Traumatic Tympanic Membrane Perforations Diagnosed in Emergency Departments.

Importance: Tympanic membrane perforations (TMPs) are frequent events leading to evaluation in the primary care and otolaryngology offices or the emergency department (ED). Despite specific warning labels on packaging of cotton-tipped applicators regarding the risk of injury to the ear canal with personal use, these products are commonly used to remove ear cerumen. Objective: To analyze the mechanism of injury for traumatic TMPs among patients presenting to the ED. Design, Setting, and Participants: Cross-sectional analysis of cases from 100 emergency departments in the United States. The National Electronic Injury Surveillance System was searched on April 3, 2015, for ear-related injuries with analysis information regarding patient age, patient sex, time and date of injury, specific injury diagnoses, and specific injury mechanisms that occurred across 5 years, from January 1, 2010, through December 31, 2014. Main Outcomes and Measures: Diagnoses of traumatic TMP documented in the ED visit record as well as patient demographics, diagnoses, and other aspects of the injury, including mechanism of injury. Results: There were 949 case entries in the database for traumatic TMP, which extrapolates to 4852 ED visits nationally. Of 949 patients evaluated, 568 (59.8%) were men and 381 (40.2%) were women resulting in a male to female ratio of 1.49:1. Most injuries occurred in patients 18 years or younger (602 of 949 [63.4%]) with children younger than 6 years most at risk (331 of 949 [34.9%]). Ear canal instrumentation including foreign bodies was noted in 581 of 949 cases (61.2%), with cotton-tipped applicators noted in 261 (44.9%) of these cases. While foreign body instrumentation represented the leading cause of traumatic TMP in patients aged 0 to 5 years (284 of 331 cases [85.8%]), 6 to 12 years (108 of 158 [68.4%]), 19 to 36 years (85 of 223 [38.1%]), 37 to 54 years (48 of 91 [52.7%]), and 55 years or older (22 of 33 [66.7%]), water trauma was the leading cause of TMP in patients aged 13 to 18 years (43 of 113 cases [38.1%]). Conclusions and Relevance: Traumatic TMP represents a common reason for evaluation in the ED. Despite common warnings regarding risk of injury to the tympanic membrane with use of a cotton-tipped applicator, it is still a major cause of traumatic TMPs. Other injury mechanisms also play an important role in the teenage and young adult populations.

Quinolone Ear Drops After Tympanostomy Tubes and the Risk of Eardrum Perforation: A Retrospective Cohort Study.

Background: This study investigated whether quinolone ear drops, with or without corticosteroids, increase the risk of perforation requiring tympanoplasty following tympanostomy tube (TT) placement in children. Methods: This was a retrospective cohort study using Medicaid encounter and pharmacy billing data from 29 US states between 1999 and 2006. Children <18 years old without predisposing factors for perforation during a 6-month look-back period entered the cohort after TT placement and first dispensing of antibiotic ear drops. Included ear drops were quinolones (ofloxacin, ciprofloxacin plus hydrocortisone, or ciprofloxacin plus dexamethasone) or neomycin plus hydrocortisone. Children were followed until end of 2006, end of Medicaid enrollment, or occurrence of study outcome. A Cox regression model, adjusted for age, sex, race/ethnicity, initial TT indication, reinsertion of TT, adenoidectomy, and number of ear drop prescriptions was used to compare the rate of perforation between quinolone and neomycin plus hydrocortisone ear drop-exposed children. Perforation was defined by its diagnosis code followed by a tympanoplasty code. Results: A total of 96595 children entered the study cohort. Patients exposed to quinolone ear drops had a higher risk of perforation, with an adjusted hazard ratio of 1.61 (95% confidence interval [CI], 1.15-2.26). The adjusted hazard ratios were 1.49 (95% CI, 1.05-2.09) for ofloxacin, 1.94 (95% CI, 1.32-2.85) for ciprofloxacin plus hydrocortisone, and 2.00 (95% CI, 1.18-3.41) for ciprofloxacin plus dexamethasone. Conclusions: Exposure of children with TT to quinolone ear drops is associated with increased risk of perforations requiring tympanoplasty, which appears to be further exaggerated by corticosteroids. Clinicians should consider the risk of perforation and counsel patients/families accordingly when prescribing quinolone ear drops.

