Effect of the coronavirus disease 2019 pandemic on paediatric bilateral myringotomy and tube insertion rates in New Brunswick, Canada.

OBJECTIVE: To assess the effect of the coronavirus disease 2019 pandemic on paediatric bilateral myringotomy and tube insertion rates in New Brunswick, Canada. METHODS: All paediatric bilateral myringotomy and tube insertion cases from 1 July 2015 through 30 June 2021 were provided by New Brunswick Medicare. The numbers of otolaryngologists, cataract surgical procedures, total hip arthroplasties and thyroidectomies were collected to assess the availability of operating theatres and otolaryngologists. Negative binomial logarithmic regressions were used for analyses. RESULTS: Of the 5175 paediatric bilateral myringotomy and tube insertion cases that were included, the bilateral myringotomy and tube insertion rate significantly decreased by 2.9 times (p < 0.001) during the pandemic. Thyroidectomies, cataract surgical procedures and total hip arthroplasties did not significantly decrease. The number of otolaryngologists increased (20 vs 16-17). CONCLUSION: Paediatric bilateral myringotomy and tube insertion rates significantly decreased during the pandemic. This cannot be accounted for by reduced otolaryngologists or operating theatre availability. The paediatric bilateral myringotomy and tube insertion rate decrease is likely due to public health measures reducing the transmission of upper respiratory tract infections, resulting in fewer indications for paediatric bilateral myringotomy and tube insertion.

The use of lidocaine spray (Xylocaine) as a topical anaesthetic for minor ear procedures.

BACKGROUND: Injectable anaesthetic agents, topical creams and aqueous solutions have previously been used to anaesthetise the tympanic membrane for minor ear procedures. Topical creams take 20-30 minutes to work and injectable anaesthetics can cause canal swelling. The effectiveness of lidocaine spray has not previously been investigated in patients undergoing minor ear procedures. METHODS: Eighteen participants attending for out-patient grommet insertion or intratympanic steroid injection were prospectively recruited for this study over six months. Post-operatively, they were asked about their perceived level of pain and overall experience. RESULTS: The median level of pain measured on an 11-point visual analogue scale was 2 out of 10. Forty-four per cent reported the overall experience as pleasant, with the remainder selecting slightly unpleasant (66 per cent). All participants stated they would undergo the procedure again. CONCLUSION: Xylocaine spray is simple to administer, rapid-acting and well tolerated by patients for anaesthesia of the tympanic membrane during minor ear procedures in the out-patient setting.

In-Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery.

OBJECTIVES/HYPOTHESIS: Evaluate technical success, tolerability, and safety of lidocaine iontophoresis and tympanostomy tube placement for children in an office setting. STUDY DESIGN: Prospective individual cohort study. METHODS: This prospective multicenter study evaluated in-office tube placement in children ages 6 months through 12 years of age. Anesthesia was achieved via lidocaine/epinephrine iontophoresis. Tube placement was conducted using an integrated and automated myringotomy and tube delivery system. Anxiolytics, sedation, and papoose board were not used. Technical success and safety were evaluated. Patients 5 to 12 years old self-reported tube placement pain using the Faces Pain Scale-Revised (FPS-R) instrument, which ranges from 0 (no pain) to 10 (very much pain). RESULTS: Children were enrolled into three cohorts with 68, 47, and 222 children in the Operating Room (OR) Lead-In, Office Lead-In, and Pivotal cohorts, respectively. In the Pivotal cohort, there were 120 and 102 children in the <5 and 5- to 12-year-old age groups, respectively, with a mean age of 2.3 and 7.6 years, respectively. Bilateral tube placement was indicated for 94.2% of children <5 and 88.2% of children 5 to 12 years old. Tubes were successfully placed in all indicated ears in 85.8% (103/120) of children <5 and 89.2% (91/102) of children 5 to 12 years old. Mean FPS-R score was 3.30 (standard deviation [SD] = 3.39) for tube placement and 1.69 (SD = 2.43) at 5 minutes postprocedure. There were no serious adverse events. Nonserious adverse events occurred at rates similar to standard tympanostomy procedures. CONCLUSIONS: In-office tube placement in selected patients can be successfully achieved without requiring sedatives, anxiolytics, or papoose restraints via lidocaine iontophoresis local anesthesia and an automated myringotomy and tube delivery system. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:S1-S9, 2020.

Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement.

BACKGROUND: Myringotomy tube placement is a pediatric procedure frequently performed under inhalational anesthesia without intravenous line placement. Emergence delirium is common following sevoflurane anesthesia, and can lead to patient harm and escalation of nursing care. Our goal was to determine if intraoperative acupuncture, compared to standard of care, reduces emergence delirium in children undergoing myringotomy tube placement. METHODS: Single center, randomized, controlled trial at a university hospital, including children ages 1-6 years with ASA physical status 1-3 scheduled for myringotomy tube placement. Participants were stratified based on midazolam premedication and randomized to intraoperative acupuncture (AC, N.=49) or standard anesthesia care (SC, N.=50). Acupuncture needles were placed in bilateral Heart 7 (HT7) and ear Shen Men points after anesthesia induction. A blinded observer in the PACU assessed emergence delirium using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Endpoints were highest PAED score in the recovery room and post-discharge agitation and sleep quality. RESULTS: Patient baseline characteristics were similar between treatment groups. With midazolam premedication, the highest PAED score was 11.6 in patients receiving AC and 12.0 for SC. Without midazolam premedication, the highest PAED was 11.8 in patients receiving AC and 10.7 for SC. The overall PAED score difference between AC and SC groups was 0.33 (95% CI -1.5, 2.2, P=0.723). CONCLUSIONS: Intraoperative acupuncture at HT7 and ear Shen Men did not reduce PAED scores after myringotomy tube placement. Based on these data, it is therefore unlikely that a larger study of the same design would demonstrate a significant effect of intraoperative acupuncture on emergence delirium after brief sevoflurane anesthesia. However, other acupuncture points or techniques could be considered.

Otitis Media: Rapid Evidence Review.

Acute otitis media (AOM) is the most common diagnosis in childhood acute sick visits. By three years of age, 50% to 85% of children will have at least one episode of AOM. Symptoms may include ear pain (rubbing, tugging, or holding the ear may be a sign of pain), fever, irritability, otorrhea, anorexia, and sometimes vomiting or lethargy. AOM is diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and either recent-onset ear pain (less than 48 hours) or intense erythema of the tympanic membrane. Treatment includes pain management plus observation or antibiotics, depending on the patient's age, severity of symptoms, and whether the AOM is unilateral or bilateral. When antibiotics are used, high-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is first-line therapy unless the patient has taken amoxicillin for AOM in the previous 30 days or has concomitant purulent conjunctivitis; amoxicillin/clavulanate is typically used in this case. Cefdinir or azithromycin should be the first-line antibiotic in those with penicillin allergy based on risk of cephalosporin allergy. Tympanostomy tubes should be considered in children with three or more episodes of AOM within six months or four episodes within one year with one episode in the preceding six months. Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of AOM.

Assessing ototoxicity and patients' satisfaction of topical local anaesthesia in myringotomy and ventilation tube insertion.

OBJECTIVES: Animal studies have suggested that exposure of the middle ear to topical local anaesthesia may be ototoxic. This study aimed to report sensorineural hearing outcomes and patients' satisfaction in those who underwent myringotomy and ventilation tube insertion using topical local anaesthesia. METHODS: Twenty-nine patients (32 ears) were operated on. Pre- and post-operative audiology findings were compared. A Likert-type questionnaire on treatment satisfaction was completed at the end of the procedure. RESULTS: Median patient age was 55 years (range, 27-88 years). Pre- and post-operative bone conduction pure tone averages were 26.76 dB and 25.26 dB respectively (mean reduction of -1.22 dB, 95 per cent confidence interval of -5.91 to 8.13 dB; p = 0.7538). One ear (3 per cent) had a reduction in pure tone average of 10 dB. CONCLUSION: The results suggest that sensorineural hearing loss is not a complication of ear exposure to topical local anaesthesia during myringotomy and ventilation tube insertion. The procedure was well perceived.

