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Maria Wolniewicz, *Lidia Zawadzka-Głos
Indications for tympanostomy tube insertion in children
Wskazania do drenażu wentylacyjnego u dzieci
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Drenaż wentylacyjny jest jednym z podstawowych zabiegów z zakresu laryngologii dziecięcej. Podstawowe wskazanie do planowej kwalifikacji do zabiegu stanowi wysiękowe zapalenie ucha środkowego (OME). Nie ma aktualnie zaleceń, które propagowałyby farmakologiczne metody leczenia wysięku. W przypadkach nawracających zapaleń ucha środkowego czy ostrych powikłaniach zapalenia ucha środkowego często jest to procedura wykonywana z wyboru jako uzupełnienie antybiotykoterapii ogólnoustrojowej.
Cel pracy. Celem głównym pracy była analiza wskazań do zabiegu drenażu wentylacyjnego, natomiast cele wtórne stanowiły charakterystyka badanej populacji oraz ocena kondycji błony bębenkowej w momencie wykonywania zabiegu.
Materiał i metody. Przeanalizowano retrospektywnie procedury drenażu wentylacyjnego przeprowadzone w Klinice Otolaryngologii Dziecięcej WUM od 1 stycznia do 31 grudnia 2018 roku.
Wyniki. W 2018 roku w Klinice Otolaryngologii Dziecięcej WUM zabiegowi drenażu wentylacyjnego zostało poddanych 213 dzieci (wiek od 2. miesiąca życia do 18 lat) i założono 368 drenów, głównie z powodu wysiękowego zapalenia ucha środkowego. Zabiegi planowe stanowiły 69,48%. Na drugim miejscu znalazły się nawracające stany zapalne ucha środkowego (22,07%) oraz powikłania ostrego zapalenia ucha środkowego, przede wszystkich ostre zapalenie wyrostka sutkowatego (23,33% zabiegów w trybie pilnym). W przeważającej większości umieszczano w błonie bębenkowe dreny typu Mikołów, w pojedynczych przypadkach dreny długoterminowe (14 drenów typu T, 7 drenów typu Paparella). Dominujący charakter wysięków stanowił wysięk śluzowy (62,44%). W ponad połowie przypadków (62,44%) przeprowadzono drenaż jako samodzielną procedurę, natomiast prawie 1/3 zabiegów była wykonana wraz z adenotomią. U 28 pacjentów (13,14%) w momencie zabiegu stwierdzono mikroskopowo zmiany w obrębie błony bębenkowej świadczące o zaawansowaniu przewlekłego stanu zapalnego.
Wnioski. Zabieg drenażu, choć powszechnie akceptowalny, nie jest procedurą pozbawioną negatywnych konsekwencji. Możliwe powikłania obejmują: przetrwałą perforację błony bębenkowej, tympanosklerozę, przedwczesne wypadnięcie drenu wentylacyjnego, wyciek z ucha, zaburzenia drożności drenu, czasami konieczność operacyjnego usunięcia drenu. Zatem wykonanie zabiegu wymusza stałą i regularną opiekę laryngologiczną.
Summary
Introduction. Tympanostomy tube insertion is one of the basic paediatric otolaryngological procedures.
Otitis media with effusion (OME) is the primary indication for elective qualification for this procedure. Currently, there are no recommendations suggesting pharmacotherapy for effusion. In cases of recurrent otitis media or acute complications of otitis media, tube insertion is a method of choice to support systemic antibiotic therapy.
Aim. The main aim of this study was to evaluate indications for tympanostomy tube insertion. Secondary aims included characteristics of the study population and an intraoperative assessment of the tympanic membrane.
Material and methods. We conducted a retrospective analysis of ear tube placement procedures performed in the Department of Paediatric Otorhinolaryngology of the Medical University of Warsaw between January 1, 2018 and December 31, 2018.
Results. A total of 213 children (aged between 2 months and 18 years) underwent tympanostomy tube insertion and a total of 368 tubes were placed due to otitis media with effusion in 2018 in the Department of Paediatric Otorhinolaryngology of the Medical University of Warsaw. Elective tube insertion accounted for 69.48% of procedures. Recurrent otitis media (22.07%), complications of acute otitis media and, most of all, acute mastoiditis (23.33% of urgent procedures) came second. In a large majority of cases, Mikolow tympanostomy tubes were placed; in isolated cases, long-term tympanostomy tubes were used (14 T-tubes, 7 Paparella tubes). Mucous effusion dominated (62.44%). Ear tube placement alone was performed in more than half of cases (62.44%), while in 1/3 of patients the procedure was combined with adenoidectomy. Microscopically confirmed tympanic lesions indicative of advanced inflammation were found in 28 patients (13.14%).
Conclusions. Although commonly accepted, tympanostomy tube insertion is not devoid of negative consequences. Possible complications include persistent tympanic perforation, tympanosclerosis, premature extrusion of an ear tube, ear discharge, tube obstruction and, in some cases, the need for surgical tube removal. Therefore, the procedure requires permanent and systematic otolaryngological care.
Introduction
Tympanostomy tube insertion (grommets) is one of the basic otolaryngological procedures performed in children (1). Otitis media with effusion (OME), which is defined as fluid retention behind the eardrum for at least 3 months, accompanied by 25-30 dB hearing loss, is the primary indication for elective tube insertion (2, 3). A more individual approach is needed in children with Down syndrome or craniofacial defects, including cleft palate, due to an increased predisposition to fluid secretion and its long-term persistence (2, 3).
