Assessment of complications of the condition and of the treatment of otitis media with effusion

doi:10.1016/S0165-5876(99)00170-6

International Journal of Pediatric Otorhinolaryngology

Volume 49, Supplement 1, 5 October 1999, Pages S247-S251

https://doi.org/10.1016/S0165-5876(99)00170-6 Get rights and content

Abstract

Persistent otitis media with effusion (OME) may cause long-term changes of the tympanic membrane and middle ear, resulting in some degree of hearing loss. One of the traditional aims of treatment with ventilation tubes is to prevent these complications from developing. Ventilation tubes themselves, however, are also known to induce changes of the tympanic membrane. Several recent studies have addressed the questions: what are the effects of the disease, and what are the result of its treatment? The object of this study was to present the state of the art, by literature review, regarding structural and functional complications of OME and treatment with ventilation tubes. In both observational and experimental studies tympanosclerosis is reported to occur in 39–65% of ears treated with ventilation tubes as opposed to 0–10% of untreated ears. For segmental atrophy these percentages are 16–73 and 5–31, respectively. Regarding the prevalence of atelectasis and attic retraction, the difference between ventilated and untreated ears is less: 10–37% as opposed to 1–20% for atelectasis, and 10–52% as opposed to 29–40% for attic retraction. The average hearing loss associated with these tympanic membrane abnormalities is less than 5 dB. Although ventilation tubes have proven very effective in improving hearing in the short term, they have not proven effective in preventing long-term changes of the tympanic membrane related to OME, nor in keeping some degree of hearing loss from developing.

Introduction

Persistent otitis media with effusion (OME) may cause damage to the tympanic membrane and middle ear structures, resulting in such conditions as tympanosclerosis, atrophy and retraction of the pars tensa and pars flaccida. These abnormalities may affect hearing in the long term. One of the traditional aims of treatment with ventilation tubes is to prevent these complications from developing. The question now is whether tubes actually achieve that end. After all, they are known to induce changes of the tympanic membrane themselves. New ground regarding this subject was broken in the 1980s in Denmark by Tos et al. [1], [2] and by Lildholdt [3], who demonstrated through observational as well as experimental studies that ventilation tubes cause changes to the tympanic membrane that are associated with some degree of hearing loss. Because of these changes and the favourable natural course of OME, they advanced a judicious approach to the use of ventilation tubes. Remarkably, this evidence has had no influence on the rate of ventilation tube insertions for persistent OME, which since then has only risen.

Recently, several research groups have returned to the questions: what effects are caused by the disease, and what are the results of its treatment? Their results form the basis of this paper, which presents the state of the art regarding structural and functional complications of OME and treatment with ventilation tubes.

Section snippets

Material and methods

Articles on the effects of OME and ventilation tubes on the tympanic membrane and hearing published in 1993–1998 were identified by a computerized literature search. Both observational studies in open and clinical populations and clinical experimental studies were included.

Results

Eight studies were identified; three experimental studies [4], [5], [6], [7] and five observational studies [8], [9], [10], [11], [12] in birth cohorts or clinical populations. Table 1 summarizes the incidences of atrophy, tympanosclerosis, atelectasis [13] and attic retraction [14] in surgically treated and untreated ears as found in these studies.

Certain of these studies [5], [6], [11], [15], [16] established the effect of tympanic membrane abnormalities on hearing thresholds. As in the 1989

Discussion

This paper reviews recent studies on the complications of OME and ventilation tubes. No meta-analysis was performed. Although the results of the studies vary as a result of a different design, follow-up, population and perhaps interpretation of the tympanic membrane abnormalities, the overall trend in the evidence is clear. Ventilation tubes cause tympanosclerosis and local atrophy: these abnormalities are found in the majority of surgically treated ears. Ventilation tubes have also proven

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Grommets versus paracentesis in secretory otitis media
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Long-term sequelae of ventilation tube insertion for the treatment of otitis media with effusion and recurrent otitis media
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A.G.M. Schilder et al.
Long-term effects of otitis media with effusion: otomicroscopic findings
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Cited by (34)