Identifying eustachian tube dysfunction prior to hyperbaric oxygen therapy: Who is at risk for intolerance?

PURPOSE: Determine whether specific risk factors, symptoms and clinical examination findings are associated with hyperbaric oxygen therapy (HBOT) intolerance and subsequent tympanotomy tube placement. MATERIALS AND METHODS: A retrospective case series with chart review was conducted from 2007 to 2016 of patients undergoing HBOT clearance at a tertiary care university hospital in an urban city. Eighty-one (n=81) patient charts were reviewed for risk factors, symptoms and clinical examination findings related to HBOT eustachian tube dysfunction and middle ear barotrauma. Relative risk was calculated for each variable to determine risk for HBOT intolerance and need for tympanotomy tube placement. Risk factor, symptom, physical examination and HBOT complication-susceptibility scores were calculated for each patient. RESULTS: Mean risk factor, clinical and HBOT complication-susceptibility scores were significantly higher in patients who did not tolerate HBOT compared to patients who tolerated HBOT. Patients reporting a history of otitis media, tinnitus, and prior ear surgery were at a higher risk for HBOT intolerance. Patients reporting a history of pressure intolerance and prior ear surgery were more likely to undergo tympanotomy tube placement. Patients noted to have otologic findings prior to HBOT were at a higher risk for both HBOT intolerance and tympanotomy tube placement. CONCLUSIONS: A thorough otolaryngological evaluation can potentially predict and identify patients at risk for HBOT intolerance and tympanotomy tube placement.

Delayed Effect of Active Pressure Treatment on Endolymphatic Hydrops.

OBJECTIVE: To identify eventual correlations between the effect of low-pressure treatment and endolymphatic hydrops in Ménière patients. MATERIAL AND METHODS: The study group consisted of subjects affected by definite Ménière disease (2015) and a severe degree of disability, who received a ventilation tube with or without a low-pressure treatment before undergoing a surgical procedure (vestibular neurectomy). After the placement of the ventilation tube, the subjects were either left alone with the tube or received 1 month of self-administered low-pressure therapy with a portable device. In all subjects, an electrocochleography (ECochG) was performed and specific questionnaires - Dizziness Handicap Inventory (DHI) and Functional Scale Level (FSL) - were completed before starting either arm of treatment, at the end of treatment, and then 3 and 6 months later. RESULTS: All selected subjects presented with an ECochG pattern that was indicative of endolymphatic hydrops before starting either treatment. At the end of pressure treatment, 80% showed symptomatic improvement while maintaining the hydropic ECochG pattern. At the 3-month control stage, the hydropic pattern resulted normalized (<0.5) in all the improved subjects. CONCLUSIONS: Although 1 month of low-pressure treatment provided a positive symptomatological outcome, normalization of the hydropic ECochG parameters occurred only at a later time. Therefore, it is possible to assume that endolymphatic hydrops could be concurrent with a non-symptomatic stage of Ménière disease, and that the anti-hydropic effect of the low-pressure treatment, if any, would present with a certain delay after its completion.

[The application of the method of radiofrequency myringotomy under the experimental conditions and in the clinical practice]. / Primenenie metoda radiovolnovoi miringotomii v usloviiakh éksperimenta i v klinicheskoi praktike.