Otitis media in children vaccinated during consecutive 7-valent or 10-valent pneumococcal conjugate vaccination schedules.

BACKGROUND: In 2001 when 7-valent pneumococcal conjugate vaccine (PCV7) was introduced, almost all (90%) young Australian Indigenous children living in remote communities had some form of otitis media (OM), including 24% with tympanic membrane perforation (TMP). In late 2009, the Northern Territory childhood vaccination schedule replaced PCV7 with 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10). METHODS: We conducted regular surveillance of all forms of OM in children in remote Indigenous communities between September 2008 and December 2012. This analysis compares children less than 36 months of age who received a primary course of at least two doses of PCV7 or PHiD-CV10, and not more than one dose of another pneumococcal vaccine. RESULTS: Mean ages of 444 PCV7- and 451 PHiD-CV10-vaccinated children were 20 and 18 months, respectively. Bilaterally normal middle ears were detected in 7% and 9% respectively. OM with effusion was diagnosed in 41% and 51% (Risk Difference 10% [95% Confidence Interval 3 to 17] p = 0.002), any suppurative OM (acute OM or any TMP) in 51% versus 39% (RD -12% [95% CI -19 to -5] p = 0.0004], and TMP in 17% versus 14% (RD -3% [95% CI -8 to 2] p = 0.2), respectively. Multivariate analyses described a similar independent negative association between suppurative OM and PHiD-CV10 compared to PCV7 (Odds Ratio = 0.6 [95% CI 0.4 to 0.8] p = 0.001). Additional children in the household were a risk factor for OM (OR = 2.4 [95% CI 2 to 4] p = 0.001 for the third additional child), and older age and male gender were associated with less disease. Other measured risk factors were non-significant. Similar clinical results were found for children who had received non-mixed PCV schedules. CONCLUSIONS: Otitis media remains a significant health and social issue for Australian Indigenous children despite PCV vaccination. Around 90% of young children have some form of OM. Children vaccinated in with PHiD-CV10 had less suppurative OM than children vaccinated with PCV7. Ongoing surveillance during the PCV13 era, and trials of early intervention including earlier and mixed vaccine schedules are warranted.

Blast-related ear injuries among U.S. military personnel.

Blast-related ear injuries are a concern during deployment because they can compromise a servicemember's situational awareness and adversely affect operational readiness. The objectives of this study were to describe blast-related ear injuries during Operation Iraqi Freedom, identify the effect of hearing protection worn at the point of injury, and explore hearing loss and tinnitus outcomes within one year after injury. The Expeditionary Medical Encounter Database was used to identify military personnel who survived blast-related injury, and it was linked with outpatient medical databases to obtain diagnoses of hearing loss and tinnitus. The prevalence of ear injuries was 30.7% (1,223 of 3,981). The most common ear injury diagnoses were "inner or middle ear injury involving tinnitus" and tympanic membrane (TM) rupture. Hearing protection reduced the odds of ear injury involving tinnitus. Personnel with TM rupture had higher odds of hearing loss (odds ratio [OR] = 6.65, 95% confidence interval [CI] = 5.04-8.78) and tinnitus outcomes (OR = 4.34, 95% CI = 3.12-6.04) than those without TM rupture. Ear injuries and hearing impairment are frequent consequences of blast exposure during combat deployment. Hearing protection is warranted for all servicemembers at risk of blast exposure.

Ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in management of pars tensa cholesteatoma.

OBJECTIVE: To compare anatomical and audiological outcomes of ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in patients with pars tensa cholesteatoma. STUDY DESIGN: Prospective clinical study. SETTING: Otolaryngology department, Tanta University Hospital, Egypt. PATIENTS AND METHODS: Over three years, 60 ears in 60 patients underwent surgery for either sinus or tensa retraction cholesteatoma, reconstructed using either a ring-shaped (30 ears) or Mercedes-Benz symbol shaped (30 ears) cartilage-perichondrium graft, with at least two years' follow up. Post-operative drum perforation and retraction, cholesteatoma residue and recurrence, middle-ear effusion, and hearing acuity were monitored. RESULTS: Anatomical outcomes were equivalent in both groups, but slightly better in the Mercedes group. Hearing improved significantly in both groups (pre- vs post-operative results), but significantly more so in the ring group. Within-group hearing outcomes were unaffected by cholesteatoma type or tympanoplasty type. CONCLUSION: The Mercedes-Benz technique may be superior to the ring technique in preventing neodrum retraction. However, the ring graft technique had better hearing outcomes, perhaps due to its more physiological design.

