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  1. 1. Journal Club By Osama Alshaaili R2116 ANH
  2. 2. Agenda • Introduction • History of Myringotomy • Indications for Ventilatory tubes • Types of Tubes and complications • Article • Critical appraisal & Conclusion
  3. 3. Introduction • Commonest pediatrics procedure • Self extruded within 6 to 18 months • Considered retained is stays > 2 years • No current management guidelines • Should they be removed ? When ?
  4. 4. Indications • Recurrent AOM with middle ear effusion • Chronic otitis media with effusion (OME) • Eustachian tube (ET) dysfunction
  5. 5. Hx Of Myringotomy • First Formal Myringotomy in 1649 , by Jean Riolan • Artificial perforations a cure for congenital deafness. • Sir Astley Paston Cooper , in 1800, used trocar • Politzer first described his rubber grommet in 1868
  6. 6. Types A-Armstrong beveled grommet B-Paparella I grommet C-Reuter bobbin D-Goode T-tube E-butterfly tube Materials : fluoroplastic, silicone elastomer, or metal
  7. 7. Complications • Tube Otorrhea • Extrusion and Retention • Persistent Perforation • OCCLUSION
  8. 8.  Four different types  Armstrong tubes, Donaldson , Shepard tubes and straight tubes  silicone or fluoroplastic  400 patients , each ear different type  Results :  Short tubes extruded earlier than long tubes  silicone tubes result in the longest time to first infection.  Infection in VT ears does not significantly affect the extrusion rate  No significant differences were found regarding tube occlusion, tube extraction or persistent perforation.
  9. 9.  A prospective, randomized study.  75 patients , 44 female , 31 male  Shepard grommet, Armstrong beveled tube, Reuter-Bobbin tube, and Goode T-tube  Followed up to 17 months  Shepard and Armstrong tubes showed a comparatively low rate of plugging and otorrhea, 0 and 17%, respectively, whereas the T-tube had a 50% incidence of otorrhea and the Reuter- Bobbin had a 42% incidence.
  10. 10. LITERATURE REVIEW • Factors incidence of OME & complication rate • Most studies have excluded high-risk patients • 1 SYSTEMATIC REVIEW • 1 prospective study • 3 retrospective studies
  11. 11. • Prospective study - 120 pediatric patients, 6-12 years old • Goode T-tubes intubation period (6, 12, 18, and 24 months ) • ============== • Recurrence rate of OME significantly lower (<5% vs. 10%–20%). (after 12 months) • Rate of otorrhea increased (15%–20% vs. <7%) • Granulation around the tube (28% vs. <18%) • Rate of permanent TM perforation (30%–40% vs. <10%) • Author suggested tubes should be left in place for 12 to 18 months
  12. 12. • Retrospective study of 137 pediatric patients. • Three types of tubes (Shepard, Goode T, and Paparella) • Shepard (5.9 months) • Goode T tube (10.7 months) • Paparella type II (15.1 months) • Recurrence lower after 12 months + patient's age 7-9 years old • Recommended removal longer than 18-24 months or reach age of 8
  13. 13.  Retrospective study of 126 pediatric patients  Two groups: patients <7 years old (N = 67) and aged ≥7 years (N = 59)
  14. 14. • The only systemic review of medical literature since 1990 • 10 articles on pediatric patients • no consensus • majority of studies recommend removal of retained tubes after (>2–3 years) • Author recommended can be safely followed every 6 to 8 months for spontaneous extrusion. • Weight anesthesia vs complications of retained tube
  15. 15. Best Practice Summary • Based on current literature • Asymptomatic Retained tubes under the age of 7 to 8 years may remain in place. • IF the intubation period exceeds 18 months, removal may be considered to avoid complications. • Further prospective studies are needed
  16. 16. Critical appraisal

Notas do Editor

  • =Tympanostomy tube insertion remains one of the most performed pediatric procedures in the United States each year. With over 600,000 children undergoing anesthesia for this procedure, it is imperative that the a tube with adequate ventilation, low extrusion rates, tube otorrhea and infection be chosen to minimize repeat trips to the operating room for reinsertion.

    =The majority of tympanostomy tubes self-extrude within 6 to
    18 months due to the natural epithelial migration of tympanic
    membrane (TM);

    =Currently, there are no guidelines
    for the management of retained tubes in asymptomatic
    patients. Should they be removed? If so, when?
  • He hypothesized that artificial perforations of the tympanic membrane might be a cure for congenital deafness.
    He used a trocar concealed within a cannula to create a perforation (Figure 2) and recommended the anteroinferior quadrant as the appropriate site in order to preserve the ossicles. The procedure was, however, performed blind. His sole indication for the procedure was deafness due to Eustachian tube obstruction, and he was adamant that bone conduction must be present in these patients. He assessed this by placing a watch on their incisors or mastoid and finding that they could hear it more clearly than when it was held near the auricle. For these observations, at the age of 34, he was awarded the Copley medal, the highest honor bestowed by the Royal Society
    It had 3 flanges and 2 grooves to allow it to sit across the tympanic membrane, as well as a silk thread to prevent it falling into the middle ear
    1954 when TTs regained popularity after Armstrong published a successful series of five patients with polyethylene tube insertion
  • They share a grommet design with 2 flanges of varying size separated by a short shaft. The different designs and materials have slightly different rates of occlusion (clogging), infection, duration of function, and rates of persistent perforation after extrusion.17-19 None is clearly superior
  • =In 1995, a randomized controlled trial of 125 children receiving a Silastic TT in one ear
    and a silver oxide impregnated TT in the other ear found a long-term decrease in incidence of tube otorrhea in the silver oxide-impregnated TTs.
    =to decrease tube otorrhea is the use of semipermeable membranes within the lumen of the tubes
  • In 1983
    t the Shepard and Armstrong tubes showed a comparatively low rate of plugging and otorrhea, 0 and 17%, respectively, whereas the T-tube had a 50% incidence of otorrhea and the Reuter-Bobbin had a 42% incidence.34
  • The majority of studies focused on
    factors influencing the incidence of OME (e.g., age, ET
    function, the effect of adenoidectomy) and complications
    rates from retained tubes as the main determinant factors
    in deciding the ideal duration of tube intubation
    most studies have excluded high-risk patients
    (e.g., cleft palate and craniofacial abnormalities)
  • The authors recommended that patients can be
    safely followed every 6 to 8 months for spontaneous tube
    extrusion as long as there is no granulation tissue or
    recurrent otorrhea unresponsive to topical treatment.
    Furthermore, the risk of anesthesia for tube removal
    should be weighed against the risk of complications associated
    with retained ventilation tubes.
  • asymptomatic retained tubes in children under
    the age of 7 to 8 years may remain in place to avoid recurrent
    OME until such times that complications occur