Exudative otitis media is a widespread pathological condition in the human population. In the recent years, the treatment with the electric current having the frequency up to 3.8 MHz has found the increasingly frequent application, in addition to shunting and laser myringotomy, for the perforation of the tympanic membrane to facilitate removal of exudate. The objective of the present study was to evaluate the effectiveness of the application of the electric current with the frequency up to 4 MHz for myringotomy in the patients presenting with exudative otitis media under the experimental conditions and in the clinical practice. The experimental studies were carried out with the use of the isolated temporal bones (ex vivo) and laboratory animals (in vivo). The clinical studies included the surgical treatment of 41 patients presenting with exudative otitis media using the electric current with the frequency of 4 MHz and laser irradiation with the subsequent evaluation of the inflammatory manifestations in the tympanic membrane tissues during the early post-operative period. It was shown that the method of myringotomy with the application of the electric current having the frequency of 4 MHz is safe and causes no complications. Moreover, it is accompanied by the development of the minimally active inflammatory processes in the tympanic membrane tissues during the early post-operative period.

Tympanostomy tube placement in awake, unrestrained pediatric patients: A prospective, multicenter study.

OBJECTIVES: Tympanostomy tube (tube) placement is the most common pediatric otolaryngologic surgery in the United States. Most surgeries are performed in an operating-room setting under general anesthesia due to the lack of tolerable and reliable local anesthesia methods suitable for pediatric patients, and concerns regarding myringotomy procedures in a mobile child. This study evaluated the safety and efficacy of an iontophoresis system (IPS) to achieve local anesthesia in combination with a tube delivery system (TDS) for tube placement in pediatric patients in an office setting. METHODS: A prospective, single-arm study was conducted at 9 otolaryngology sites in the United States. Participants included pediatric patients aged 6 months to less than 22 years requiring tube placement. Patients were prepared for the procedure using behavioral support techniques and tube placement was attempted under local anesthesia using the IPS in conjunction with the TDS. No physical restraints were allowed and no anxiolytics, analgesics, or sedatives were permitted. Safety was assessed through the occurrence of adverse events and success rates for tube placement under local anesthesia were determined. Tolerability of the procedure was evaluated using the 5-point Wong-Baker FACES Pain Rating Scale and parental satisfaction was assessed using a postoperative survey. RESULTS: Seventy patients (127 ears) were enrolled in the study [mean (SD) age=7.0 (3.9) years]. No serious adverse events occurred in the 70 enrolled patients. Tube placement using the TDS was successful in 96.6% (114/118) of attempted ears. A single TDS was required in 105 ears, while more than 1 device was required in 9 ears. Of the 70 patients enrolled in study, 63 (90.0%) successfully received tubes in all indicated ears during their in-office visit. The mean (SD) change in pain score from pre-anesthesia to post-surgery was +0.9 (1.8). Favorable ratings for overall satisfaction with the in-office procedure were obtained from 96.9% (63/65) of respondents. Tube retention at 2 weeks was 99.1%. As only 15 patients were enrolled who were 3 years old or younger, the ability to generalize these results to younger patients is limited. CONCLUSIONS: In this study, use of the IPS and TDS technologies enabled safe, reliable, and tolerable placement of tubes in awake, unrestrained pediatric patients.

Grommets in HBOT patients: GA vs LA, unanswered questions.

We read with interest the article on grommet procedures for patients undergoing hyperbaric oxygen therapy (HBOT), and have a number of comments. It appears the authors may have missed a number of cases. In a previous paper from The Townsville Hospital Hyperbaric Unit (TTH HMU), Commons et al presented 14 of 106 patients (13%) who required grommets over the period between June 2009 and May 2010. These patients are included in the Lamprell et al data set. Figure 1 shows an apparent spike in their cases in 2010 (n = 13, part of the period covered in the previous paper) when compared to the remaining four years of their study (mean number of cases 4.5 per year, for an incidence of 3%). This difference in incidence is statistically significant (chi square = 8.336, df = 1, P = 0.004). We suspect the difference may be the result of missed cases rather than a true spike; however, it is not possible to determine this from the paper. Lamprell et al describe identifying cases using the TTH HMU patient database. Did the authors also consider using the operating theatre database and/or ENT clinic records to ensure all cases were captured? We also have concerns regarding Lamprell's primary outcome measure: time from ENT referral to date of re/commencement of HBOT. These data are presented as median values with the associated ranges, rather than an interquartile range (IQR), the traditional measure of dispersion in non-parametric data. We believe the data sets contain a number of outliers that should be excluded, e.g., 98 days. We ask to see the IQRs and box-and-whisker plots for both data sets, and suspect the statistically significant difference in medians might not remain with outliers excluded from the analysis. There is also no discussion about the clinical relevance of this difference of seven days. Based on the most common indications for HBOT listed, most patients would have received at least 30 daily sessions of HBOT. What impact does a delay of seven days have on their treatment? As doctors who have worked at this HMU, we know patients preferentially received their grommets under GA prior to 2012 at the request of the ENT surgeon, who believed that insertion under LA was poorly tolerated. The authors do not describe whether the insertion of grommets under LA was associated with patient discomfort; a limitation of this retrospective paper, but a clinically relevant factor in the decision-making process of which form of anaesthesia to use. The paper by Lamprell et al has shown us that patients may experience a more rapid insertion of grommets and return to HBOT, if inserted under LA versus GA, but this difference may not be important clinically. We believe the authors may have failed to collect all cases and exclude outliers and this, coupled with the lack of documentation about patient satisfaction with insertion under LA, leaves us with more questions than answers.

