[Physiology and physiopathology of middle ear ventilation. I. Middle ear volume and its gas content. Physiology of the eustachian tube].
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[Study on middle ear ventilation using positional tympanometry--normal ear].
The middle ear is a cavity surrounded by solid bones, lined with mucosa, which has a gas-filled lumen. Cavernous organs such as the ear should have their own ventilation system under atmospheric pressure. The mechanism of ventilation in the middle ear has not been sufficiently clarified. Ventilation performed in the middle ear may be classified into two types: 1) passive ventilation via the Eustachian tube, required in cases of abnormal pressure and 2) unique physiological active ventilation of the middle ear performed under atmospheric pressure and not involving the Eustachian tube. The purpose of the present study is to prove the existence of this active ventilation under atmospheric pressure. The subjects were 50 normal ears and elevation of middle ear pressure in the lateral position (determined by positional tympanometry) was studied. The change in the peak level, on tympanometry, was used as an index. The results were continuously recorded every 12 seconds. The following results were obtained. 1. Middle ear pressure was elevated by changing from the sitting to the lateral position. Venous pressure was regarded as a causative factor in this pressure elevation. 2. The elevated middle ear pressure in the lateral position suggested gas production from mastoid cells of the middle ear. The observation that the middle ear pressure was stabilized with the increase in pressure, up to a level of 85-90 mm H2O, indicated the existence of gas leakage from the Eustachian tube and a mechanism for controlling gas production from the mastoid cells of the middle ear.
Acoustic Impedance Tests↗
Long-term middle ear ventilation.
Successful long-term middle ear ventilation was established in 12 patients with chronic eustachian tube hypofunction that had failed to respond to repeated myringotomy and tympanotomy tube insertions by conventional techniques. The 12 patients (13 ears) had insertion of an untrimmed large flange "Per-Lee" type tube through a posterior-inferior tympanomeatal flap approach. The flange extended under the long process of the malleus, and into the hypotympanum and middle ear opening of the eustachian tube. The stem of the tube was brought out through the inferior central pars tensa. All tubes have remained in place for more than three years without serious complications providing adequate middle ear ventilation and preventing adherence of the tympanic membrane to the promontory.
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Effects of middle ear ventilation on cholesteatoma development in experimental animals.
This study was designed to evaluate the effect of middle ear ventilation on cholesteatoma formation following propylene glycol application in experimental animals. Fifteen chinchillas had stainless steel ventilation tubes chronically implanted in their bullae and 60% propylene glycol was subsequently instilled into the middle ear cavities. The animals were kept alive for 4 weeks, during which time the middle ear pressure was monitored tympanometrically and the tubes were frequently inspected to verify patency. Of the 30 ears in the study, 20 (66.6%) developed middle ear cholesteatoma--a rate of occurrence comparable to that found in earlier studies in which middle ear ventilation was not provided. These results indicate that negative middle ear pressure is not a necessary factor for cholesteatoma development following application of chemical irritants in experimental animals.
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Middle ear ventilation mechanism.
The ventilation mechanism of the middle ear is very important as regards the pathogenesis of middle ear disease, but its mode of function is still obscure. Therefore, we tried to measure the ventilation and clearance of the middle ear using radio-isotope imaging techniques and 133Xe in order to gain a clearer picture of the ventilation mechanism. In normal Eustachian tube cases, approximately 10% of the initially insufflated gas immediately entered into the middle ear cavity and mastoid air cells. The gas introduced into the middle ear diminished at a rate of 8% of volume per hour in the normal resting state. Two hours after the first procedure, air was insufflated, and gas volume in the middle ear cavity immediately diminished by 30%. In stenotic tube cases, it proved difficult to insufflate the gas into the middle ear, however, its diminishing rate with the passage of time was slightly faster than in normal tube cases. From this data, it was evident that air could easily and quickly enter into even the periphery of the mastoid air cells by insufflation via the Eustachian tube, despite the fact that the middle ear and mastoid air cells form a closed cavity. In the resting state, moreover, the air in the middle ear was thought to be absorbed mainly into the middle ear mucosa at a regular rate. It was confirmed that the insufflation procedure as a therapy for tubal stenosis and OME is very useful for the ventilation of the middle ear.
