Hearing results with the use of different tympanostomy tubes: a prospective study

er

93

0165~5876/88,‘$03.50

@ 1988

ivision)

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development of language and cognitive disabilities [9,5,12]. Most otolaryngologists, even those critical of the popularity of Qmpanostomy tubes, acknowledge their efulness in improving conductive hearing losses secondary to 0 any physicians, however, point to the complications associattd with the insertion of tympanostomy tubes and object to their widespread use [7,8]. Bonding and Tos [2] analyzing the distribution of average hearing thresholds prior, during, and after tympanostomy tube insertion concluded tha tubes outperformed paracentesis only during the period that the ears. It thus behoves us as Smyth [lo] recommends, to

mpanaslomy tube

life The 95 subjects included in this study underwent a of tympanostomy tubes dufing the years 1982-1985 a These patients did not have cleft palates tein College of ed previously. Patients were randomly ass tympanostomy of 15 tympanostomy tubes. It was at tie the rest, so a second phase, in whi

astomy t

usedin the stui@

1 sit 13rotnmet Tubc# with wire(tcflon) (14) 2 chimevelltilatimTubfz(tenon)(12) 3 Reuter Bobbii Drain ‘Me (metal)(8) 4 Spoon Bobbin Drain Tube, with wire (metal) (8) S BeveledDrain Tube, end(teflon) (8) 6

7 8 9 10 I1 12 13 1 1s

‘sT ‘Me (silkone) (45)

Demographics of the SD. = ( ). Time bePof subjects Female Age range Average age

Complications

1982-1985 95 60

42

umival the time points 30,90, and 183 days after insertion diiference among the survival rates of tbe tubes. At 365 an single tube was shown to be better cantly outperformed the average. of the Papa&la-III tubes in place at 365 and Richard’s T-tubes for those

post-operative patie

TABLE III Pmentage of the Paparella-III and Richard’s T-tube versusthe awrage of all the other tubesat 365 and 448 deys

rspment numberof observed tubes that

111 T-tu

were actually functioning. Chi square test of

365

n

448

n

100 65 24

( 41 (17) (14)

100 67 21

( 4) (12) ( 9)

with all past-opemtivepatients and the s&my

indB.Furetoneavetage=(SOO+1

Hz)/3. SD. is in brackets.

SY

Pum tone mrage

Feception thre&old

Air

20.3 13.2 (5.4) 10.2 (42)

24.2 15.0 (1.9) 11.4 (1.8)

Bone

5.9 (::h

of thase

Frequency

Pre-operatiw

Fast-all

16.8 3.2 15.6 5.0 12.4

zu

30

30

25

25

20

20

e 15 zi P IO 3 5 0

13.5 2.8 11.7 2.8 9.1

15 10 5 0

10 20 30 40 50 60 70 60 90

0

dB

25

0

10 20 30 404650 60 70 60 90

44

The air bone gap was in both analyses diminished, but not eliminated. In addition, bone conduction which was nod 0 before surgery, does not reach 0 even with functioning tubes in place. The same pattern noted above is evideat even when the results for each & examined individually. This is illustrated in Table V. e gap for functioning tubes at 250 Hz was 9 dB, at 20% Hz was S dB, and a differences so to further examine the change ostosny tube insertion, we analyzed the 1 shows vidual ears were affec st-opers by frequency. In

40

40

35

35

30

30

8 25

25

k!s 20

20

1 I5 z#

15

= 10

10

5

5

0 0

Fib 2. I-list

lc) 'IO j3

0 40 50 60

0

IO 20 30 40 50 60 d0

t-operative hearing thresholds at each frequency. tubes, black non-functioning.

45 40 35

JO 25 b.z520 15 10 5 0

40 35 cn

30 25 20 15 10 5 0

TABLEVI 17reperceniage of ears that achieved the air conduclionhearing thresholdsof 0, IO, and 20 ears with jbnctioning rvmpanastony tubes OdB

(1OdB

among thvse

46 TABLE VII

Pre-opemtivepure tone avemges and post-operative pure tone average when tubes were functioning Only those ears for which complete pre- and post-operative data were available are

n-

presented.

