A comparison of outcomes following tympanostomy tube placement or conservative measures for management of otitis media with effusion.

Abstract

We obtained the charts of 183 patients (197 ears) who had undergone surgery for chronic otitis media (COM), and we reviewed their otic histories to analyze the series of events that ultimately culminated in surgery. All ears had originally been treated for otitis media with effusion (OME); 125 ears had been treated with tympanostomy tube placement, and 72 ears had been treated with conservative measures. Our goal was to compare the influence that these two strategies had on the subsequent development of COM and its sequelae (i.e., retraction pockets, tympanic membrane perforations, and cholesteatomas) and thereby determine which strategy is preferable. We found that although retraction pockets developed in a significantly higher proportion of the tympanostomy-treated ears than the conservatively treated ears (58 vs. 35%; p < 0.01), a significantly greater percentage of retractions in the tympanostomy-treated ears were mild and situated in the anterior part of the tympanic membrane (52 vs. 32%; p < 0.05). Moreover, severe retractions were significantly more common in the conservatively treated ears (40 vs. 16%; p < 0.02); the incidence of complete retractions in the two groups of ears was similar (tympanostomy: 32%; conservative treatment: 28%). Cholesteatomas developed in a significantly lowerpercentage of tympanostomy-treated ears (67 vs. 81%; p < 0.05), and the incidence of large cholesteatomas that involved the tympanic and mastoid cavities was likewise significantly lower in these ears (44 vs. 69%; p < 0.05). There was no significant difference in the incidence of tympanic membrane perforations. Finally, even though all of these ears eventually required surgery for COM, the tympanostomy-treated ears required significantly fewer repeat surgeries (16 vs. 28%; p < 0.05) and significantly fewer radical modified tympanomastoidectomies (30 vs. 44%; p < 0.05). Therefore, we conclude that myringotomy with insertion of tympanostomy tubes to treat OME is superior to conservative treatment.

Introduction

Myringotomy with insertion of tympanostomy tubes continues to be a popular method of treating middle ear effusion. (1,2) Some studies have shown that this procedure reduces the risk of the development of cholesteatoma, but others have shown that repeated procedures are associated with the development of not only cholesteatomas, but also retraction pockets and tympanic membrane perforations. (3-7)

In this article, we describe the results of a study we conducted to compare the development of middle ear changes in patients who had undergone either tympanostomy tube insertion or conservative measures for the treatment of otitis media with effusion (OME).

Patients and methods

We reviewed the charts of all patients who had undergone surgery for chronic otitis media (COM) at the Mayo Clinic from January 1990 through December 1999. All of these patients had previously been treated for OME with either tympanostomy tube placement or conservative measures. We included in our review patients who had been referred to us for surgery after their OME had been treated elsewhere in addition to those patients who had received all their treatment at our institution.

We identified 183 such patients--102 males (56%) and 81 females (44%); 14 of these patients had bilateral COM, bringing the number of operated ears to 197. A total of 128 ears had undergone tympanoplasty or wall-up tympanomastoidectomy, and 69 had undergone radical modified tympanomastoidectomy.

We divided these ears into two groups based on how their earlier OME had been treated. The records showed that 125 ears (63%) had been treated with tympanostomy tube placement and 72 (37%) had been managed conservatively. We then examined the records to determine the outcomes of OME treatment in the two groups. Specifically, we looked for the development of retraction pockets (size and site), cholesteatomas (size and site), and tympanic membrane perforations as determined by otomicroscopy before and during the surgery. We also compared the number and type of operations that were required to treat COM in the two groups.

Results

Onset and treatment of OME. The onset of OME had occurred at an early age for most patients, but the tympanostomy group was significantly younger (mean age: 2.74 [+ or -] 1.63 vs. 6.24 [+ or -] 3.57 yr; p < 0.001).

In the tympanostomy group, 48 of the 125 ears (38%) required only one tube insertion for the management of OME; 19 ears (15%) required four or more insertions (table 1).

