Impact of Patient Socioeconomic Disparities on Time to Tympanostomy Tube Placement

Objectives: Extensive literature exists documenting disparities in access to healthcare for patients with lower socioeconomic status (SES). The objective of this study was to examine access disparities and differences in surgical wait times in children with the most common pediatric otolaryngologic surgery, tympanostomy tubes (TT). Methods: A retrospective cohort study was performed at a tertiary children’s hospital. Children ages <18 years who received a first set of tympanostomy tubes during 2015 were studied. Patient demographics and markers of SES including zip code, health insurance type, and appointment no-shows were recorded. Clinical measures included risk factors, symptoms, and age at presentation and first TT. Results: A total of 969 patients were included. Average age at surgery was 2.11 years. Almost 90% were white and 67.5% had private insurance. Patients with public insurance, ≥1 no-show appointment, and who lived in zip codes with the median income below the United States median had a longer period from otologic consult and preoperative clinic to TT, but no differences were seen in race. Those with public insurance had their surgery at an older age than those with private insurance ( P < .001) and were more likely to have chronic otitis media with effusion as their indication for surgery (OR: 1.8, 95% CI: 1.2-2.5, P = .003). Conclusions: Lower SES is associated with chronic otitis media with effusion and a longer wait time from otologic consult and preoperative clinic to TT placement. By being transparent in socioeconomic disparities, we can begin to expose systemic problems and move forward with interventions. Level of Evidence: 4

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Delayed Onset Post-Tympanotomy Otorrhea

Otolaryngology ◽

10.1177/019459988809800203 ◽

1988 ◽

Vol 98 (2) ◽

pp. 111-115 ◽

Cited By ~ 26

Author(s):

George A. Gates ◽

Christine Avery ◽

Thomas J. Prihoda ◽

G. Richard Holt

Keyword(s):

Health Care ◽

Surgical Treatment ◽

Otitis Media ◽

Otitis Media With Effusion ◽

Acute Otitis Media ◽

Chronic Otitis Media ◽

Secretory Otitis Media ◽

Delayed Onset ◽

Tympanostomy Tubes ◽

Care Costs

Otorrhea is the most frequent complication of the use of tympanostomy tubes. When it occurs after the immediate postoperative period, otorrhea is probably the result of external contamination of the middle ear or acute otitis media. We analyzed data from 627 operations upon 1248 ears of 491 children with chronic secretory otitis media and found that delayed onset (longer than 7 weeks) postoperative otorrhea occurred after 26.4 percent of the 382 operations in which tympanostomy tubes were used. The average number of episodes of otorrhea per case was 1.46 and ranged from 1 to 9. The rate of otorrhea occurrence in patients with tubes in place was significantly higher in the summer months. Otorrhea also occurred after 9.0 percent of 245 myringotomy procedures. The average number of episodes was 1.32 and ranged from 1 to 3. Treatment of postoperative otorrhea increases the health care costs of surgical treatment of chronic otitis media with effusion; this problem should be included in the calculation of cost-effectiveness.

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Tympanostomy Tube Selection: A Review of the Evidence

International Journal of Head and Neck Surgery ◽

10.5005/jp-journals-10001-1259 ◽

2016 ◽

Vol 7 (1) ◽

pp. 17-22

Author(s):

Ho Sandra ◽

David J Kay

Keyword(s):

Otitis Media ◽

Middle Ear ◽

Otitis Media With Effusion ◽

Acute Otitis Media ◽

The United States ◽

Tube Placement ◽

Tympanostomy Tube ◽

Middle Ear Effusion ◽

Surgeon Experience ◽

Ear Effusion

ABSTRACT Tympanostomy tube (TT) insertion for ventilation of the middle ear is one of most commonly performed procedures in the United States. Indications for tube insertion include otitis media with effusion, recurrent acute otitis media, hearing loss caused by middle ear effusion and persistent acute otitis media. In general, TTs are divided into two categories, short-term tubes and long-term tubes. Depending on the indications for tube placement and surgeon experience with the TT, different tubes can be used. A myriad of tubes have been created since their first documented use in 1845 in attempts to provide better middle ear ventilation, improve ease of placement and prevent complications, such as post-tube otorrhea, persistent perforation and tube occlusion. In order for a tube to be effective, it should be biocompatible with the middle ear to minimize a foreign body reaction. Teflon and silicone remain two of the most commonly used materials in TTs. In addition, the tube design also plays a role for insertion and retention times of TTs. Lastly, TTs can also be coated with various substances, such as silver-oxide, phosphorylcholine and more recently, antibiotics and albumin, in order to prevent biofilm formation and decrease the rate of post-TT otorrhea. Persistent middle ear effusion affects many children each year and can impact their quality of life as well as hearing and language development. With nearly 1 out of every 15 children by the age of 3 years receiving TTs, it is imperative that the right tube be chosen to facilitate optimal ventilation of the middle ear while minimizing complications. How to cite this article Ho S, Kay DJ. Tympanostomy Tube Selection: A Review of the Evidence. Int J Head Neck Surg 2016;7(1):17-22.