Correction and response to: Grommets in HBOT patients: GA vs. LA, unanswered questions.

We thank Gibbs and Commons for their interest in our paper. There is a key difference between the datasets for Commons et al and our study. Our data set, has grouped five years of data according to the calendar year. This is different from Commons et al's study population recruited between 01 June 2009 and 31 May 2010. We feel this may explain the difference of one case between the two papers in 2010. Our data collection used the standard clinic and operating theatre databases, and we were advised that there was no searchable clinical code for grommet procedures undertaken with local anaesthetic (LA) in the outpatient clinic. The alternative, to review many hundreds of patients, was considered beyond the study's scope. Instead, the TTH Hyperbaric Medicine Unit (HMU) database was used to recruit cases and cross checked with operating theatre data. We have since re-investigated the operating theatre database to identify any additional bilateral grommet procedures during 2008 to 2012 and cross checked these with the HMU database. This has identified one to four additional patients per year in the general anaesthesia (GA) group and one additional LA patient that meet the criteria for recruitment into the study. There was one further unconfirmed patient from each of 2008 and 2010, whose charts were unavailable for this response, and have not been included in this amendment. The corrected Figure 1 reflects these changes. Despite the additional cases, the frequency spike during 2010 remains. A published audit of the number of middle ear barotrauma (MEBT) cases between 2007-2010 also reports an increased incidence of MEBT in 2009-2010 compared with previous years at our unit. Possible reasons for this may be the introduction of new technology at the unit, in the form of the digital Macro View™ otoscope during this period, leading to a possible change in clinical practice and an increased detection of MEBT, or a lower threshold for ENT referral for grommet placement. Alternatively, a 'Hawthorne effect' from the conduct of a prospective study within the TTH HMU, during 2009-2010 may be considered. With the outliers removed using ROUT's test, the significant difference in the delay time to surgery remains (LA median 1, IQR 2, range 0-5 days; GA median 7.5, IQR 6, range 0-24 days; P < 0.0001; Figure 2). The data values of 98 days and 86 days from the GA group published in our paper are corrected to six days and 12 days respectively. On review, the first individual was found to have had two HBOT courses, and it was only in the second round of HBOT that an ENT referral for grommets was made. The second individual was found to have been offered two ENT referrals after experiencing MEBT, the first was followed by the patient declining further HBOT until representing to TTH HMU four months later and receiving prophylactic grommets before recommencing HBOT; this second ENT referral date has been used in the amended data. These corrections have not been found to change the primary outcome of statistical significance between the LA and GA groups. A delay of seven days may not be considered clinically relevant in the most common cases requiring HBOT, aside from affecting patient convenience and logistics as well as hospital efficiency and resources. In emergency cases, knowledge of factors able to reduce the delay for grommet insertion is clinically relevant. In centres where a long wait for GA is the norm, LA may convey a clinically important lesser waiting time. As a retrospective study, only data documented in the patient records could be studied, and patient discomfort was not consistently recorded in the charts. We would liken this to undertaking other surgical procedures, where clinicians often do not routinely document pain scores for the benefit of retrospective research. Several studies have examined patients' tolerance of grommets under LA, finding the technique tolerable.

