Vertiginous Episodes in Menière Disease following Transmyringeal Ventilation Tube Insertion: A Systematic Review on the Current State of Evidence

Abstract Introduction Menière disease (MD) is a disorder characterized by episodes of vertigo, sensorineural hearing loss, tinnitus and aural fullness. Objectives To assess the effect of ventilation tube insertion (VTI) on vertiginous episodes in patients (≥ 18 years old) with MD. Data Synthesis A systematic literature search on randomized clinical trials (RCTs), nonrandomized trials and other systematic reviews was performed. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to assess the overall certainty of evidence. Two RCTs and four nonrandomized studies were identified. Data extraction was only possible for one RCT. Results showed that the number of patients with no vertigo attacks significantly increased following active treatment (relative risk 1.52; [95% confidence interval: 1.19-1.94]). The quality of evidence was rated as low. None of the nonrandomized trials included a proper control group, which hindered data extraction and quality assessment. Conclusion There are currently no RCTs that specifically assess the efficacy of VTI in patients with MD. Current limited data suggest a considerable positive effect on the number of vertiginous episodes in patients with MD. However, due to poor evidence, a fluctuating course and a substantial placebo-effect associated with MD-treatment, no solid conclusion(s) regarding the efficacy of VTI can be made. There is a need for high-quality RCTs.

One-stage tympanic cavity ventilation tube placement in canal wall down tympanomastoidectomy / 临床耳鼻咽喉头颈外科杂志

Objective:To research the clinical application of tympanic cavity ventilation tube placement in canal wall down tympanomastoidectomy. Method:There were 52 patients with otitis media received canal wall down tympanomastoidectomy. We placed ventilation tube in posterior hypotympanum during the surgery. After surgery, all patients were followed up in 12 days, 1 month, 2 months, 6 months, and 1 year. The ventilation tubes were withdrew 6 months later, and then the hearing level and tympanic cavity status was evaluated after another half year. Result:All cases were followed up at least 1 year after surgery. Forty-four patients' tubes were removed 6 months later, but other 8 tubes had been extruded within 1 to 3 months. After 1 year, all 52 cases of ears were dry; 39 patients' tympanic membranes were stable, the postoperative complications included tympanic membrane retraction in 7 cases, middle ear effusion in 4 cases, and tympanic membrane perforation at anterior-inferior quadrant in 2 cases; CT examination indicated that 39 patients' aeration between tympanic cavity and Eustachian tube bony portion was normal, 9 patients' tympanic cavity aeration was smaller, and 4 patients' cavity was obstructed; 52 patients' average air conduction thresholds were 12.5 dB lower than that of preoperation. Conclusion:One-stage tympanic cavity ventilation tube placement is a simple, safe and effective method in canal wall down tympanomastoidectomy for middle ear diseases with Eustachian tube severe stenosis or obstruction in bony portion.

Systematic Review of Management of Otitis Media with Effusion in Children.

Aim: Otitis media with effusion in children can result in impairment of speech and language development secondary to the effects of conductive hearing loss from the disease. The review was conducted as part of a clinical practice guideline to assist healthcare providers in the management of this condition. Study Design: Systematic review. Place and Duration of Study: Development Group on Otitis Media with Effusion in Children Clinical Practice Guidelines, Medical Development Division, Ministry of Health Malaysia, between 17 August 2010 and 21 February 2012 Methodology: Literature search was carried out on multiple electronic databases. In addition, the reference lists of all retrieved articles were searched to identify relevant studies. Experts in the field were also contacted to identify further studies. All searches were officially conducted between 17 August 2010 and 21 February 2012. All literature retrieved was appraised using Critical Appraisal Skills Programme (Oxford) by at least two members and presented in the form of evidence tables and discussed during development group meetings. The articles used in this review were graded using the US/Canadian Preventive Services Task Force Level of Evidence [7]. Results: A total of 356 relevant titles were identified and 147 abstracts were screened Thirty one articles were used in the results. There was good evidence for non surgical intervention as the initial mode of management. It consists of active observation and medical therapy. Short term (less than six weeks) intranasal steroid can be used for otitis media with effusion (OME) with concurrent allergic rhinitis and adenoid hypertrophy (p<0.001). There was good evidence that oral steroids, prolonged intranasal steroids, antibiotics, antihistamines or decongestants, auto inflation, homeopathy and mucolytics are not beneficial. Surgical intervention should be considered after three months of persistent otitis media with effusion with in children with hearing loss >25 dB (at three frequency average). Myringotomy with ventilation tube (VT) insertion is the procedure of choice. Combined adenoidectomy should be considered in children with persistent OME and hypertrophied adenoids (p<0.001). Conclusion: The initial management of OME in children consists of active observation. Short term (up to 6 weeks) use of intranasal steroids can be used in children with concurrent adenoid hypertrophy or allergic rhinitis. Surgical management is considered after three months of persistent OME. Myringotomy with VT insertion is the procedure of choice.