OME is diagnosed annually in about 2.2 million children in the USA (2). It affects about 50-90% of children < 5 years of age (2), and 667 000 children below 15 years of age undergo ear tube insertion (1).
Fluid retention behind the eardrum is due to Eustachian tube dysfunction and occurs in upper respiratory tract infections or as an inflammatory response to previous inflammation, representing a residual phase of acute otitis media. However, fluid retention should last no longer than 3 months, which is considered a persistent condition, and which may consequently lead to permanent remodelling of the tympanic membrane and cavity. Such a conductive hearing loss (0-50 dB, 28 dB on average) is believed to affect child’s development, causing ear discomfort, sleeping disorders, worse speech development, poor learning results compared to healthy peers, or behavioural problems, such as problems with balance (2). This is currently the most common cause of hearing loss in developed countries (2).
Both US and UK guidelines recommend careful observation and, optionally, surgical intervention instead of pharmacologic management of effusion (steroids, antibiotics, antihistamines, mucosal decongestants, antireflux therapy) (2, 3). As outlined in the US guidelines, adenoidectomy with or without grommets is recommended for children aged > 4 years, while tympanostomy tube insertion is recommended in younger children unless there is clinical evidence of adenoid hypertrophy. British guidelines recommend concurrent adenoidectomy in children with persistent and/or frequent upper respiratory tract infections (URTIs) (3).
Recurrent acute otitis media (rAOM), usually defined as 4 inflammatory episodes within 12 months or 3 episodes within 6 months, is another indication for grommets (4). It may be performed in an elective mode, during subsequent recurrent AOT and indicated myringotomy, or as the final stage of treatment for recurrent otitis media.
Tympanostomy tube insertion in rAOM is a more debatable issue. The therapeutic effect is less clear and, according to multiple analyses, including the Cochrane database, further research to assess its efficacy is needed (5).
Urgent procedures due to complications of acute suppurative otitis media are the third group of indications.
Although commonly accepted, tympanostomy tube insertion is not devoid of negative consequences. Possible complications include persistent tympanic perforation, tympanosclerosis, premature extrusion of an ear tube, ear discharge, tube obstruction and, in some cases, the need for surgical tube removal.
Aim
The main aim of this study was to evaluate indications for tympanostomy tube insertion. The characteristics of study population and an intraoperative assessment of the tympanic membrane were secondary aims.
Material and methods
We performed a retrospective analysis of ear tube placement procedures performed in the Department of Paediatric Otorhinolaryngology of the Medical University of Warsaw between January 1, 2018 and December 31, 2018, using the CGM Clininet system. Data on indications for the procedure, mode of procedure (elective vs. urgent), otolaryngological history, and the course of procedure, including the state of the tympanic membrane, and the presence/properties of fluid behind the membrane, were analysed. Microsoft Excel was used for data collection and analysis.
Results
A total of 213 children aged between 2 months and 18 years (mean age about 4.5 years, SD about 2.8 months) and median age 4 years and 1.5 months underwent tympanostomy tube insertion in 2018 in the Department of Paediatric Otorhinolaryngology of the Medical University of Warsaw. Boys accounted for 63.38%. A total of 368 tubes were inserted in the eardrum, including 177 in the right and 191 in the left ear. Otitis media with effusion (fig. 1), accounting for 59.15%, alone or in combination with rOM (7.98%), was the primary indication for the procedure. Recurrent AOM came second (22.07%).
Fig. 1. Indications for tympanostomy tube insertion
There were 69.48% of elective procedures, 28.17% urgent and 2.35% accelerated urgent procedures as the final stage of treatment of recurrent inflammation (fig. 2).
Fig. 2. Mode of procedure
Indications were dominated by otitis media and its complications, usually in the form of acute mastoiditis (23.33%): bilateral in 1 patient, concomitant with nerve VII paresis in 1 case and concomitant with thrombosis of the sigmoid sinus in 1 patient. Other complications included isolated labyrinthitis (6.67%), including 1 bilateral; and peripheral nerve VII paresis (5.00%). In one case, grommet insertion was performed due to sudden hearing loss and identification of mucous effusion behind the eardrum, which was successfully treated with an additional use of hyperbaric oxygen therapy and vitamin supplementation.
The vast majority of tubes used in our center are Mikolow tympanostomy tubes (94.32%). We also used long-term ear tubes: 14 T-tubes and 7 Paparella tubes. They were placed in children with a history of several otolaryngological interventions (AT and/or tympanocentesis and/or grommet(s) (50.00%; 30% for repeated tube insertion) or with submucous cleft palate (30.00%).
Tympanic tube insertion was performed as an independent intervention in more than half of cases (62.44%). Adenoidectomy, optionally with tonsillotomy, was the most common additional procedure (repeated procedure in 2.35%), accounting for 32.39%. In some acute cases, concurrent antromastoidectomy was performed ? about 5.16% of complex procedures. Eleven patients received an indication for adenoidectomy within a follow up of 5 months to 1 year and 5 months.
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Piśmiennictwo
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3. Surgical management of otitis media with effusion in children. NICE Feb 2008.
4. Granath A: Recurrent Acute Otitis Media: What Are the Options for Treatment and Prevention? Curr Otorhinolaryngol Rep 2017; 5: 93-100.
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7. Gisselsson-Solen M (on behalf of the Reference group for the National Quality Register for Tympanic Membrane Ventilation Tubes): The Swedish grommet register ? Hearing results and adherence to guidelines. Int J Pediatr Otorhinolaryngol 2018; 110: 105-109.
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