Retrospective review of grommet procedures under general versus local anaesthesia among patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: One significant side effect of hyperbaric oxygen treatment (HBOT) is middle ear barotrauma (MEBT) may require tympanostomy tube (grommet) insertion by the Ear, Nose and Throat service. Where timely HBOT is needed, routine insertion of grommets under local anaesthesia (LA) is becoming common. AIMS: To investigate the differences between patients receiving HBOT and concurrent grommets under LA versus general anesthesia (GA) at The Townsville Hospital (TTH). METHODS: A retrospective chart analysis of patients receiving HBOT between 2008 and 2012 and requiring grommets was undertaken. RESULTS: Thirty-one (5%) out of 685 patients treated with HBOT from 2008 to 2012 received grommets. Twelve cases received grommets under LA, and 19 under GA. Twenty out of the 31 cases had grommets following MEBT and the remainder prophylactically. Complications of grommet insertion comprised two cases with blocked grommets. There was a significant difference (P = 0.005) in the time in days from ENT referral to HBOT between the LA group (median 1 day, range 0-13 days) and the GA group (median 8 days, range 0-98 days). CONCLUSION: A greater number of hyperbaric patients received grommets under GA than LA at the TTH. Insertion of grommets under LA was safe, offering advantages to both the patient and the treating team in the setting of HBOT-associated otic barotrauma.

A novel technique of otic barotrauma management using modified intravenous cannulae.

This article provides the first detailed description and systematic evaluation of the management of otic barotrauma using modified intravenous cannulae. A 24-gauge IC cannula was modified as a tool for tympanostomy tube placement and middle ear ventilation. The medical records of 271 ears of 156 adult patients (median age 49 years) who underwent this procedure were reviewed retrospectively. Hundred and ninty-one tubes were placed for otalgia because of hyperbaric oxygen therapy, 58 tubes were inserted for air travel prophylaxis and 22 tubes were placed for management of otic barotrauma post-flight. All the patients who had this procedure for prophylaxis experienced regular otic barotrauma symptoms during air travel prior to tube placement. All patients were reviewed 6 weeks (range 2-9 weeks) post-procedure. This technique of otic barotrauma management worked effectively in 99 % of treated patients. On follow-up, 88 % of tubes were found to be extruded and non-extruded tubes were removed in clinic without any anaesthesia. 99.6 % of tympanic membrane had healed completely and spontaneously without sequelae. Given the safety, effectiveness, low risk of complications associated with this novel tympanostomy technique, it provided a simple yet effective therapeutic option for the management of otic barotrauma. Finally, this technique can be easily applied in all health settings as it only requires medical supplies readily available in hospitals, therefore there is no additional cost.

Novel rat model of tympanostomy tube otorrhea.