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Chronic Secretory Otitis Media: Effects of Surgical Management

Annals of Otology Rhinology & Laryngology ◽

10.1177/00034894890981s202 ◽

1989 ◽

Vol 98 (1_suppl2) ◽

pp. 2-32 ◽

Cited By ~ 42

Author(s):

George A. Gates ◽

J. C. Cooper ◽

Christine A. Avery ◽

Thomas J. Prihoda

Keyword(s):

Hearing Loss ◽

Otitis Media ◽

Surgical Management ◽

Middle Ear ◽

Otitis Media With Effusion ◽

Chronic Otitis Media ◽

Secretory Otitis Media ◽

Tympanostomy Tubes ◽

The Mean ◽

First Recurrence

To study the effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion, we randomly assigned 578 4- to 8-year-old children to receive one of the following: Bilateral myringotomy and no additional treatment (group 1), tympanostomy tubes (group 2), adenoidectomy and myringotomy (group 3), or adenoidectomy and tympanostomy tubes (group 4). The 491 who accepted surgical treatment were evaluated at 6-week intervals for up to 2 years. Treatment effect was assessed by four main outcomes: Time with effusion, time with hearing loss, time to first recurrence of effusion, and number of surgical re-treatments. For the groups (in order), the mean percent of time with any effusion in either ear was 49, 35, 30, 26 (p < .0001); the mean percent of time with hearing thresholds 20 dB or greater was 19, 10, 8, and 7 (p < .0001) in the better ear; and 38, 30, 22 and 22 in the worse ear (p < .0001); the median number of days to first recurrence was 54, 222, 92, and 240 (p < .0001); and the number of surgical re-treatments was 66, 36, 17, and 17 (p < .0001). The most notable adverse sequela, purulent otorrhea, occurred in 22%, 29%, 11%, and 24% of the patients assigned to groups 1 through 4, respectively (p < .001). In severely affected children who have chronic otitis media with effusion resistant to medical therapy, adenoidectomy is an effective treatment. Adenoidectomy plus bilateral myringotomy lowered posttreatment morbidity more than tympanostomy tubes alone and to the same degree as did adenoidectomy and tympanostomy tubes. Adenoidectomy appears to modify the underlying pathophysiology of chronic otitis media with effusion. This effect is independent of the preoperative size of the adenoid. Tympanostomy tube drainage and ventilation of the middle ear provide adequate palliation so long as the tubes remain in place and functioning. We recommend that adenoidectomy be considered in the initial surgical management of 4- to 8-year-old children with hearing loss due to chronic secretory otitis media that is refractory to medical management and, further, that the size of the adenoid not be used as a criterion for adenoidectomy. Concomitant bilateral myringotomy with suction aspiration of the middle ear contents also should be done, with or without placement of tympanostomy tubes at the discretion of the surgeon.

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Defective Immunoregulation in Children with Chronic Otitis Media with Effusion

Otolaryngology ◽

10.1177/019459988609400313 ◽

1986 ◽

Vol 94 (3) ◽

pp. 334-339 ◽

Cited By ~ 4

Author(s):

Joel M. Bernstein ◽

Byung H. Park

Keyword(s):

T Cell ◽

Otitis Media ◽

Otitis Media With Effusion ◽

Cell Subset ◽

Chronic Otitis Media ◽

The United States ◽

Peripheral Blood Lymphocytes ◽

T Cell Subsets ◽

Pokeweed Mitogen ◽

T Cell Growth Factor

Otitis media and middle ear effusions (MEE) are most common clinical problems in early childhood, for which an estimated one million tympanostomies are performed each year in the United States. Although many factors have been associated with MEE (age, sex, genetics, otitis media, socioeconomic status, feeding style, atopy or hypersensitivity, certain bacteria and viruses), a defective immunoregulatory mechanism in the host may also contribute to the pathogenesis. During the past 2 years, we have evaluated immune function in 90 randomly selected children who underwent repeated tympanostomy for persistent MEE. The T-cell subset ratio (OKT-4/OKT-8) was reduced (below 1.25) In 16%. In 33 children, generation of T-cell growth factor (IL-2) by peripheral blood lymphocytes (PBL) was evaluated and found to be decreased in 11. The mitogenic response of PBL to phytohemaglutinin (PHA) and pokeweed mitogen (PWM) stimulation was abnormal in almost half of the cases. Imbalance of T-cell subsets and decreased production of IL-2 indicate defective immunoregulatory function in some of these children, which may play a role in the pathogenesis of persistent MEE.

