TREATMENT FOR OTITIS MEDIA WITH EFFUSION BY VENTILATION TUBE INSERTION
Hoàng Phước Minh*. Lê Thanh Thái*
Background: Otitis media with effusion (OME) is a common disease especially in children.
Objective: To study clinical, tympanometry, audiometry and the results of ventilation tube insertion. Materials and methods: Prospective study in 114 ears of 76 patients with OME.
Results: The most common age group was ≤ 6 years of age (39.5%). Common symptoms in
≤6 years of age group are nasal obstruction (73.3%), rhinorrhea (66.7%); in >6 years of age group are tinnitus (78.3%), hearing loss (76.1%). Tympanic membrane findings: completed opaque (40.4%), air-fluid level (64.1%), contracted eardrum (44.7%), losing cone of light (87.7%). Tympanogram type B was 78.1%. Audiogram was conductive hearing loss with pure tone average (PTA) > 20 db (100%). Ventilation tube insertion one or both side associated with or without adenoidectomy. After 6 months of follow-up, postoperative mean PTA was 28.41,6 dB. Most of cases have dry ear, hearing improvement, tubes on the tympanic membrane. Common complications were otorrhea and tube extrusion. Conclusion:
OME is asymptomatic especially in children. Tympanogram plays a key role in diagnosis.
Ventilation tube insertion improves the hearing and restores the normal function of the middle ear.
Keyword: otitis media with effusion, ventilation tube insertion
1. INTRODUCTION
Otitis media with effusion (OME) is defined as a collection of fluid behind the closed eardrum in the middle ear without signs or symptoms (fever, otalgia, irritability) of infection.
OME is one of the most common diseases in childhood and unless treated properly will cause severe sequelae in the middle ear reducing the function of eardrum, middle ear and leading to hearing loss, affecting the language development and learning. In Vietnam, according to Nguyen ‘s study, the prevelence of this disease is 8.9% [1]. OME occurs commonly during the childhood , with as many as 90 percent of children having at least one episode of OME by age 10, mostly occurs from 6 months to 4 years of age [2]. OME is usually asymptomatic [3]. The symptoms are not aggressive, the progress of the disease is latent and easily overlooked on examination. Currently, beside the development of modern medicine, many new technologies have contributed to diagnose and treat OME. Many kinds of ventilation tube are produced in order to drain the fluid out of the middle ear cavity.
Ventilation tube insertion improves significantly hearing, reduces the recurrent acute otitis media, and create the drainage mechanism and local antibiotic treatment of long-term acute otitis media. Additionally, ventilation tube insertion improves the quality of people ‘s life who have OME. The frequency of ventilation tube insertion with surgical indications create a pressure to have evidence-based guidelines to help doctors give the right indication, monitor and evaluate post-operative care. Based on the above issues, to contribute to the diagnosis
and treatment of OME, this study was conducted aims to evaluate “Treatment for otitis media with effusion by ventilation tube insertion”
2. MATERIALS AND METHODS
2.1. Materials. 114 ears of 76 patients with OME had ventilation tube insertion (VTI) in Hue Central Hospital and Hue Medical University Hospital from 03/2014 to 05/2016.
2.2.Methods. Prospective study with clinical intervention.
The criteria for the study: age, gender, symptoms, tympanic membrane findings, audiogram, tympanogram,surgical procedure, result of VTI.
Study facilities: Endoscope, ENT microscope, audiometer, tympanometer, ventilation tube, microsurgical instruments.
Study steps. Pre-operation: ask for medical history and current status, do examination and capture image of the tympanic membrane, do tympanometry, do audiometry for patients who have their ages >6. Do VTI with or without adenoidectomy if having indication. Post- operation: evaluate the result after 3 months , 6 months.
Children ‘s parent and older patients are fully explained and agree to participate in the study with the informed consent.
Import and do statistical analysis by SPSS 18.0 biostatistical software.
3. RESULTS
3.1. General features
Age and gender: The most common age group was ≤ 6 years of age including 30 patients (39.5%), mean age is 19.5±2.3. Age in our study have huge disparities, the youngest case is 1 year old and the oldest is 84 years old. The percentage of male patients is 52.6% (40/76 patients), and female patients is 47.4% (36/76 patients).
The number of patients’ ears. There are 38 patients having OME in both ears (50%). Most of cases are in ≤6 years of age group with 21 patients.
3.2. Clinical symptoms Table 3.1. Clinical symptoms
Age group
Clinical symptoms Nasal
obstruc tion
Rhinorr
hea Tinnit
us Hearin
g loss Snori
ng Speech
delay Otal
gia Autoph ony
≤6 years
(30 patients) n 22 20 7 13 16 10 7 0
% 73.3 66.7 23.3 56.7 53.3 33.3 23.3 0
>6 years
(46patients) n 18 18 36 35 14 2 16 8
% 39.1 39.1 78.3 76.1 30.4 4.4 34.8 17.4
(76 patients) % 52.6 50.0 56.6 63.2 39.5 15.8 30.3 10.5 In ≤6 years of age group, symptoms of nasal pharynx are prominent: nasal obstruction (73.3%) and rhinorrhea (66.7%) due to adenoiditis.