Middle ear changes. Following the treatment of OME, retraction pockets were significantly more common in the tympanostomy-treated ears (58 vs. 35%; p < 0.01) (table 2). However, these patients had a significantly greater percentage of mild retractions located in the anterior part of the tympanic membrane (52 vs. 32%; p < 0.05). Conversely, the incidence of severe retractions was significantly higher in the conservatively treated ears (40 vs. 16%; p < 0.02). The incidence of complete retractions was similar (tympanostomy: 32%; conservative treatment: 28%).

Cholesteatomas developed in a significantly lower per centage of tympanostomy-treated ears (67 vs. 81%; p < 0.05) (table 2). Also, the incidence of large cholesteatomas that involved the tympanic and mastoid cavities was significantly lower in these ears (44 vs. 69%; p < 0.05).

There was no significant difference between the two groups in the incidence of tympanic membrane perforations (table 2).

Treatment of COM. Prior to surgery for COM, the tympanostomy group had a significantly lower mean hearing level than did the conservative group (39.5 [+ or -] 8.3 vs. 47 [+ or -] 10.8 dB; p < 0.001).

The conservatively managed patients were significantly younger at the time of surgery (8.58 [+ or -] 3.27 vs. 10.25 [+ or -] 3.42 yr; p < 0.001) (table 3). Some 76% of the conservatively treated ears were in patients 10 years of age or younger.

As for the type of surgery for COM, either tympanoplasty or wall-up tympanomastoidectomy was performed on 70% of the tympanostomy-treated ears and 56% of the conservatively-treated ears (table 3). Conversely, radical modified tympanomastoidectomy was required for 30% of the tympanostomy-treated ears and 44% of the conservatively treated ears. These differences were statistically significant (p < 0.05).

Finally, a significantly lower percentage of tympanostomy-treated ears required more than one operation for COM (16 vs. 28%; p < 0.05) (table 3).

Discussion

Our retrospective analysis led to some interesting findings regarding age. On average, the patients who had undergone tympanostomy had been diagnosed with OME at a significantly earlier age than the patients who had undergone conservative management (mean age: 2.74 vs. 6.24 yr). At the time of surgery for COM, however, the patients who had been managed conservatively were significantly younger than the tympanostomy patients (mean age: 8.58 vs. 10.25 yr). Yet, even though the differences in age were statistically significant, we do not believe they were clinically significant.

The rate of cholesteatoma following treatment for OME was significantly lower in the tympanostomy group than in the conservative group (67 vs. 81%). Also, the rate of the most serious cholesteatomas--that is, large lesions that involved the tympanic and mastoid cavities--was significantly lower in the tympanostomy group (44 vs. 69%). This latter finding supports the opinion of some authors (2) that tympanostomy tube insertion prevents the development of severe retraction pockets and cholesteatomas. Although the overall incidence of retraction pockets was significantly higher in the tympanostomy patients (58 vs. 35%), most of these lesions were mild and located in the anterior part of the tympanic membrane. On the other hand, severe retractions in the posterosuperior quadrant (Prussak space), which increase the risk of cholesteatoma development, were significantly more common in the conservative group (40 vs. 16%). As a result of the differences in middle ear involvement, fewer patients who were treated with tympanostomy tubes required radical surgery.

We conclude that patients who undergo tympanostomy tube placement for OME experience better outcomes than patients who are managed conservatively. These patients experience fewer serious episodes of retraction pockets and cholesteatomas. We also conclude that early diagnosis of OME and rapid placement of tympanostomy tubes might obviate the need for early, repeated, and radical ear surgery in the future.

References

(1.) Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: Implications for prevention and treatment. Int J Pediatr Otorhinolaryngol 1998;42(3):207-23.

(2.) Rakover J, Keywan K, Rosen G. Comparison of the incidence of cholesteatoma surgery before and after using ventilation tubes for secretory otitis media. Int J Pediatr Otorhinolaryngol 2000;56(1): 41-4.

