanic membrane, which heals without cicatrization and becomes obliterated after 2-3 weeks. It is enough in many cases to achieve a complete cure of the middle ear (5).
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