Acute
T or F: Clinicians should perform tympanostomy tube insertion of children with a single episode of otitis media with effusion less than 3 months in duration
F - this is statement 1 of CPG.
The purpose of this statement is to avoid unnecessary surgery in children with OME of short duration that is likely to resolve spontaneously.
70% prevalence rate of OME at 2 weeks, 40% at 1 month, 20% at 2 months, and 10% at 3 months after AOM
T or F: Clinicians should recommend bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer AND documented hearing difficulties
F - statement 3: Clinicians should OFFER tubes.
Randomized trials showing that many otherwise healthy children with mild hearing loss from OME do not necessarily benefit from more prompt tympanostomy tube insertion.
Once OME has persisted in both ears for 3 months or longer, the chance of spontaneous resolution is low: approximately 20% within 3 months, 25% after 6 months, and only 30% after 1 year of additional observation.
However, OFFER is the key word.
When is an audio warranted?
- When OME has been present for 3 months or longer
- prior to tube placement
Above 2 are from statement 2, but you should also consider audio post op.
What is the most common sequelae of tympanostomy tubes?
Otorrhea.
Occurs in about approximately 16% of children within 4 weeks of surgery and 26% of children at any time the tympanostomy tube remains in place.
How long do the tubes stay in on average?
depends
- short term tubes 10-18 months
- long term tubes several years
Statement 10:
In the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended followup schedule, and detection of complications.
What is recurrent acute otitis media?
Three or more well-documented and separate AOM episodes in the past 6 months or at least 4 well-documented and separate AOM episodes in the past 12 months with at least 1 in the past 6 months
For children with chronic OME that do not receive tubes, what interval should they be monitored?
3 - 6 months
Statement 5: Clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who do not receive tympanostomy tubes, until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected.
What is the maneuver that can be performed to help perfuse topical antibiotic drops into the middle ear?
Pump the tragus
What is this?
Myringosclerosis.
- white patches in the ear drum from deposits of calcium and can be seen while the tube is in place or after extrusion
- usually confined to the eardrum
- rarely causes significant hearing issues
What sort of follow-up do children need after the tympanostomy tubes are placed?
"4 to 6 months"
the child should be evaluated periodically by an otolaryngologist while the tympanostomy tubes are in place.
After extrusion, an additional follow-up appointment with the otolaryngologist should occur to ensure the ears are healthy and to identify any need for further surveillance or treatment.
Statement 10
When should clinicians offer tympanostomy tube placement for children with recurrent acute otitis media?
When a middle ear effusion is seen on exam at the time of assessment for tube candidacy.
Statement 6 and 7 - children with recurrent acute otitis media
- no fluid, no tube
- fluid, offer tube
There is a 21mo M with down's syndrome who has had a few ear infections the past year. Mom does not know how many. On exam, you see fluid behind the right TM. At peds WCC from 3 months ago, the pediatrician noted bilateral effusion. Would you offer this patient tubes?
Yes
Statement 9: Clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer. (Option)
What are these pictures showing:
Occluded tube (7%)
Granulation surrounding tube (4%)
Tube displacement in middle ear (0.5%)
Above percentages are for potential adverse effects of tube placement
True or False:
Tympanic membrane atrophy, atelectasis, and retraction pockets are all more commonly observed in children with otitis media who are treated with tympanostomy tubes than in those who are not
True
The mother of a patient that had tubes placed 3 months ago is calling because the the patient is having greenish drainage from the right ear. No fevers and the patient does not seem bothered by it. What would you recommend?
Topical antibiotic ear drops
STATEMENT 11. ACUTE TYMPANOSTOMY TUBE OTORRHEA: Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea.
Strong recommendation
Persistence of symptoms or signs of AOM during antimicrobial therapy (treatment failure) and/or relapse of AOM within 1 month of completing antibiotic therapy.
What are some symptoms related chronic OME?
- vestibular (balance) problems
- poor school performance
- behavioural problems
- ear discomfort
- reduced quality of life (physical suffering, hearing loss, speech impairment, activity limitations, emotional distress and caregiver concern)
Statement 4 - Clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) AND symptoms that are likely attributable to OME
Children who have otitis media with effusion are at increased risk for developmental difficulties (delay or disorder) if they have the following risk factors:
Permanent hearing loss independent of otitis media with effusion
Suspected or confirmed speech and language delay or disorder
Autism-spectrum disorder and other pervasive developmental disorders
Syndromes (eg, Down) or craniofacial disorders that include cognitive, speech, or language delays
Blindness or uncorrectable visual impairment
Cleft palate, with or without associated syndrome
Developmental delay
Statement 8
How likely would a patient have a persistent perforation after tube extrusion?
1-6%
*** Bonus question - at what age, do you fix it? ***
You are counseling a patient and mother about ear tubes, and the mother asks about swimming and wearing ear plugs. What do you say?
Ear plugs are not needed for swimming because very little water goes through the tube.
STATEMENT 12. WATER PRECAUTIONS: Clinicians should not encourage routine, prophylactic water precautions (use of earplugs or headbands; avoidance of swimming or water sports) for children with tympanostomy tubes.