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Contact diode laser myringotomy for medium-duration middle ear ventilation in children.
OBJECTIVE: To prospectively compare contact diode laser for myringotomy (CDLM) to myringotomy with tube insertion (M&T) for the surgical management of otitis media with effusion (OME) in children. STUDY DESIGN AND SETTING: Prospective randomized controlled study at a tertiary care pediatric institution. METHODS: Thirty children for whom PE tube insertion was indicated were randomized for treatment by CDLM or by M&T, in order to investigate length of time for middle ear ventilation, and complication rates. Surgical time was measured, post-operative parental questionnaires were reviewed, and follow-up examinations were performed. INTERVENTION: Middle ear ventilation by CDLM or M&T. RESULTS: Middle ear ventilation by CDLM took an average of 4.1min, and was maintained for an average of 3.5 months, compared to surgical time of 10.2min for M&T, and duration of middle ear ventilation of 6.3 months. These differences were statistically significant (p=0.005 for surgical time, and p<0.001 for duration of ventilation). Complication rates were equivalent. CONCLUSION: CDLM allowed for medium-duration middle ear ventilation in children compared to M&T. Further study to clarify the role of CDLM in the management of OME in children is indicated.
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Anterior subannular T-tube for prolonged middle ear ventilation during tympanoplasty: evaluation of efficacy and complications.
OBJECTIVE: We previously described the use of anterior subannular T-tubes (n = 20) for long-term middle ear ventilation. In the current study, we examine a larger patient population (n = 38) and a longer follow-up interval (average >2 years) to evaluate the efficacy and safety of anterior subannular tympanostomy. STUDY DESIGN: Retrospective nonrandomized case review. SETTING: Tertiary referral hospital. PATIENTS: Our series consisted of 38 consecutive patients with a diagnosis of eustachian tube dysfunction, adhesive otitis media, or chronic otitis media with a perforation who underwent a tympanoplasty. INTERVENTION: A subannular T-tube was placed anteriorly at the time of tympanoplasty to provide long-term middle ear ventilation. MAIN OUTCOME MEASURES: The main outcomes of this study are tube position, tube patency, and middle ear ventilation. In addition, hearing was evaluated both preoperatively and postoperatively and any complications were noted. RESULTS: There were 38 patients and 38 ears that received an anterior subannular T-tube at the time of tympanoplasty. The study group consisted of 24 female patients and 14 male patents with a median age of 36 years (range, 10-75 yr). All 38 patients had eustachian tube dysfunction, 22 had adhesive otitis media, 23 had chronic otitis media, 13 had a cholesteatoma, 11 had tympanic membrane perforations, and 3 patients had a cleft palate. All patients underwent tympanoplasty. Eighteen patients had a concomitant ossiculoplasty and 7 had a mastoidectomy. Follow-up ranged from 1 month to 48 months (average, 26 mo). Three tubes had extruded within 2 years, in 1 case resulting in a persistent perforation. Postoperative complications included 1 patient with a partially extruded prosthesis, 2 patients with tipped prosthesis and persistent tympanic membrane retraction, and 1 patient with a plugged tube. All other tubes were patent and showed no evidence of migration. Furthermore, there were no cases of anterior canal blunting or ingrowth of epithelium around the tube. CONCLUSION: Anterior subannular tympanostomy is a safe and effective method for long-term middle ear ventilation in patients with chronic eustachian tube dysfunction.
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Nasal surgery and eustachian tube function: effects on middle ear ventilation.