[Temporal bone surgery. Surgical sequelae and complications]. / Felsenbeinchirurgie. Komplikationen und unerwünschte Operationsfolgen.

The saying "no surgery, no surgical complications" is certainly true for all specialties. Three categories of undesired events may occur following surgery: surgical sequelae, failure to cure and complications. A critical self-analysis of surgical complications often reveals that these arise in vexing fashion according to Murphy's law, i.e. "what can go wrong, will go wrong". Incomplete preoperative evaluation, insufficient exposure of the surgical field, failure to identify surgical landmarks and misjudgment of the patient's preoperative complaints may culminate in an undesired surgical outcome. Modern preoperative radiology, the possibilities of actual or even virtual temporal bone drilling in the laboratory and the surgeon's level of experience all ensure the relative rarity of relevant surgical complications in otology.

Análisis de coste-efectividad de la vacunación antineumocócica en España / Cost-effectiveness analysis of pneumococcal vaccination in Spain

Objetivo: Análisis de coste-efectividad de la vacunación antineumocócica pediátrica en Espa˜na.Métodos: Se utilizó un modelo determinístico poblacional en forma de árbol de decisión con un horizontetemporal de 1 a˜no para estimar el impacto de la vacunación con Synflorix® o Prevenar13® sobre lapoblación menor de 2 a˜nos en Espa˜na, bajo la perspectiva del Sistema Nacional de Salud. Los datos epidemiológicosse obtuvieron del Conjunto Mínimo Básico de Datos al alta hospitalaria y de la literatura.Los datos sobre costes se obtuvieron de bases de datos nacionales de costes sanitarios. Los principalesresultados en salud medidos fueron los casos evitados de enfermedad neumocócica invasora, otitis mediaaguda (OMA), miringotomías y hospitalizaciones por neumonía. Todos los costes se expresaron en eurosde 2010. La efectividad se midió en a˜nos de vida ajustados por calidad (AVAC).Resultados: El potencial demostrado por Synflorix® para prevenir episodios de OMA causados por Haemophilusinfluenzae no tipificable podría traducirse en la prevención adicional de 41.513 episodios deOMA, 36.324 prescripciones de antibióticos y 382 miringotomías, y supondrían la ganancia de 143 AVACfrente a Prevenar13®. El coste total de la vacunación con Synflorix® resultaría unos 22 millones de eurosmenor.Conclusiones: La vacunación antineumocócica de la población menor de 2 a˜nos en Espa˜na con Synflorix®,en comparación con la vacunación con Prevenar13®, podría resultar en un mayor número de AVAC, asícomo en una reducción sustancial del coste total, resultando una estrategia dominante en términos decoste-efectividad (AU)

Objective: To perform a cost-effectiveness analysis of pediatric pneumococcal vaccination in Spain.Methods: A deterministic population-based model in the form of a decision-tree with a 1-year timehorizon was used to estimate the impact of vaccination with Synflorix® or Prevenar13® in children agedless than 2 years in Spain from the perspective of the National Health System. Epidemiological data wereobtained from the hospital discharge minimum data set (MDS) and the literature. Data on costs wereobtained from national health costs databases. The main outcomes measured were the number of casesavoided of invasive pneumococcal disease, acute otitis media (AOM) and myringotomies, and hospitaladmissions for pneumonia. All costs were expressed in 2010 euros. Effectiveness was measured as thenumber of quality-adjusted life years (QALYs) gained.Results: The efficacy of Synflorix® in preventing episodes of AOM caused by non-typeable Haemophilusinfluenzae could lead to additional prevention of 41,513 episodes of AOM, 36,324 antibiotic prescriptionsand 382 myringotomy procedures and 143 QALYs gained compared with Prevenar13®. The totalvaccination cost with Synflorix® would result in savings of 22 million euros.Conclusions: Pneumococcal vaccination with Synflorix® in comparison with Prevenar13® in children agedless than 2 years old in Spain could achieve a higher number of QALYs and a substantial cost offset.Vaccination with Synflorix® would be a dominant strategy in terms of cost-effectiveness (AU)