Factors Affecting Tympanic Membrane Perforation in Refractory Secretory Otitis Media after the Extubation of Ventilation Tube / 听力学及言语疾病杂志

Objective To explore the treatment using two different ventilation tubes insertion for secretory o-titis media ,and to determine which factors are associated with the tympanic membrane perforation after a extrusion or surgical removal of a ventilation tube(VT) .Methods A retrospective analysis of 121 cases (210 ears) with re-fractory secretory otitis media from 1998 June to 2013 March was carried out .There were 58 cases (105 ears ) and 63 cases (105 ears) in patients and control group ,respectively .All subjects had more than 2 years of history ,and were treated by two types of ventilation tube (Goode -T and Shepard tube) .Various factors were analyzed to deter-mine the factors associated with persistence of a tympanic membrane perforation after VT extrusion or removal ,in-cluding gender ,age ,medical history ,ventilation tube pattern ,location ,history of previous VT insertions ,intuba-tion period reason for VT insertion ,condition of the TM ,nature of the tympanic cavity effusion and previous ade-noidectomy ,et .Results Analysis factors of perforation group (105 ears) and the control group (without perfora-tion ,105 ears) ,were statistically significant in ventilation tube pattern (χ2 =6 .916 ,P<0 .01) ,history of previous VT insertions(χ2 =7 .325 ,P<0 .01) ,frequency of previous VT insertions (χ2 =13 .01 ,P<0 .01)and the nature of the tympanic cavity effusion(χ2 =7 .04 ,P<0 .01) .The proportion of perforation group about Goode - T ventilation tube ,history of previous VT insertions ,the frequency of tube (more than 3 times) ,mucus of the middle ear cavity were 58 .4% ,57 .3% ,66 .7% and 57 .9% respectively ,others had no significant difference between the two groups . The multivariate analysis showed that ,regardless of the ventilation tube ,the frequency of tube was the tympanic membrane perforation risk factor ;Goode-T tube increased the risk of perforation of tympanic membrane was 1 .637 times than Shepard tube(OR=1 .637 ,P<0 .01) .Conclusion Using the Goode - T type ventilation tube ,history of previous VT insertions ,the frequency of tube (more than 3 times) ,mucus of the middle ear cavity were four risk factors for persistence of a tympanic membrane perforation after VT insertion for secretory otitis media .

Factors Affecting the Extrusion Rate of Ventilation Tubes

OBJECTIVES: The objective of this study was to determine the various factors that affect the extrusion rate of ventilation tubes (VTs), including the nature of the middle ear effusion. METHODS: A retrospective chart review of 82 pediatric patients (177 ears) who received VT insertion surgery under general anesthesia was carried out to evaluate the relationship between various factors and the VT extrusion rate. The factors we analyzed included age, gender, the adenoid size, the amount and content of the middle ear effusion after myringotomy, bleeding events, associated adenoidectomy and the findings of the tympanic membrane status, the tympanometry and the audiometry of the air bone gap. RESULTS: The mean extrusion time was 254 days (range, 11 to 809 days). The patients with no history of previous VT insertion had a longer extrusion time (mean, 279 days) than did the patients who had undergone previous VT insertion (mean, 203 days). The patients with serous effusion had the shortest extrusion time (mean, 190 days) as compared to those patients with glue (273 days) and pus (295 days) effusions. Other factors had no statistical significant relationship with the extrusion time. CONCLUSION: The mean VT extrusion time was 254 days. The VT extrusion time was significantly related to the characteristics of the middle ear effusion and a history of previous VT insertion. Thus, the nature of middle ear effusion can provide a clinical clue to predict the VT extrusion time.

Retaining time of tympanic ventilation tube and aural complications / 临床耳鼻咽喉头颈外科杂志