OBJECTIVES: To investigate the effect of nasal obstruction surgery on eustachian tube function and middle ear ventilation. DESIGN: Prospective study. SETTING: University Campus Bio-Medico of Rome. PARTICIPANTS: Forty consecutive patients who underwent nasal surgery were evaluated for middle ear ventilation and tubal function. MAIN OUTCOME MEASURES: Pre- and postoperative Valsalva and Toynbee tubal function tests, tympanometry and ear fullness sensation were evaluated for both ears of each patient. RESULTS: Results of postoperative tubal function tests were significantly better than preoperative ones (90% versus 46%; P<0.001). No significant difference in tympanometric values was found. The majority (95%) of the patients reported a postoperative improvement of ear fullness sensation compared with preoperative (25%; P<0.001). CONCLUSIONS: Surgery for chronic nasal obstruction significantly improves clinical tubal function but 1-month postoperative tympanometric findings remain almost the same.
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Prolonged middle ear ventilation with the cartilage shield T-tube tympanoplasty.
BACKGROUND: In 1994, the favorable experience with composite cartilage shield tympanoplasty was reported to the American Otological Society. On that occasion, the technical question regarding the concomitant placement of a ventilating tube was posed. In response, the authors proposed that the tympanostomy tube be incorporated in the cartilage graft. Moreover, they proposed that this marriage, when used to reverse atelectasis and to repneumatize the middle ear, should offer the advantage of both procedures while reducing the incidence of tube extrusion and other complications of prolonged intubation. Although attractive in theory, this supposition could be validated only after prolonged follow-up, reported here. OBJECTIVE: To describe an effective means to secure prolonged middle ear ventilation in a patient population prone to atelectasis and chronic middle ear effusion and to establish the incidence of favorable and unfavorable outcomes after 6 years of observation. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Forty patients (28 adults and 12 children) who underwent tympanic membrane reconstruction with a composite cartilage shield T-tube "unit."RESULTS The overall retention rate was 62.5% over 6 years. Sixty-five percent of retained tubes were maintained for a minimum of 4 years in adult patients. Extrusion and permanent perforation rates were 0%. CONCLUSION: The cartilage shield T-tube tympanoplasty can effectively reverse atelectasis and provide prolonged middle-ear ventilation. The technique can be used safely and minimizes the risk of tympanic membrane perforation and other complications associated with prolonged middle ear intubation.
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A clinical evaluation of gold-plated tubes for middle-ear ventilation.
Gold-plated tympanostomy tubes have been recently marketed as possessing qualities making them ideal for middle-ear ventilation. The performance of these tubes was compared with that of similarly designed Teflon tubes in a controlled, prospective study. Twenty-eight children underwent bilateral myringotomy and tube placement. One ear was randomly chosen for intubation with a gold-plated tube, and a Teflon tube was inserted into the other ear. Patients were examined monthly for 12 months and evaluated for otorrhea, tube occlusion, and early tube extrusion. Although the incidence of otorrhea and tube occlusion were higher for the gold-plated tube, these differences were not statistically significant. The gold-plated tube had a significantly higher rate of early extrusion than the Teflon tube. Based on these findings, there appears to be no advantage to using gold-plated tubes for middle-ear ventilation.
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A new ventilation tube for long-term middle ear ventilation.