(3.) van Cauwenberge P, Watelet JB, Dhooge I. Uncommon and unusual complications of otitis media with effusion. Int J Pediatr Otorhinolaryngol 1999;49(Suppl 1):119-25.

(4.) Riley DN, Herberger S, McBride G, Law K. Myringotomy and ventilation tube insertion: A ten-year follow-up. J Laryngol Otol 1997;111(3):257-61.

(5.) Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with ventilation tube insertion. Arch Otolaryngol Head Neck Surg 1999;125(7):754-7.

(6.) Herdman R, Wright JL. Grommets and cholesteatoma in children. J Laryngol Otol 1988;102(11):1000-2.

(7.) Mortensen EH, Lildholdt T. Ventilation tubes and cholesteatoma in children. J Laryngol Otol 1984;98(1):27-9.

From the Department of Otorhinolaryngology-Head and Neck Surgery, State Medical and Pharmaceutical University "N. Testemitanu," Chisinau, Moldova (Dr. Diacova), and the Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic College of Medicine, Rochester, Minn. (Dr. McDonald).

Reprint requests: Thomas J. McDonald, MD, 3245 Hill Ct. SW, Rochester, MN 55902. Phone: [phone]; fax: [phone].

Svetlana Diacova, MD; Thomas J. McDonald, MD

Table 1. Number of tube insertions in the
tympanostomy group (n = 125 ears)

No. of                         No. (%)
insertions                     of ears

1                                 48 (38)
2                                 39 (31)
3                                 19 (15)
[greater than or equal to] 4      19 (15)

Table 2. Post-treatment development of inner ear changes

                            Tympanostomy    Conservative Tx
                           (n = 125 ears)    (n = 72 ears)
                               n (%)             n (%)

Retraction pocket          73 (58)          25 (35)
  Mild                           38 (52)           8 (32)
  Severe                         12 (16)          10 (40)
  Complete                       23 (32)           7 (28)

Cholesteatoma              84 (67)          58 (81)
  Small, tympanic cavity         12 (14)           5 (9)
  Large, tympanic cavity         35 (42)          13 (22)
  Large, tympanic                37 (44)          40 (69)
  and mastoid cavities

Perforation                  45 (36)        33 (46)

                           Statistically
                            significant
                            difference

Retraction pocket            p < 0.01
  Mild                       p < 0.05
  Severe                     p < 0.02
  Complete

Cholesteatoma                p < 0.05
  Small, tympanic cavity
  Large, tympanic cavity
  Large, tympanic            p < 0.05
  and mastoid cavities

Perforation

Table 3. Age at the time of surgery for COM and the type and number
of surgeries

                                Tympanostomy        Conservative Tx
                               (n = 125 ears)        (n = 72 ears)
                                    n (%)                n (%)

Age (yr)
  0 to 6                           25 (20)              26 (36)
  7 to 10                          41 (33)              29 (40)
  11 to 14                         31 (25)              11 (15)
  [greater than or equal
    to] 15                         28 (22)               6 (8)
Mean age                     10.25 [+ or -] 3.42   8.58 [+ or -] 3.27

Type of surgery
  Tympanoplasty or wall-up         88 (70)              40 (56)
    tympanomastoidectomy

  Radical modified                 37 (30)              32 (44)
    tympanomastoidectomy
No. of surgeries
1                                 105 (84)              52 (72)
  [greater than or equal
    to] 2                          20 (16)              20 (28)

                                Statistically
                                 significant
                                 difference

Age (yr)
  0 to 6
  7 to 10
  11 to 14
  [greater than or equal
    to] 15                        p < 0.01
Mean age                          p < 0.001

Type of surgery
  Tympanoplasty or wall-up        p < 0.05
    tympanomastoidectomy

  Radical modified                p < 0.05
    tympanomastoidectomy
No. of surgeries
1                                 p < 0.05
  [greater than or equal
    to] 2                         p < 0.05