1.
Journal Club
By Osama Alshaaili
R2116
ANH

2.
Agenda
• Introduction
• History of Myringotomy
• Indications for Ventilatory tubes
• Types of Tubes and complications
• Article
• Critical appraisal & Conclusion

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.
Indications
• Recurrent AOM with middle ear effusion
• Chronic otitis media with effusion (OME)
• Eustachian tube (ET) dysfunction

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.
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.
Complications
• Tube Otorrhea
• Extrusion and Retention
• Persistent Perforation
• OCCLUSION

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.
 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.
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.
• 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.
• 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.
 Retrospective study of 126 pediatric patients
 Two groups: patients <7 years old (N = 67) and aged ≥7 years (N = 59)

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.
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.
Critical appraisal