Grommets (ventilation tubes) for recurrent acute otitis media in children.

BACKGROUND: Acute suppurative otitis media is one of the most common infectious diseases in childhood. Recurrent acute otitis media is defined for the purposes of this review as either three or more acute infections of the middle ear cleft in a six-month period, or at least four episodes in a year. Strategies for managing the condition include the assessment and modification of risk factors where possible, repeated courses of antibiotics for each new infection, antibiotic prophylaxis and the insertion of ventilation tubes (grommets). OBJECTIVES: To establish whether ventilation tube insertion reduces the frequency of episodes of recurrent acute otitis media and the proportion of children with symptoms of ear disease. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2008), MEDLINE (1950 to 2008), EMBASE (1974 to 2008), CINAHL, mRCT (the metaRegister of Controlled Trials for ongoing/unpublished trials), NRR (National Research Register), LILACs, KoreaMed, IndMed, PakMediNet, Zetoc, ISI Proceedings and Cambridge Scientific Abstracts. Reference lists of articles retrieved from the electronic searches were scanned for further trials. Systematic reviews and other meta-analyses were also searched for and their reference lists scanned. Contact was sought with authors of published trials and other experts in the field. The date of the last search was March 2008. SELECTION CRITERIA: No trials that included a treatment and a control group that met the inclusion criteria were excluded. Abstracts were screened and full text articles of studies that met our inclusion criteria obtained. Two authors independently applied the inclusion criteria. Studies included in the review underwent quality assessment performed independently by all authors adapting the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the authors and synthesised descriptively. Five randomised controlled trials were identified, of which two fulfilled the inclusion criteria. MAIN RESULTS: Two studies involving 148 children were included in the review. One of these studies, involving 95 children, showed that ventilation tube insertion leads to a mean reduction of 1.5 episodes of acute otitis media in the first six months after treatment. This study also showed a significant increase in the proportion of children with no episodes of AOM (p < 0.001) in the ventilation tube group. The other included study also found a higher proportion of patients in the ventilation tube group had no episodes of AOM in the six months after intervention, but the difference did not reach statistical significance (p = 0.16). AUTHORS' CONCLUSIONS: Ventilation tubes have a significant role in maintaining a 'disease-free' state in the first six months after insertion. Further research is required to investigate the effect beyond six months. Clinicians should consider the possible adverse effects of grommet insertion before surgery is undertaken.

The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery.

BACKGROUND: Bleeding during endoscopic sinus surgery (ESS) may increase complications and negatively effect the surgery and its outcome. The aim of this study was to compare the surgical field in patients in whom total intravenous anesthesia (TIVA) is used as opposed to inhalation anesthesia. A prospective randomized controlled trial was performed. METHODS: Fifty-six patients undergoing ESS were randomly assigned to receive either inhaled sevoflurane with incremental doses of fentanyl (n = 28) or TIVA via a propofol and remifentanil infusion (n = 28) for their general anesthesia. The surgical field was graded every 15 minutes using a validated scoring system. RESULTS: The two groups were matched for surgical procedure and computed tomography scores. Patients in the TIVA group were found to have a significantly lower surgical grade score than in the sevoflurane group (p < 0.001). Surgical grade score increased with time in both groups. Mean arterial pressure and pulse were found to influence the surgical field independently (p = 0.003 and p = 0.036 respectively). Mean surgical field grade scores were higher in the patients with allergic fungal sinusitis and nasal polyposis as opposed to chronic rhinosinusitis without polyps or fungus. Lund-Mackay computed tomography scores were found to correlate positively with surgical grade (Spearman rank correlation, p = 0.001). CONCLUSION: In patients undergoing ESS, TIVA results in a better surgical field than inhalational anesthesia.

Endoscopic sinus surgery rescue of failed osteoplastic flap with fat obliteration.

PURPOSE OF REVIEW: The modified endoscopic Lothrop procedure has been used as an alternative to osteoplastic flap with obliteration in the management of chronic frontal sinusitis. More recently it has been used to rescue cases of failed osteoplastic flap. This article reviews the recent literature regarding endoscopic rescue of failed osteoplastic flap with obliteration. RECENT FINDINGS: Endoscopic sinus surgery is indicated in cases of osteoplastic flap failure when there is objective evidence of mucocele formation. All patients require CT and MR imaging preoperatively. Clinical improvement can be achieved in up to 89% of patients in the first 12 to 18 months postoperatively. SUMMARY: The modified endoscopic Lothrop procedure is effective in the management of failed osteoplastic flap with obliteration in the short term. Long-term evaluation of this technique is still required. Endoscopic rescue is technically challenging and requires an experienced surgeon, ideally with access to image guidance equipment.