OBJECTIVE: Tympanostomy tube otorrhea (TTO), caused by the presence of pathogenic bacteria in the middle ear, is the most common complication of TT insertion. No studies have described a reproducible animal model of TTO. We aimed to develop a rat model of TTO which, in turn, could be used to assay the levels of TNF-α and IL-1ß through the course of the infection. METHODS: The left Eustachian tubes of 55 male Sprague-Dawley albino rats were occluded with gutta-percha (ETO=Eustachian Tube Occlusion). Middle ear (ME) effusion was ascertained by weekly otomicroscopy. At 3 weeks tympanostomy tubes were placed bilaterally and the MEs were inoculated bilaterally with Streptococcus pneumoniae through the tubes. The rats were randomly assigned to one of two daily ototopical treatments: ciprofloxacin/dexamethasone (CDX) or placebo. The animals in each of the two treatment groups were further divided to receive 1, 2, 5 or 7 days of treatment. The rats were sacrificed after treatment was finished. The rates of otorrhea, positive middle ear (ME) cultures, and levels of TNF-α and IL-1ß in the ME fluid were measured. RESULTS: Left ETO followed by ME inoculation with S. pneumoniae and treatment with placebo resulted in persistent infection (100% culture-positive ME fluid at 10 days) and otorrhea (85.7%). Persistent infection of the left ear was accompanied by significantly elevated the levels of IL-1ß and TNF-α. Ears treated with CDX had lower rates of otorrhea at all time points and lower levels of IL-1ß and TNF-α. CONCLUSIONS: This study is the first to describe a reproducible animal model of acute TTO. Surgical obstruction of the ET, followed by TT placement and ME inoculation with S. pneumoniae induced persistent otorrhea and infection. Both IL-1ß and TNF-α appear to be potential markers of persistent middle ear infection. This novel model may be used in future studies of the pathogenesis and therapy of TTO.

Demographics and microbiology of otorrhea through patent tubes failing ototopical and/or oral antibiotic therapy.

OBJECTIVES: Posttympanostomy tube otorrhea (PTTO) results in significant health care cost and decreased satisfaction with care. The authors reviewed PTTO failing initial ototopical and/or oral antibiotic therapy and microbiology/susceptibility data from cultures. STUDY DESIGN: Case series with chart review. SETTING: A community university satellite ambulatory clinic and the outpatient clinic of a children's hospital. METHODS: Review of 202 patients with 228 discrete episodes of culture-positive otorrhea from January 2004 to January 2009. RESULTS: PTTO occurred an average of 13 months after tube placement. Median otorrhea duration was 21 days (mean, 42 days). A mean of 1.6 visits (range, 1-6) to the pediatric otolaryngology office was required for PTTO resolution. Ototopical therapy was reported used in 198 of 228 (87%) episodes of otorrhea prior to pediatric otolaryngology visit. Nearly 50% of patients were prescribed at least 1 or more courses of systemic antibiotics. Staphylococcus aureus accounted for 52% of the organisms cultured, with 57% methicillin-resistant S aureus (MRSA). S aureus resistance to clindamycin was high (49%) and resistance to levofloxacin was low (1.8%). MRSA was 68% clindamycin resistant, much higher than both ours and the children's hospital's clindamycin resistance rate of MRSA cultured from all other body sites. CONCLUSIONS: PTTO that presents as having failed ototopical and/or oral antibiotics most commonly consists of S aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa. MRSA is highly prevalent in this population. It is not necessary to culture PTTO that presents to an otolaryngology office, as resistance to levofloxacin was only 1.8%. It is unclear why the same fluoroquinolone ototopical therapy that failed initially is often successful in treating PTTO after otolaryngologist visit.

Myringotomy and ventilation tube insertion with minims tetracaine drops.

We present a novel and safe technique for insertion of ventilation tubes under local anaesthetic which we feel improves the patient's experience and shortens the overall procedural time.

Resolved effusion on myringotomy: a study of dry tap without general anesthesia.