OBJECTIVES: The treatment of secretory otitis media often requires repeated tubulation of the tympanic membrane as the standard ventilation tubes are extruded before the disease of the middle ear has remitted. The T-tube and its modification have been developed to remain longer in situ, often requiring surgical removal. The rates of subsequent persisting tympanic membrane perforations and granulations around the tube have been unacceptably high. In the search for a long-term ventilation tube with fewer complications, the Duravent tube (Smith and Nephew) has been developed. The aim of the study was to estimate duration in situ and observe complications in using the Duravent tube compared with standard tubes and T- tubes. STUDY DESIGN: Retrospective study. METHODS: In all, 51 patients have been treated with the Duravent tube over a 2-year period. In all, 72 Duravent tubes have been inserted. All patients were subsequently invited for a follow-up examination at a median time of 28 months (range, 11-43 mo) after the tube insertion and were followed up for 5 years. RESULTS: The duration in situ was optimal with a median duration of 17 months. The Duravent tube was extruded spontaneously in all but four cases in which surgical removal was necessary. The rate of persisting perforations of the tympanic membrane was low (4.2%) compared with 24% after the use of the T-tube. Likewise, the usual complications connected with long-term ventilation tubes were less frequent (14% compared with 35% when using the T-tube). CONCLUSIONS: In the present study, the Duravent tube has proved superior to other known long-term ventilation tubes. The problem of granulations, otorrhoea, and tube occlusion was significantly less than reported in other studies using the T-tube.
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Swimming unprotected with long-shafted middle ear ventilation tubes.
Patients, parents, and physicians are all concerned about the risks of swimming unprotected with middle ear ventilation tubes. The risks have not previously been carefully quantified or correlated with the degree of swimming activity. In this study, 53 children with tympanometrically proven patent long-shafted tubes were allowed to swim unprotected. They suffered six middle ear infections that were clearly caused by swimming. Five of these infections occurred in divers. The rate of infections for divers was approximately one per 100 days of swimming activity. The rate for non-divers was approximately one per 600 days. Unprotected swimming was well accepted by almost all parents and patients. The need for earplugs for all children who swim with long-shafted ventilation tubes is questioned.
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Otorrhoea in children with middle ear ventilation tubes: a comparison of different types of tubes.
Otorrhoea is a troublesome complication of middle ear ventilation tubes. This investigation of children with various ventilation tubes shows that the incidence of this complication varies with the type of tube used. In particular, Paparella type 2 tubes are associated with a higher rate of otorrhoea, and should be reserved for use when long-term ventilation is necessary.
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Inhibition of experimentally induced endolymphatic hydrops by middle ear ventilation.
The tympanic membrane was perforated (n = 19) or a tube was inserted into the middle ear through the wall of the tympanic bulla (n = 6) immediately after blockage of the endolymphatic duct in guinea pigs. Total cochlear endolymph volume and volumes in each cochlear turn were determined from serial sections of the temporal bones and volume changes were analyzed statistically by comparison with hydropic controls without treatment (n = 12). Results showed that both middle ear ventilation procedures significantly reduced the subsequent development of endolymphatic hydrops. This inhibition of hydrops was presumed to be due to pressure release into the middle ear and/or improved oxygenation of the middle and inner ears. Findings suggest the possible merit of a tympanostomy as a treatment for Meniere's disease in carefully selected patients refractory to medical management.
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[Middle ear ventilation tubes: present indications and prospects].
Myringotomy and insertion of ventilation tubes, as a form of treatment of serous otitis media with effusion, has become one of the most frequently performed operations in otolaryngology. In this paper, we review the actual indications of artificial middle ear ventilation by the insertion of tubes. The complications of this surgical procedure are then discussed. Laser assisted tympanostomy offers a new option to achieve middle ear ventilation without tubes and appears to cure half of the crises with otitis media and effusion.
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[Study on middle ear ventilation using positional tympanometry--post mastoidectomy ear].
