Does Type of Cleft Palate Repair Influence Postoperative Eustachian Tube Dysfunction?

PURPOSE: Otitis media (OM) is a frequent occurrence in the cleft palate population. Palate repair is thought to positively contribute to Eustachian tube function. The purpose of this study is to determine the proportion of cleft patients in our cohort with OM, and if palatoplasty closure technique influences future OM differently. The authors posited that Z-plasty palate repair would result in improved Eustachian tube function, compared with straight-line repair. METHODS: Patient records were accessed and data was recorded on palatoplasties from 2005 to 2007 as well as from 2012 to 2014. Type of palatoplasty (straight-line vs. Z-plasty) was recorded and compared to prevalence of pressure equalizer tube placement and antibiotic prescriptions in various assessment intervals following repair 1) <6 months, 2) 6 months to 1 year. Statistical analysis included Welch 2 sample t test. RESULTS: The type of cleft palate was similar between the 2 groups. Prior to palate repair, over 30% of subjects in both groups required either tubes or antibiotics for OME. At the time of surgery, over 50% of patients received ear tubes, in both groups. Following repair, for straight versus Z, 0 versus 11%; and, 27.8 versus 20% required ear tubes for intervals 1) and 2), respectively. P values for both intervals are 0.9183 and 0.328, respectively. Antibiotics during interval one were required in 22.2% versus 23.5% of straight-line closures and Z-plasty, respectively. Antibiotics in the second interval were needed for 33.3% and 30% of straight-line closures and Z-plasty closures, respectively. P values for antibiotic use in the first and second intervals were 0.5353 and 0.4316 respectively. CONCLUSION: Cleft palate patients have a high prevalence of OM. Palatoplasty technique (straight-line and Z-plasty) does not affect Eustachian tube dysfunction differently following repair as measured by pressure equalizer tube placement and antibiotic use.

Clinical practice guideline: tympanostomy tubes in children--executive summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tympanostomy Tubes in Children. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed address patient selection, surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.

Clinical practice guideline: Tympanostomy tubes in children.

OBJECTIVE: Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. PURPOSE: The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Peripherally inserted central catheters (PICCs) in the CF population: one center's experience.

Cystic fibrosis (CF) is a common fatal genetic disorder characterized by chronic pulmonary infections, some of which require intravenous (i.v.) antibiotics. Peripherally inserted central catheters (PICCs) have proven to be an effective means of i.v. delivery in a variety of populations. An evaluation of the effectiveness of the use of PICCs for patients at a CF center in New England was conducted over a 25-consecutive month period. During this time, 61 PICCs were placed in 32 patients with CF requiring i.v. antibiotics. The catheters were in place for a median of 15 days (range 1-155 days). The total number of catheter days in this series was 1,139. Although no serious complications were encountered, minor complications or technical problems occurred in 18 (29.5%) of the 61 catheters. Complications included external breaks in the catheters, shoulder pain, phlebitis, catheter occlusion, accidental dislodgement, local irritation at the insertion site, and yeast infection at the insertion site. No long-term sequelae resulted, and the rate of i.v. antibiotic completion with this mode of i.v. access was high. As a result of the evaluation, PICC access remains the standard of care at this institution for patients with CF requiring i.v. antibiotics for pulmonary exacerbations.