On the contrary, in >6 years of age group (n=46) who can recognize and communicate well, the most common symptoms are tinnitus (78.3%) and hearing loss (76.1%). The percentage of autophony is 17.4%.
3.3. Tympanic membrane findings
Table 3.2. Clinical features of tympanic membrane in the ears with OME (N=114)
Clinical findings N Percentage %
Opaque
Normal 25 21.9
Partial opaque 43 37.7
Completed opaque 46 40.4
Total 114 100.0
Air-fluid level
No 41 35.9
Yes 73 64.1
Total 114 100.0
Color
White grey 23 20.2
Partial yellow 64 56.1
Completed yellow 27 23.7
Total 114 100.0
Morphology
Normal 4 3.5
Contracted 51 44.7
Flat 1 0.9
Slight budging 47 41.2
Completed budging 11 9.7
Total 114 100.0
Mobility
Normal 27 23.7
Less mobile 74 64.9
Immobile 13 11.4
Total 114 100.0
Cone of light
Normal 14 12.3
Less/Lost 100 87.7
Total 114 100.0
3.4 Tympanogram results
Table 3.3. Type of tympanogram in the ears with OME (N=114)
Type N Percentage %
Flat 92 80.7
Wide curve 19 16.7
Straight line to the left 3 2.6
Total 114 100.0
Flat type tympanogram takes the majority of percentages 80.7% (92/114 ears).
Table 3.4. Pre-operative compliance level in in the ears with OME (N=114)
Compliance level N Percentage % Mean (mmHo)
>0,2 mmHo 25 21.9
0.120.16 (0;0.7)
0,2 mmHo 89 78.1
Total 114 100.0
Low compliance level (0.2 mmHo) has a very high proportion (78.1%), mean is 0. 2±0.16 mmHo, lowest case is 0 mmHo, highest case is 0.7 mmHo.
3.5 Audiogram results
Table 3.5. Mean PTA pre-operative and post-opearative VTI 6 months (n=78)
PTA (dB) Pre-operating After 6 months
p<0.01
Mean 39.21.4 28.41.6
Minimum 21.7 15.3
Maximium 75.1 78.9
There are 78/114 ear were done audiometry pre-operative and postoperative VTI 6 months. PTA in the re-examination is 28.4±1.6 dB, lower than the pre-operative PTA, p<0.01.
3.6. Treatment methods
Table 3.6. Treatment methods (n=76)
Treatment methods Patients
n Percentage %
VTI on one side 31 40.8
VTI on both sides 9 11.8
VTI in one side + adenoidectomy 7 9.2
VTI on both sides + adenoidectomy 29 38.2
Total 76 100.0
VTI on one side takes the majority of percentages 40.8%. The next is VTI on both sides + adenoidectomy 38.2%.
3.7. Complications after 3 and 6 months of VTI
After 3 months of VTI there were 19 ears (16.7%) having complications while after 6 months of VTI the number of ears having complications were 44 ears (40.4%).
Table 3.7. Results after 3 and 6 months of VTI Time
Result 3 months % 6 months %
No complication 95 83.3 65 59.6
Extrusion 5 4.4 20 18.3
Tube obstruction 3 2.6 6 5.5
Otorrhea 11 9.7 16 14.7
Infection 0 0.0 2 1.9
Total (N) 114 100.0 109 100.0
After 3 months of VTI otorrhea is the complication having the highest percentage (9.7%).
After 6 months, extrusion is the most common complication (18.3%).
4. DISCUSSION
4.1 General features. According to our study OME occur at any age, the mean age is 19.452.3, OME is highly prevalent in young children, especially ≤6 years of age group 39.5%. Other authors show that OME prevalent rate is high at pre-school age (from 0 to 6 years old) [1], [5], this prevalent rate in our study is still low, while the rate of older children and adults is higher, possibly because the sample size is not large enough, the age range of sampling is wide, and OME is asymptomatic so that parents usually overlook or confuse with other pediatric diseases.
4.2 Clinical symptoms. The symptoms in ≤6 years of age group are the symptoms of nasal pharynx accidentally discovered when their parent brought them to visit clinical physicians because of naso-pharyngeal symptoms, secondly diagnosed hearing loss through the signs and symptoms: speech and language delay, no response when calling or worsen studying or can not hear the lesson. In table 3.1, there are 73.3%
nasal obstruction, 66.7% rhinorrhea, 33.3% speech delay. In Nurliza ‘s study, the leading presenting complaints were ear infection (50%), hearing loss (46%) and speech delay/problem (35%) which was seen at below 12 years old [6]. In >6 years of age group, patients can recognize and communicate well so that the most common symptoms are tinnitus (78.3%) and hearing loss (76.1%). The percentage of autophony is 17.4%.