Manejo de cuerpos extraños nasales y óticos en niños / Management of foreign bodies in ears and nose in children

Los cuerpos extraños en los oídos y las fosas nasales son muy frecuentes en la urgencia de otorrinolaringología. La edad de los pacientes afectos suele estar entre 2–5 años, pero pueden producirse a cualquier edad, incluso en adultos. Se puede ver todo tipo de cuerpos extraños, como pequeños juguetes, lápices, plastilinas, semillas, trozos de comida y hasta insectos. Muchas de estas situaciones se solucionan en salud primaria y solo los casos más difíciles llegan a nuestra especialidad. Debemos tener conocimiento de la anatomía de estas zonas, conocer el material ideal con el que se debe trabajar, las técnicas y las alternativas de extracción, y los cuidados postextracción para provocar el menor traumatismo posible y no provocar secuelas a corto ni a largo plazo (AU)

Foreign bodies in the ears and nose are very frequently seen in the otolaryngology emergency service. The age of the affected patients is generally between 2–5 years. However, this may occur at any age, even in adults. All kinds of foreign bodies can be seen, such as small toys, pencils, Plasticines, seeds, bits of food and even insects. Many of these situations are solved in primary health care and only the most difficult cases come to our speciality. It is important to have knowledge of the anatomy of these areas, knowing the best material to work with, the techniques and extraction alternatives and post-extraction care in order to have the least possible trauma and not cause short and long term sequels (AU)

[Complication rate of out-patient removal of ear wax: systematic review of the literature]. / Komplikationshäufigkeit bei der ambulanten Zerumenentfernung : Systematische Literaturübersicht.

BACKGROUND: Cerumen impaction is known as a frequent problem both in general practice as well as in community based ENT surgeries. The aim of the present review was to describe the frequency and types of complications due to different methods of ear wax removal. METHODS: A systematic review of the literature was carried out (Pubmed, Cochrane, Scopus) and data from the arbitration board for medical liability were evaluated. RESULTS: Controlled studies addressing the complications of ear wax removal are lacking in the literature and absolute risks could not be reported. Perforation of the tympanic membrane was observed in up to 1% of the cases. Syringing seems to result in a greater number of complications than mechanical removal using a curette. CONCLUSIONS: Complication rates were found to be higher than previously assumed. However, none of the publications had initially been intended to detect adverse events. It can be concluded that syringing can be delegated to trained staff members only if pre-existing defects of the tympanic membrane have been excluded.

A systematic review of concomitant interventions to prevent persistent perforations following the removal of long-term ventilation tubes.

OBJECTIVE: To review the current evidence for the use of concomitant interventions to reduce the persistent perforation rate following the removal of long-term ventilation tubes. TYPE OF REVIEW: A systematic review of the literature and meta-analysis of randomised controlled trials on this topic. SEARCH STRATEGY: Medline (1952-2008), EMBASE (1974-2008) and the Cochrane Central Register of Controlled Trials. A combination of search terms were used in a search strategy derived from guidance from the Cochrane collaboration. EVALUATION METHOD: A review of all trials by two authors with grading of the level of evidence. RESULTS: Fifteen studies using a variety of interventions were identified. CONCLUSION: A multi-centre randomised controlled trial is indicated to validate findings of previous studies and elucidate any optimum intervention to reduce the persistent perforation rate.

Cochlear implantation in patients with acute or chronic middle ear infectious disease: a review of the literature.

Although in the past cochlear implantation was considered contraindicated in patients with acute (AOM) or chronic suppurative otitis media (CSOM) with or without middle ear cholesteatoma, recent developments now make it possible to perform cochlear implantation in these patients. Various procedures are available to make the ears of patients with either acute or CSOM suitable for cochlear implantation and to minimize the risk of recurrence of the disease, device extrusion, or intracranial complications. This review discusses these different approaches for optimizing implant survival and preventing complications related to otitis media. We performed a comprehensive literature search of the MEDLINE database. Cochlear implantation can be safely performed in patients with otitis media. However, the infection should be adequately controlled well before implantation, and all measures should be taken to prevent recurrent disease. Therefore, the procedure used should be tailored to individual clinical findings. This article provides a guideline to optimize the course of action in patients suffering from AOM, CSOM or their sequelae in preparation for cochlear implantation.