Long-term follow-up after recurrent otitis media and ventilation tube insertion: Hearing outcomes and middle-ear health at six years of age
2022, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Some of those studies found that worse hearing outcomes and tympanic membrane abnormalities are generally more common in children who underwent VTI [18–20], whereas others showed no significant differences in long-term hearing outcomes compared to children who did not receive VTI [21,22]. Hong et al. [19] and Johnston et al. [23] have also reported that although children who underwent VTI had significantly elevated hearing levels in the long term, their hearing was within normal limits, while Rosenfeld et al. [24] and Schilder [25] noted that this impact on hearing is not of clinical significance. The long-term impact of VTI on hearing outcomes is still unclear due to limitations of previous studies, including small sample size [18,19,22], lack of control for potential confounding variables [19,20], age differences between groups [19], and/or lack of observation [21] or reference group [18,19].
To investigate the long-term impact of recurrent otitis media (rOM) and ventilation tube insertion (VTI) in early childhood on hearing outcomes and middle-ear health three to five years later, in a prospective pregnancy cohort study.
Children were classified into rOM (n = 314), VTI (n = 94), and reference (n = 1735) groups, according to their otitis media (OM) history in their first three years of life. Audiometry at frequencies 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, and tympanometry were performed when children were approximately six years of age.
A binary logistic regression incorporating a range of potential confounding variables showed that hearing outcomes and middle-ear health status in children who had early childhood rOM with or without undergoing VTI were not significantly different to those in the reference group. The only significant difference was found in the VTI group for both tympanometry (OR = 2.190; 95% CI = 1.123, 4.270) and audiometry outcomes at 4000 Hz (OR = 3.202; 95% CI 1.341, 6.717), in the left ear only. The median score of the better ear 4FA was 20 dB in children in all groups.
Children with rOM with or without undergoing VTI in the first three years of childhood had comparable hearing outcomes and middle-ear health status to those with no history of the disease, at around the age of six years. Although children who underwent VTI had an increased risk of abnormal middle-ear status and some elevation in hearing levels in their left ear only, their audiometry results were still within normal limits, indicating that the impact of VTI in early childhood is unlikely to have clinically significant adverse impact on later hearing outcomes.
No evidence of cholesteatoma in untreated otitis media with effusion in children with primary ciliary dyskinesia
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
This is an important finding as retraction is thought to be important in the pathogenesis of cholesteatoma formation, and it has previously been found to be higher in untreated OME [16,17]. Our finding supports those by Schilder et al. [27] in a literature review in 1999 where the prevalence of attic retractions was higher (10–52%) in ears treated with VTs when compared to untreated ears (29–40%). Our observation challenges the belief that untreated OME causes retraction of the TM.
Primary Ciliary Dyskinesia (PCD) describes a group of inherited disorders that result in abnormal ciliary motion leading to mucous stasis. Clinical features include almost universally otitis media with effusion (OME), particularly in infants. PCD patients provide us with a cohort of patients with OME that is not treated with ventilatory tube (VT) insertion as these have been shown to result in frequent complications including chronic otorrhoea, early extrusion and persistent perforation without significant improvement to hearing in the long term. This cohort was used to investigate whether children with PCD and OME not treated with VT were predisposed to cholesteatoma formation in the setting of a paediatric quaternary referral centre.
A retrospective chart review was performed of all the children attending a multi-disciplinary PCD clinic at a national quaternary referral centre with a diagnosis of OME. We reviewed otoscopic findings, and audiometry and tympanometry results. We assessed the children in four groups: Watchful waiting, hearing aids, VT, and VT and hearing aids.