OBJECTIVES: Finding a resolution of middle ear effusion using myringotomy, or dry tap (DT), is relatively common, but its clinical outcome is confounded by general anesthesia (GA). The confounding effect of GA and a time delay can be removed because laser myringotomy can be completed under topical anesthesia, which is a routine procedure for otitis media with effusion (OME) before GA in our clinic. DT without GA would clarify the clinical outcome, and the percentage of recurrence for OME after DT would be clinically relevant. The objectives of the present study are (1) to clarify the clinical nature of DT without including the confounding effect of GA and a time delay and (2) to determine if OME recurs when a ventilation tube (VT) is not used for DT. METHODS: The control group consisted of 308 children who received an unilateral myringotomy due to a natural resolution in the contralateral ear. The experimental group consisted of 296 children who had a bilateral myringotomy, and a ventilation tube was not inserted for DTs after laser myringotomy under topical anesthesia. The rate of DT and the recurrence rate of OME without tube insertion was the main outcome measure. RESULTS: In the control group, which showed a natural resolution, the rate of DT was 16.9% (52/308) of patients, and DT was more common in non-B tympanometry, which only had a recurrence rate of 17.3% (9/52). In the study group, 3.7% of patients showed unilateral DT (UDT) with contralateral positive effusion, and 5.4% of patients showed bilateral DTs (BDTs). BDT showed a non-B tympanometry pattern and a low rate of recurrence (25.0%), which was similar to the control group. UDT showed a B-type tympanometry in 81.8% of the patients, and the recurrence rate was significantly higher (68.2%; 15/22) than the BDT and control patients. BDT or DT with signs of natural resolution showed a low rate of OME recurrence regardless of tympanometry, and thus, patients do not need a VT. CONCLUSIONS: DT was not rare even without GA and the associated time delay, and DT was more common in the children that showed a natural resolution. However, microscopy and tympanometry was imperfect to predict dry tap, and thus, the surgeon needs to be prepared for individualized management of DT. UDT with B-type tympanometry and contralateral persistent effusion frequently recurred without tubes, and thus, VT for UDT appeared to be necessary.

Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion.

AIM: To further investigate the effect of acupuncture in postoperative pain and emergence agitation in children undergoing bilateral myringotomy and tympanostomy tube (BMT) placement. BACKGROUND: BMT insertion surgery in children is routinely performed under general anesthesia and is associated with a high incidence of postoperative pain and agitation upon emergence from anesthesia. Various medications have been investigated to alleviate the pain and agitation, which have been accompanied by high incidence of adverse effects. In children, anecdotal reports suggest that acupuncture may offer postoperative analgesia. METHODS/MATERIALS: This prospective randomized controlled trial is to evaluate the effectiveness of acupuncture to control pain and agitation after initial bilateral myringotomy tube placement in 60 nonpremedicated children. Acupuncture was applied at points LI-4 (he gu) and HT-7 (shen men) immediately after induction of anesthesia. A single-blinded assessor evaluated postoperative pain and agitation using CHEOPS and emergence agitation scale. Pain and agitation scores were significantly lower in the acupuncture group compared to those in the control group at the time of arrival in the post anesthesia care unit and during the subsequent 30 min. RESULTS: Acupuncture treatment provided significant benefit in pain and agitation reduction. The median time to first postoperative analgesic (acetaminophen) administration was significantly shorter in the control group. The number of patients who required analgesia was considerably fewer in the acupuncture group than that in the control. No adverse effects related to acupuncture treatment were observed. CONCLUSION: Our study suggests that acupuncture therapy may be effective in diminishing both pain and emergence agitation in children after BMT insertion without adverse effects.

Ototoxicity of topical ciprofloxacin/dexamethasone otic suspension in a chinchilla animal model.

OBJECTIVE: To determine the ototoxic potential of ciprofloxacin/dexamethasone eardrops. METHODS: Ventilation tubes were inserted in the ears of 15 chinchillas. One ear was randomized to receive four drops of ciprofloxacin/dexamethasone. A control solution (0.45% NaCl) was applied in the contralateral ear. The eardrops were delivered twice daily for 7 consecutive days. Auditory brain stem response (ABR) measurements were recorded at baseline (post-tympanostomy tube insertion), and on days 4, 8, 15, 22, and 60. RESULTS: An initial transient increase of 8.11 dB nHL was noted in the mean thresholds of the experimental ears at day 4. On the last ABR evaluation (day 60), the mean thresholds were 16.33 +/- 6.93 dB nHL in the experimental ears and 13.66 +/- 6.65 dB nHL in the control ears. The difference in the mean thresholds between the experimental and control ears at day 60 was not significant (95% confidence interval, 3.12, -8.02). Scanning electron microscopy demonstrated normal morphology in all experimental ears that were assessed. CONCLUSION: Ciprofloxacin/dexamethasone eardrops did not appear ototoxic when used in chinchillas post-ventilation tube insertion.