Compared to placebo, long-term antibiotics resolve otitis media with effusion (OME) and prevent acute otitis media with perforation (AOMwiP) in a high-risk population: a randomized controlled trial.

BACKGROUND: For children at high risk of chronic suppurative otitis media (CSOM), strategies to prevent acute otitis media with perforation (AOMwiP) may reduce progression to CSOM. METHODS: In a double blind study in northern Australia, 103 Aboriginal infants with first detection of OME were randomised to receive either amoxicillin (50 mg/kg/d BD) or placebo for 24 weeks, or until bilateral aerated middle ears were diagnosed at two successive monthly examinations (success). Standardised clinical assessments and international standards for microbiology were used. RESULTS: Five of 52 infants in the amoxicillin group and none of 51 infants in the placebo group achieved success at the end of therapy (Risk Difference = 9.6% [95% confidence interval 1.6,17.6]). Amoxicillin significantly reduced the proportion of children with i) perforation at the end of therapy (27% to 12% RD = -16% [-31,-1]), ii) recurrent perforation during therapy (18% to 4% RD = -14% [-25,-2]), and iii) reduced the proportion of examinations with a diagnosis of perforation during therapy (20% to 8% adjusted risk ratio 0.36 [0.15,0.83] p = 0.017). During therapy, the proportion of examinations with penicillin non-susceptible (MIC > 0.1 microg/ml) pneumococci was not significantly different between the amoxicillin group (34%) and the placebo group (40%). Beta-lactamase positive non-capsular H. influenzae (NCHi) were uncommon during therapy but more frequent in the amoxicillin group (10%) than placebo (5%). CONCLUSION: Aboriginal infants receiving continuous amoxicillin had more normal ears, fewer perforations, and less pneumococcal carriage. There was no statistically significant increase in resistant pneumococci or NCHi in amoxicillin children compared to placebo children who received regular paediatric care and antibiotic treatment for symptomatic illnesses.

Antibiotics for the prevention of acute and chronic suppurative otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common childhood illness. These middle ear infections may be frequent and painful. AOM may be associated with perforation of the tympanic membrane and can progress to chronic suppurative otitis media (CSOM). OBJECTIVES: To determine the effectiveness of long-term antibiotics (for longer than six weeks) in preventing any AOM, AOM with perforation and CSOM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (January 1966 to March Week 3 2006), OLD MEDLINE (1950 to 1965), EMBASE (1990 to December 2005) and the references of relevant studies. SELECTION CRITERIA: All randomised controlled trials of long-term (longer than six weeks) antibiotics versus placebo or no treatment for the prevention of AOM, AOM with perforation, or CSOM were eligible. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data for: any AOM; episodes of AOM; any recurrent AOM; episodes of illness; any side effects; any antibiotic resistance, as well as outcomes at end of intervention (any AOM); and following cessation of intervention (any AOM). For dichotomous outcomes, the summary risk ratio (fixed and random-effects models) was calculated. For rate outcomes, the summary incidence rate ratio was calculated. MAIN RESULTS: Sixteen studies involving 1483 children met our inclusion criteria. All studies enrolled children at increased risk of AOM, and in seven studies the children were prone to otitis media. The majority of studies were high quality and most (15 studies) reported data for our primary outcomes. None reported AOM with perforation or CSOM. Long-term antibiotics reduced any episode of AOM (13 studies, 1358 children, risk ratio (RR) 0.62, 95% CI 0.52 to 0.75; random-effects model) and number of episodes of AOM (12 studies, 1112 children, incidence rate ratio (IRR) 0.48, 95% CI 0.37 to 0.62; random-effects model). Approximately five children would need to be treated long term to prevent one child experiencing AOM whilst on treatment. Antibiotics prevented 1.5 episodes of AOM for every 12 months of treatment per child. Statistical heterogeneity was explored. Long-term antibiotics were not associated with a significant increase in adverse events (11 studies, 714 children, RR 1.99, 95% CI 0.25 to 15.89; random-effects model). AUTHORS' CONCLUSIONS: For children at risk, antibiotics given once or twice daily will reduce the probability of AOM while the child is on treatment. Antibiotics will reduce the number of episodes of AOM per year from around three to around 1.5. We believe that larger absolute benefits are likely in high-risk children. These conclusions were not affected by sensitivity analyses.

Comparative observation of protective effects of earplug and barrel on auditory organs of guinea pigs exposed to experimental blast underpressure.