One-hundred-and-one of 107 patients included in the study had a diagnosis of otitis media with effusion. No child with OME and PCD was diagnosed with a cholesteatoma during the follow up period. The only children who had insertion of a ventilatory tube were those who had the procedure prior to the formal diagnosis of PCD. We found a significant complication rate in the children with VT insertion. Hearing improved over time. The prevalence of retraction pockets in untreated OME was 1.72% (3 out of 174 ears).
In children with PCD, OME is an almost universal finding in younger children, but not in adolescents. The study supports the current preference to avoid VT insertion in children with PCD as it confers a significantly higher rate of complications. No cases of cholesteatoma were found in this cohort of PCD children with OME managed without VTs.
Inhibitory effect of N-acetyl cysteine and ascorbic acid on the development of myringosclerosis: AN experimental study
2014, International Journal of Pediatric Otorhinolaryngology
This study investigated the effects of ascorbic acid and N-acetyl cysteine (NAC) antioxidants on the development of myringosclerosis (MS) in an experimental model.
Myringotomies were performed in the ears of 15 guinea pigs, and Spongostan^® pieces were placed on the perforated regions of the tympanic membrane. The subjects were divided randomly into three groups and treated with three different solutions on the Spongostan—group 1: (control, 0.9% saline), group 2 (ascorbic acid), and group 3 (NAC). On day 15 after treatment, specimens from the tympanic membranes were obtained and examined via light microscopy. Sclerosis and inflammation scores and the tympanic membrane thicknesses were evaluated. Immunohistochemical methods were used to evaluate the expression of VEGF, TGF-β, iNOS, and IL1-β in all groups.
Lower sclerosis and inflammation scores and reduced tympanic membrane thicknesses were observed in groups treated with NAC or ascorbic acid compared with the control group. Immunohistochemical studies revealed significantly less expression of VEGF, TGF-β, and iNOS in groups 2 and 3 compared with group 1. Additionally, IL1-β expression was significantly less in group 3 than in group 1. Compared with group 1, group 2 animals exhibited reduced inflammation in the lamina propria, fewer active fibroblasts, less leukocyte infiltration, and decreased thickness of the vessels; group 3 animals exhibited decreased numbers of active fibroblasts and collagen fibers in the lamina propria.
Inflammation scores, cellular infiltration, and expression of VEGF, TGF-β, and iNOS were reduced by ascorbic acid and/or NAC treatments, thereby decreasing MS development. Decreased expression of IL1-β was observed only in animals treated with NAC.
Association of otoscopic findings and hearing level in pediatric patients with otitis media with effusion
2010, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Retraction may result in continuing problem of hearing loss or permanent tympanic membrane abnormality whereas the incidence of OME decreases with time [14]. Evidences including our study, suggested that hearing test should be done when retraction was found [3,16]. Mobility of the tympanic membrane was found to be significantly associated with the presence of hearing loss and the hearing level in decibels in univariable analysis.
To find the association between the abnormalities of tympanic membrane characteristics and the hearing level in pediatric patients with otitis media with effusion.
Sixty-three pediatric patients with otitis media with effusion had undergone ear examinations by pneumatic otoscopy to assess the color, transparency, mobility, fluid level and retraction of the tympanic membrane. An audiogram was done in the same setting, average hearing threshold and air-bone gap were measured. Otoscopic findings and the result of the hearing test were analyzed to identify the association between the abnormalities of the tympanic membrane characteristics and elevated hearing threshold.
Hearing loss was found in 92.1% of the patients. Mean hearing level was 31.7 ± 10.3 dB. From linear regression analysis, the patients with dull or opaque tympanic membrane had a significantly higher hearing threshold of 7.2 dB than the patient with translucent ear drum after adjusting for mobility and retraction. The patients with tympanic membrane retraction had a higher hearing threshold of 5.1 dB than the patient who had no retraction after adjusting for transparency and mobility. Mobility had a significant relationship to elevated hearing threshold in the univariate analysis but not in multivariable analysis.
Opacity and retraction were the two characteristics of abnormal tympanic membrane that were associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.