The middle ear is a cavity surrounded by solid bone, lined with mucosa with a lumen filled with gas. To examine this unique ventilation system under atmospheric pressure, the middle ear pressure of 50 normal ears was previously examined. Positional tympanometry, whereby the middle ear pressure is increased as the subject assumes the lateral position under atmospheric pressure was used. As a result, (1) The middle ear pressure was elevated by the change from the sitting position to the lateral position. Venous pressure was regarded as causative factor of this pressure elevation. (2) The elevation of the middle ear pressure in the lateral position suggested gas production from the mastoid cells of the middle ear. In this study, a proportion of the mastoid cells were removed to resect a tumor of the internal acoustic meatus in conjunction with resection of an acoustic tumor. After resection the area was filled with fascia and fatty tissue. The middle ear pressure of each subject was monitored to determine the effect of a decrease in the mastoid cell volume on middle ear pressure. The results were continuously recorded every 12 seconds for the lower ear when the subjects were in the lateral position. The following results were obtained. (1) The elevation of the middle ear pressure due to positional change among subjects which had had acoustic tumors resected was noticeably greater than the elevation in normal ears. This is thought to have been the result of an elevation in cerebrospinal fluid pressure attributable to positional change, along with an elevation in intravenous pressure. (2) We made comparisons of increases in middle ear pressure 10 minutes after assuming the lateral position in 14 ears after acoustic tumor resection and in 21 normal ears. No noticeable differences were found in the middle ear pressure increases between the two groups despite the fact that the volume of the mastoid cells in the group that had tumors resected had been greatly reduced.
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Anterior subannular T-tube for long-term middle ear ventilation during tympanoplasty.
OBJECTIVE: A technique for providing long-term ventilation of the middle ear (ME) during tympanoplasty is described, and the results using this technique in 20 patients with chronic Eustachian tube dysfunction (ETD) are reported. STUDY DESIGN: This study was a retrospective, nonrandomized case review. SETTING: This study was conducted at an otology clinic in a tertiary referral center. PATIENTS: Twenty consecutive patients who underwent tympanoplasty with ETD, adhesive otitis media, or chronic otitis media with perforation were included in this study. INTERVENTION: All patients had a subannular T-tube placed anteriorly at the time of tympanoplasty for long-term ventilation of the ME space. MAIN OUTCOME MEASURES: The two main outcome measures were tube position and patency. Preoperative and postoperative hearing levels were also tested in most patients, and any complications were documented. RESULTS: Twenty patients (20 ears) received anterior subannular T-tubes at the time of tympanoplasty. Fourteen females and 6 males were evaluated (median age, 36 years; range, 7 to 72 years). All patients had ETD; 7 had adhesive otitis media, 10 had chronic otitis media, 8 had cholesteatoma, and 2 had cleft palate. All patients had conductive hearing loss and previous surgery. All patients underwent tympanoplasty; 11 had concomitant ossiculoplasty, and 5 had mastoidectomy. Follow-up ranged from 8 to 22 months (mean, 13.4 months). One patient was lost to follow-up. One tube extruded after 16 months. Two patients had persistent mild retraction of the tympanic membrane. All other tubes are patent and have not migrated or plugged. There has been no evidence of anterior blunting or ingrowth of epithelium around the tube. CONCLUSIONS: Anterior subannular T-tube placement is a simple, safe, and effective alternative for long-term ME ventilation in patients in whom standard transtympanic sites are not available. At their last follow-up visit, all but one patient had a patent tube. All MEs were aerated. This technique offers the advantage of ease of placement during simultaneous tympanoplasty, mastoidectomy, or ossiculoplasty. Longer follow-up is necessary to confirm these initial findings.
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Results of middle ear ventilation with Goode's tubes.
The results of a retrospective study of the effect and outcome of middle ear ventilation by Goode's tubes are presented. 83 ears from 50 patients were analyzed both as a group and in age-related sub-groups over a mean follow-up period of 1.83 years. The mean period of ventilation by Goode's tubes before removal or extrusion was 18.4 months. The tubes became infected in 70.4% and were spontaneously extruded in 44.9% of patients. Permanent perforation of the tympanic membrane ensued in 47.5% of patients and significantly more often in those aged between 10 and 20 years (P less than 0.002). Patients aged less than 10 years were significantly less likely to develop a retraction of their tympanic membranes after removal of the Goode's tube than those older (P less than 0.02). No significant relationship was found between the development of these complications and the period of ventilation, past experience of otitis media, consistency of effusion, degree of tympanosclerosis or the preoperative presence of tympanic retraction.
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