Objective:To study the relationship of retaining time of tympanic ventilation tube and aural complications. Method:Three-hundred-five patients(659 ears)with otitis media with effusion(OME)received tympanostomy tube insertion. The tube were removed 6-36 months after tube insertion. Then aural complications were recorded in different tube retaining time, followed with a statistic analysis. Result: Fifty-five tubes of 29 patients were removed at 1-6 months after tube insertion, with spontaneous extrusion 3.4%, blocked tube 10. 3%, intrusion into the middle ear O, granulation 'tissue O, cholesteatoma O, otorrhea 6.9%, perforation O. One hundred and ninty tubes of 96 patients were removed at 6-12 months after tube insertion,with spontaneous extrusion 7. 3%,blocked tube 15.6%, intrusion into the middle ear 1%, granulation tissue O, cholesteatoma O, otorrhea 5.2%,perforation O. Three huandred and eight tubes of 156 patients were removed at 12-24 months after tube insertion, with spontaneous extrusion 9%,blocked tube 12.8% ,intrusion into the middle ear 1.3%,granulation tissue 1.9% ,cholesteatoma 0.6%,otorrhea 2.5%,perforation was O. One hundred and sixty one tubes of 83 patients were removed at 24-36 months after tube insertion, with spontaneous extrusion 36.1%, blocked tube 53%, intrusion into the middle ear 6%, granulation tissue 3. 6%, cholesteatoma 2.4%, otorrhea 2.4%, perforation 2.4%. Conclusion:The occurrence of complication didn't increase with time going by when the ventilation tube retained less than two years. However, when the ventilation tube retained more than two years, the occurrence of spontaneous extrusion and blocked tube increased obviously.

Clinical Analysis of Outpatient Anesthesia in Children with Middle Ear Ventilation Tube Insertion / 대한마취과학회지

BACKGROUND: Pediatric outpatient anesthesia is beneficial because it is more comfortable to children and more convenient for families, but delayed discharge causes distress for parents and children and increases health care personnel workload. Therefore, we examined past medical records to evaluate factors affecting discharge time in pediatric outpatient anesthesia. METHODS: We reviewed the anesthetic and post-anesthetic care records of 119 children who required ventilation tube insertion for ambulatory surgery, and who were anesthetized and monitored by an anesthesiologist between June 2001 and February 2004. Data were classified according to the anesthetic technique and agents used, duration of operation and anesthesia, and complications in the recovery room. We then examined the relationships between these factors and discharge time. RESULTS: Compared to intravenous anesthesia, endotracheal anesthesia increased anesthesia time (P <0.05), but not discharge time. Ketamine dosage was found to be closely correlated with discharge time (P <0.01), and complications in the recovery room delayed discharge time (P <0.05). CONCLUSION: We conclude that excessive ketamine use and postoperative complications delay discharge in pediatric outpatient anesthesia. More attention should be paid to minimize ketamine use and reduce postoperative complications so as not to delay discharge in pediatric outpatient anesthesia.

Effect of Ventilation Tube Insertion on the Quality of Life / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Traditionally, the treatment results after ventilation tube insertion (VTI) in otitis media with effusion (OME) have been reported using the objective measures such as the changes in hearing levels, the recurrence rate of OME and the occurrence rate of tympanic membrane sequelae. This present study was to determine the effect of VTI on the quality of life (QOL) in patients of OME after the surgery. MATERIALS AND METHOD: Sixty-nine children with OME were included. For the measurement of QOL, the study was performed using questionnaires including six items such as physical suffering, hearing loss, speech impairment, emotional distress, activity limitations and care-provider concerns. We questioned the parents of the patiens on these items pre-operatively and at least one month after VTI. Test-retest reliability was determined by reviewing the results of the repeated questionnaires within 7 days in the subgroup of patients with stabilized status. The effect of VTI was determined by the standardized response mean (SRM), which is defined as the mean change score divided by standard deviation. SRM of less than 0.5 was defined as small effectiveness: greater than 0.5 but less than 0.8 as moderate effectiveness; greater than 0.8 as large effectiveness. RESULTS: Individual items of the questionnaire showed excellent test-retest reliability. The median of the preoperative QOL score was 4.1. The median change of the QOL scores after VTI was 2.4, with a SRM of 0.77 (95% confidence interval 0.54-0.99), indicating moderate effectiveness. The QOL scores of the items regarding hearing loss, care-provider concerns and physical suffering showed greater changes after VTI than those of other items. Among the items, those regarding speech impairment showed least change. CONCLUSION: VTI resulted in the improvement of QOL in most patients. Measurement of QOL could be a reliable test to study the effect of VTI in OME patients.

Ventilating Tube Method using IV Line During Closed Reduction of Nasal Bone Fracture

Recently the nasal packing after closed reduction of nasal bone fracture becomes popular procedure. However the nasal packing has adversed effects, which are nasal obstruction, discomfort, swallowing difficulty, nausea, reduction of middle ear pressure, possibility of middle ear effusion and aggravation of sinusitis, etc. During closed reduction, we inserted IV line (Safti set, Boin medica, Korea, 4mm internal diameter) in both nasal inferior meatus for ventilation. IV line could be obtained easily without cost in hospital. The flow of air was satisfactory subjectively and air resistance were tolerable. This method is applied easily without any cost and comfortable for patients.