(Pre/post). Pure tone rwerage

Tnf~ tvpe Pope Chnmet (2/l) Shea Tube (S/Z) Richard’s Wing Tube (11/Q ckunmet Type (2/2) ) (h% Canoe (6/2)

Polyethylene Tube (2/2) Rauter Bobbin (S/6)

Pre

post

13.3 21.7 23.5 28.8 27.9 21.7 29.2 14.4 20.4 20.8 28.8 22.5 29.5 22.8 28.8

5.0 5.0 5.2 6.7 9.2 10.2 11.9 12.5 12.8 13.3 13.6 13.9 14.1 16.7 21.4

and for functioni ative hearing results are illustrated for comparison of pre- and post-operative hearing. An e shows that between 0 and 15%of cars with functioning tubes actually had a hearing

TABLE VIII Not iR~~tnent

in pure tsno ave

when tub werefbnctioning

Change inauemge

(6)

22.1 18.7 18.3 17.3 16.7 15.4 15.2 11.5 8.6 8.3 7.6 7.5 7.4 6.1 1.9

Thepercentageof tubespresent at each time point in whichotorrheawas noted n=( 1. Dayspt-vpefative

C30

90

183

365

448

Gates et al, [4] discuss the hypothesis that a period of long term ventilation may correct the underlying pathology of QME. Even if differences noted between children undergoing myringotomy alone and those receiving myringotomy with placement of tympanostomy tubes occur only when the tubes are present (as reported by Gates et al. [4] and Bonding and Tos [2]), the search for a long life e compared 15 tympanostomy tube would still be a desirable undertaking. different commonly used tympanostomy tub to discover if any of them would provide long term ventilation without the erations. Since the orary hole in the purpose of tympanostomy tubes is the provision of which middle ear pressure may be equalized, we tympanic membrane lly in the tympanic membrane. If a considered only uncle peroxide solution was were not were occasionally more in an attempt to uncl functional tubes present at an earlier one. 0ur study found that at one year and one and a half’ years after surgery a percentage of Paparella-III and Richard’s T-tubes remained in brane than the average of the other tubes. The two long-life tubes so outperformed the results obtained by Yanagihara and Magi [13] using siliconrubber T-tubes. They noted 60% of tubes present at 6 months and 28% at one year, however, their study group included patients who had had repeated tympanostomy tube insertions. Both the Paparella-III and Richard’s T-tube were designed for stable anchorage in the tympanic membrane, the Paparella-III with’its larger inner flange and the Richard’s T-tube with its crossbar. We further modified the Richard’s T-tube by cutting the lateral end at a bevel of 60° so as to increase the size of the by trimming the ends of the crossbar to ensure that they would not es of the middle ear cleft. ” falls on the Yowend of the range r review of the experience of others. It must be noted that whereas hea occurring within the first 7

Paparella-III tubes were associated with utorrhea. The incidence of gmnulomas for both these tubes exceeded the overall rate between 90 and 183 days when 14% of p~lla=III tubes and 6 of Richard’s T-tubes were complicated by the presence operative hearing results obtained with the P fall within the generally used level of < 20

1 Bluestone,C., Treatmentof otitis media with effusion, Stand. J. Infect. Dis., Suppl. 39 (1983) 26-33. 2 Bonding, P. and Tos, M., Grommets versus paracentesisin secretory otitis media: a prospective, controlled study, Am. J. Qtol., 6 (1985) 455-460. 3 Gates, G., Avery, C., Frihoda, T. and olt, G., Post-tympanostomyoturrhea, L~~~~~~pe, 96 (1986) 630-634. , Treatmentof chronic otitis mediawith effusion: resultsof 4 Gates, G., Waachtendorf,C. and lor, F., C~as~~en~ of unremitti opmenta!findingsin childrenwith cl persistentmiddleear effusion, J. La~~~o~.

50

8 Naunton, R, panel on experiu~~.~with middIe ear ventWing tubes: tympanostomy tubes: the wnservative approach,Ann. OtoL,90 (1981) 529432. in chiIdhood: impkations of temporaryauditog deprivation 9 90 (1981) M-551. a with effusion: a review,Am. J. Otol., 5 (1984) 344-349. 10 11 Van Cauwenw P., Cauwe, F. and IU~yskens, P., The long-term resuIt.sof the treatmentwith in chiIdren with chronic secretory otitis media, Int. J. Pediatr. 116. 12 J., Nakaaki,K. and Tsuda, K., Total actual time in infants and chiken with o&is media with eff’usion, Int. J. Pediatr.Otorhinol 85) 171-180. term tuk in view of complications and heari