4.3 Tympanic membrane findings: The contracted eardrum was detected during examination in 51 (44.7%), partial yellow eardrum and air-fluid level were noticed in
64 (56.1%) and 73 (64.1%), respectively. Completed opaque was found in 46 (40.4%) (Tab 3.2). These findings are similar to results in Nguyen and Doan ‘s studies [1], [4].
4.4 Tympanogram results. Tympanometry showed flat type in 92 (80.7%) corresponding to type B tympanogram (Tab 3.3). In Nurliza ‘s study Type B tympanometry was noted in 74% [6], in Yousaf ‘s study tympanometry showed type B curve in 70 (62.5%) ears [5]. Low compliance level (0.2 mmHo) has a very high proportion (78.1%), mean is 0.12±0.16 mmHo (Tab 3.4). Tympanometry is the objective method to evaluate the middle ear functions even in younger patients. However, we have to eliminate the factors causing false positives such as tympanic membrane perforation or ear wax.
4.5 Audiogram results. Audiometry was done in 78 ears of older children and adults who have good cooperation. Audiogram was conductive hearing loss (CHL) with PTA >
20 db (100%). Cotton ‘s study show hearing loss in OME is CHL with a hearing loss of 15 to 45 dB [3]. This proves OME affects sufficiently the hearing. PTA in the postoperative visit is 28.4±1.6 dB, lower than pre-operative measurement with p<0.01 (Tab 3.5), reveals the benefit of VTI to remove the fluid and equalize pressure inside and outside middle ear cavity.
4.6 Treatment methods. In US, VTI is currently the most common surgical procedure in children that requires general anesthesia [7]. According to Cotton‘s study, the indications of VTI are: chronic OME with hearing loss greater than 15 dB; recurrent OME (fail chemoprophylaxis); atelectasis with retraction pocket formation;
excessively symptomatic child [3]. In our study, we performed the operation under general anesthesia in young children, with the older patients we did VTI under local anesthesia by endoscopy or ENT microscope. Most of ventilation tube are grommet (short-acting tube), in some cases of atelectasis and retraction pocket we used T-tube (long-acting tube) for the right indication and good result. VTI on both sides + adenoidectomy was seen in 29 cases (38.2%) (Tab 3.6). The combination between adenoidectomy and VTI has the good result, quickly improves functions of middle ear cavity in OME [8].
4.7 Results after 3 and 6 months of VTI. Most of cases are dry, ventilation tubes are still on eardrums, The most common complications are otorrhea, extrusion, after 3 months there are 11 cases of otorrhea (9.7%) and 5 cases of extrusion (4.4%). After 6 months
otorrhea is 13.6% [5]. In these cases, we treated with suction and antimicrobial drop.
In some cases when the ventilation tube is extrusted too soon and OME recurred we performed VTI again and had follow-up. In most cases of extrusion, the eardrum was closed, there was a case the eardrum was not closed we had to perform myringoplasty.
According to Yousaf, the percentage of perforation in eardrum is 2.3% [5].
5. CONCLUSION
- Otitis media with effusion is a common disease in childhood, common causes are adenoiditis and naso-pharyngeal infection. The symptoms in the ear are silent and hard to detect in young age group. Tympanometry plays a major role in diagnosis and objective evaluation of middle ear status.
- Ventilation tube insertion helps to restore the normal physiological functions of middle ear in otitis media with effusion and improves the hearing. The most common complication after procedure are otorrhea, extrusion.
REFERENCES
1. Nguyen Thi Hoai An (2002), Otitis media with effusion epidemic features in children in Trung Tu Ward and other Wards in Ha Noi, PhD Thesis, Hanoi Medical University.
2. Shekelle P, Takata G, Chan LS. Agency for healthcare research and quality (AHRQ) Publication. No. 03-E023. Evidence Report/Technology Assessment No. 55 (Prepared by Southern California Evidence-based Practice Center under Contract No 290-97-0001, Task Order No. 4) Rockville, MD: 2003. Diagnosis, history, and late effects of otitis media with effusion
3. Cotton Robin T. (1991), "The Surgical Management of Chronic Otitis Media With Effusion", Pediatric Annals. 20(11), pp. 628-636.
4. Doan Dieu Vi (2014), Study clinical, paraclinical features and treatment results of otitis media with effusion, Resident doctor thesis, Hue University Of Medicine and Pharmacy.
5. Yousaf M. (2012), "Medical versus surgical management of otitis media with effusion in children", J Ayub Med Coll Abbottabad. 24(1), pp. 83-85.
6. Nurliza I. (2011), "Retrospective Review of Grommet Insertions for Otitis Media with Effusion in Children in Singapore", Med J Malaysia, 66(3), pp. 227-230.
7. Flint Paul W. et al (2015), "Acute Otitis Media and Otitis Media with Effusion", Cummings Otolaryngology–Head and Neck Surgery, Elsevier, USA, pp. 3021-3040.
8. Coyte PC, Croxford R, McIsaac W, Feldman W. Friedberg J. (2001), “The role of adjuvant adenoidectomy and tonsillectomy in the outcome of insertion of tympanostomy tubes”, New England J Med, 344, pp. 1188-95
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Học vị: Thạc sĩ
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