Clinical Study of Laser Myringotomy with Ventilation Tube Insertion on Pediatric Chronic Otitis Media with Effusion / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Complications of a knife myringotomy with ventilation tube insertion is rather frequently encountered. To reduce such complications, we have performed myringotomy using a contact Nd: YAG laser. The purpose of this study was to evaluate the efficacy and safety of laser assisted myringotomy (LAM). MATERIALS AND METHODS: Sixty three patients (106 ears) of ages 1 to 7 were investigated retrospectively. Under the intravenous general anesthesia, LAM was performed to create a 2.0 mm sized perforation. After LAM, a ventilation tube was inserted. RESULTS: All ears underwent successful placement of ventilation tubes. Compared with knife myringotomies, LAM was safe to use in the atrophic tympanic membrane. There were also less intraoperative bleeding and tube plugging, with much lower postoperative otorrhea and myringosclerosis compared to knife myringotomies. Granuloma around the tube did not occurred. Postoperative improvement of air-bone gap reflects that LAM does not damage the inner ear. CONCLUSION: LAM with ventilation tube insertion is more effective than the previous knife myringotomy.

Factors That Affect the Development of Tympanosclerosis after Ventilation Tube Insertion / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The tympanosclerosis is an abnormal deposits of collagen materials on the lamina propria of the tympanic membrane or the middle ear mucosa. It usually appears as a whitish plaque on the tympanic membrane through otoscopic examination. The etiology of tympanosclerosis is not known, but there are some theories that attempt to explain the pathogenesis. The aim of this study is to understand the pathogenesis of tympanosclerosis and to find out the methods to minimize the occurrence of tympanosclerosis after ventilation tube insertion. MATERIALS AND METHODS: Otoscopic examination, impedance and pure tone audiometry were performed on 190 patients (306 ears) with serous otitis media, and on those who have undertaken ventilaton tube insertion from 1990 to 1998 at the otolaryngology department in Hanyang University Hospital. Then, the patients' medical and operative records were reviewed and analyzed in view of location and pathogenesis of tympanosclerosis. RESULTS: Incidence rate of tympanosclerosis was 42.5% in non-cleft patients and 61.9% in congenital cleft and palate patients. The rate increased when larger and heavier tube was used and the middle ear fluid was highly viscous. Most common sites for the development of tympanosclerosis were in the posteroinferior and anteroinferior portions of the tympanic membrane. Tympanosclerosis had little effect on hearing but in severe cases, it caused mild degree of hearing loss. CONCLUSION: We consider that tympanosclerosis is an inevitable result of ventilation tube insertion and its pathogenesis is multifactorial. We found that we can minimize the occurrence of tympanosclerosis by using small and light ventilation tubes, and avoid intraoperative bleeding and minimal mechanical trauma on the tympanic membrane by aspiring the middle ear fluid.

Structure of the Ventilation Tube / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Ventilation tube is a percutaneous prosthesis which is exposed to external stimuli. The duration of retention and complication rate of ventilation tube partly depends on which type of tube is used. The purpose of this study is to classify ventilation tubes according to biofunctional characteristics and to design new ventilation tubes experimentally using computer graphics. MATERIALS AND METHOD:Two hundred and forty seven ventilation tubes were classified according to shape, size and material. Experimental design of a ventilation tube was performed with various graphic modellings. RESULTS: Grommet style was most common and most of flanges showed round type. Polymer has been a material of choice in making ventilation tubes. Length of the shaft ranged 1.5mm-15mm. Four kinds of models were created for designing a ventilation tube using computer graphics. CONCLUSION: Biofunctionality should be taken into account in designing ventilation tubes.

Changes in External Ear Resonance after Ventilation Tube Insertion in Pediatric Patients with Middle Ear Effusion / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Middle ear effusion (MEE) is common in children, so the effects of the ventilation tube (VT) should be taken into account in prescribing hearing aids. With the ventilation tube, the external auditory canal communicates with the middle ear space, hence changing the impedance in the middle ear. This change, in turn, will have an effect on the external ear resonance (EER, real ear unaided response (REUR)). The aim of this study is to observe the effects of the tympanic membrane perforations caused by the ventilation tube on EER. MATERIAL AND METHODS:We selected 30 ears with MEE and measured EER before and after the ventilation tube insertion. We compared the EERs of the control group with the MEE group and two types of VT groups. RESULTS: In the subjects who had middle ear effusion, the average gain of the peak resonance was larger than that of the control group. After the VT insertion, the amplitude of the gain decreased to the level of control groups, although negative gain appeared in some cases characteristically around 1000 Hz. This negative gain was observed more frequently in the VT with larger diameter. CONCLUSION: The external ear resonance gain can be changed according to disease status or by VT insertion in patients with MEE. These changes should be considered especially in the low frequencies around 1000 Hz when prescribing the hearing aids for patients.