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Adenoidectomy and Otitis Media

Annals of Otology Rhinology & Laryngology ◽

10.1177/00034894921010s106 ◽

1992 ◽

Vol 101 (1_suppl) ◽

pp. 24-32 ◽

Cited By ~ 38

Author(s):

George A. Gates ◽

Harlan R. Muntz ◽

Brendan Gaylis

Keyword(s):

Otitis Media ◽

Pathogenic Bacteria ◽

Otitis Media With Effusion ◽

Chronic Otitis Media ◽

Tube Insertion ◽

Secretory Otitis Media ◽

Randomized Controlled ◽

Source Of Infection ◽

Randomized Controlled Studies ◽

Tympanostomy Tubes

Adenoid enlargement has traditionally been considered a factor in otitis media; adenoid size, however, does not appear to be correlated with otitis media occurrence. Presence of pathogenic bacteria in the adenoids of children with otitis media has been shown, and adenoidectomy appears to affect the middle ear primarily by removal of the source of infection in the nasopharynx. Three recent randomized, controlled studies showed the efficacy of adenoidectomy in the treatment of chronic secretory otitis media. In one study comparing no treatment, adenoidectomy, and adenotonsillectomy, a significant benefit was seen with adenoidectomy that was not enhanced by tonsillectomy. Another study that compared adenoidectomy, tympanostomy tubes, and a combination of the two showed a significant reduction in effusion time and less surgical retreatment over 2 years in the two adenoidectomy groups. The third study demonstrated the effect of adenoidectomy in children with recurrent chronic otitis media with effusion after failure of tympanostomy tube insertion. All three studies showed that the effect of adenoidectomy was independent of adenoid size. This review discusses current concepts of adenoid physiology and pathology, the major adenoidectomy studies, and indications for the procedure.

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Myringotomy With and Without Tympanostomy Tubes for Chronic Otitis Media With Effusion

Archives of Otolaryngology - Head and Neck Surgery ◽

10.1001/archotol.1989.01860340071020 ◽

1989 ◽

Vol 115 (10) ◽

pp. 1217-1224 ◽

Cited By ~ 63

Author(s):

E. M. Mandel ◽

H. E. Rockette ◽

C. D. Bluestone ◽

J. L. Paradise ◽

R. J. Nozza

Keyword(s):

Otitis Media ◽

Otitis Media With Effusion ◽

Chronic Otitis Media ◽

Tympanostomy Tubes

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Efficacy of myringotomy with and without tympanostomy tubes for chronic otitis media with effusion

The Pediatric Infectious Disease Journal ◽

10.1097/00006454-199204000-00003 ◽

1992 ◽

Vol 11 (4) ◽

pp. 270-277 ◽

Cited By ~ 68

Author(s):

ELLEN M. MANDEL ◽

HOWARD E. ROCKETTE ◽

CHARLES D. BLUESTONE ◽

JACK L. PARADISE ◽

ROBERT J. NOZZA

Keyword(s):

Otitis Media ◽

Otitis Media With Effusion ◽

Chronic Otitis Media ◽

Tympanostomy Tubes

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Tympanic Membrane Perforations and Tympanostomy Tubes

Annals of Otology Rhinology & Laryngology ◽

10.1177/00034894941030s508 ◽

1994 ◽

Vol 103 (5_suppl) ◽

pp. 27-30 ◽

Cited By ~ 16

Author(s):

Sam Levine ◽

Kathleen Daly ◽

G. Scott Giebink

Keyword(s):

Tympanic Membrane ◽

Otitis Media ◽

Middle Ear ◽

Otitis Media With Effusion ◽

Chronic Otitis Media ◽

Tympanic Membrane Perforations ◽

Tympanostomy Tubes ◽

Preoperative Factor ◽

Middle Ear Disease

Tympanoplasty and tympanostomy tubes were developed at the same time and have dramatically changed the treatment of chronic middle ear disease. One hundred forty-nine children who had tubes inserted between ages 6 months and 8 years for chronic otitis media with effusion have been prospectively followed up for an average of 4 years. Fourteen percent developed tympanic membrane perforations. No preoperative factor completely predicted the development of perforation. a majority of the perforations closed spontaneously. Three ears had noncontiguous observations of perforations during follow-up. The implications of these findings are discussed with respect to tympanoplasty.

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