Long term sequelae of otitis media with effusion during childhood
2010, Otolaryngologia Polska
Otitis media with effusion is the most common cause of hearing loss in children and myringotomy with tympanostomy tube insertion is recommended procedure to deal with the problem. The objective of the present study was to determine the results of treatment, incidence and prevalence of middle ear sequelae and hearing results among children with chronic otitis media with effusion who received standard treatment with tympanostomy tubes.
The group of 97 patients treated by tympanostomy tubes insertion in the years 1999–2001 was reevaluated after mean period of follow up 7.3 years. At the control examination videootoscopy and audiologic examinations were performed. Audiological assessment consisted of tympanometry and pure-tone thresholds of air and bone conduction.
Recurrent otitis media with effusion requiring tube insertion occurred during follow up period in 23.7% of patients. At the control examination 16.5% of children had an ongoing otitis media or ventilation tube in place or tympanic membrane perforation. Most common tympanic membrane abnormality were focal atrophy (67.2% of ears) and myringosclerosis (39.5%) followed by retraction pockets of pars flaccida (29.9%) and tensa (9.6%). Mean pure-tone audiometric threshold were significantly higher in ears with tympanic membrane abnormality by the difference did not excide 5dB HL in ears with focal atrophy and myringosclerosis and 6.5 dB HL in ears with retraction pockets.
As the percentage of recurrences after tympanostomy tubes insertion are not uncommon prolonged period of follow up of those children is recommended. Although ventilation tubes have proven very effective in improving hearing in short term, they have not proven effective in preventing long-term sequelae of tympanic membrane and some degree of hearing loss. The decision about surgical treatment should be taken cautiously taking into account the chance of spontaneous resolution.
Effect of ototopical ciprofloxacin-dexamethasone on myringotomy in a rat model
2009, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Also, Dohar et al. found that ototopical CDX is superior to oral amoxicillin/clavulanate [14]. Tympanosclerosis, retraction or atrophy may be seen after ventilation tube insertion [15–17]. Tos and Poulsen [18] reported 4% of tympanosclerosis after ventilation tube insertion in a long period.
To examine the potential of ototopical ciprofloxacin–dexamethasone (CDX) to delay the closure of myringotomy perforation and to evaluate its effect on inflammation.
Prospective, randomized, and controlled.
Effusion is obtained in the right middle ear of 24 rats by blocking nasopharyngeal opening of eustachian tube by fibrin glue. Left middle ears of 30 rats remained healthy. Animals were randomly classified into three groups; each containing eight right ears with effusion and 10 rats with healthy left ear. Bilateral myringotomy was applied to all rats and randomly divided into three groups. First group received CDX, second group received serum physiologic (SF) for 14 days. Third group served as control. Otomicroscopy was performed by days 7, 14 and 28 to assess wound healing. On day of 28, all animals were humanly euthanized in order to pathological examination of the tympanic bullas.
CDX group showed lesser perforation closure ratios both in healthy and diseased ears. Inflammation was found to be lesser at CDX group in comparison to other groups.
Closure of the myringotomy perforation can be modulated by ototopical CDX treatment. This delaying of wound healing may be attributed to antiinflammatory action of dexamethasone.

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Assessment of complications of the condition and of the treatment of otitis media with effusion

Abstract

Introduction

Section snippets

Material and methods

Results

Discussion

Int. J. Pediatr. Otorhinolaryngol.

Grommets versus paracentesis in secretory otitis media

Am. J. Otol.

Hearing loss in tympanosclerosis caused by grommets

Arch. Otolaryngol. Head Neck Surg.

Ventilation tubes in secretory otits media: a randomized, controlled study of the course, the complications and the sequelae of ventilation tubes

Acta Otolaryngol. Suppl.

Development of tympanosclerosis in children with otitis media with effusion and ventilation tubes

J. Laryngol. Otol.

Long-term sequelae of ventilation tube insertion for the treatment of otitis media with effusion and recurrent otitis media

Sequelae of secretory otitis media: changes in middle ear biomechanics

Acta Otolaryngol.

Long-term effects of otitis media with effusion: otomicroscopic findings

Am. J. Otol.