OBJECTIVE: To explore the protective effects of earplug and barrel on auditory organs of guinea pigs exposed to experimental blast underpressure (BUP). METHODS: The hearing thresholds of the guinea pigs were assessed with auditory brainstem responses (ABR). The traumatic levels of tympanic membrane and ossicular chain were observed under stereo-microscope. The rate of outer hair cells (OHCs) loss was analyzed using a light microscope. The changes of guinea pigs protected with barrel and earplug were compared with those of the control group without any protection. RESULTS: An important ABR threshold shift of the guinea pigs without any protection was detected from 8h to 14d after being exposed to BUP with a peak ranging from -64.5 kPa to -69.3 kPa ( P<0.01). The rate of perforation of tympanic membrane reached 87.5% and that of total OHCs loss was 19.46% +/- 5.38% at 14d after exposure. The guinea pigs protected with barrel and earplug had lower ABR threshold and total OHCs loss rate compared with the animals without any protection (P<0.01). All of the tympanic membrane and ossicular chain of the protected animals maintained their integrities. Meanwhile, the guinea pigs protected with the barrel had lower ABR threshold and total OHCs loss rate than those with earplug (P<0.01). CONCLUSIONS: The earplug and barrel have protective effects against BUP-induced trauma on auditory organs of the guinea pigs and the protective effects of barrel are better than those of earplug.

Immediate repair of the tympanic membrane to prevent persistent perforation after intentional removal of long-lasting tubes.

OBJECTIVE: Our purpose was to evaluate efficiency of immediate repair of the tympanic membrane perforation after intentional removal of the long-lasting tubes. METHODS: This study was done in 36 ears of 27 patients who had either Goode-T or Paparella-II silicone tube insertion due to chronic OME or ROM and tube removal. Only the ears in which tube removal was performed due to no longer need for middle ear ventilation were included to the study. After removal of the tube, the perforation edges were refreshed and Steri-Strip (3M) patch was adhered on the perforation site. Otoscopic, tympanometric and audiologic data were reported. RESULTS: Mean duration of the tube persistence was 49.58+/-11.94 months. It was found that there were two subgroups in the study group: those under regular follow-up (20 ears), and the ears which were out of regular follow-up (16 ears). Mean tube persistence times were 34.10 and 52.11 months in these subgroups, respectively (chi2-test, p=0.056). In six ears (16.67%), persistent perforation (PP) was found. PP rate (PPR) was higher in group-B (25%) than in group-A (10%) (chi2-test, p>0.1). The rest perforation was anteriorly marginal in five of six PP (83.33%). The PPR in the ears in which rest perforation was anteriorly marginal was 35.71% (5/14) while it was 4.54% (1/22) in the ears with central rest perforation (chi2-test, p<0.02). CONCLUSIONS: Even immediate repair of the perforation after removal of the long-lasting tubes resulted in a high PPR. The data in this study documented that this high PPR was associated with type and localisation of rest perforation and tube persistence time. Anteriorly, marginal perforations had about eight times higher risk of PP and longer tube persistence caused higher anterior marginal perforations after tube removal.

[Injuries caused by pressure differences while diving]. / Schäden durch Druckdifferenzen beim Tauchen. Barotraumen.

Barotraumas are caused by pressure differences. As described by Boyle's Law, barotraumas develop during the descent phase of diving (and much more rarely during the ascent). The most frequently affected are the ears and paranasal sinuses, in addition to the facial skin and eyes. The most important preventive measure is performing pressure compensation in the affected body cavities. Barotrauma is treated symptomatically.

Gelfoam plug tympanoplasty concomitant with removal of retained ventilation tubes.

OBJECTIVE: To review the charts of patients treated using a gelfoam plug and to determine the efficacy of its use as a grafting material for prevention of perforation when removing retained ventilation tubes. METHOD: Following removal of the retained tube, excision and debridement of the rim of the perforation, the perforation was plugged with gelfoam material. Between February 1998 and July 2002, we used this procedure in 27 patients aged 15 years and younger, on a total of 36 ears. RESULTS: In all 27 cases, complete healing of the perforation was attained. CONCLUSION: A minimal tympanoplastic procedure using gelfoam graft concomitantly with tube removal is effective in prevention of perforation resulting from delayed spontaneous extrusion.