Downward Trend in Resident Myringotomy and Tympanostomy Tube Experience

Introduction/Objective: Historically, myringotomy, and the insertion of tympanostomy tubes has served as one of the initial surgical training experiences for residents. Resident experience with this procedure since the introduction of pneumococcal conjugate vaccines has not been well described in the literature. The objective of this study was to identify trends in resident training experience with chronic otitis media-related surgeries, such as myringotomy and tympanostomy tube placement. While multiple factors influence resident experience, we hypothesize that resident experience has decreased since the introduction of the pneumococcal 13-valent conjugate vaccine (PCV13). Methods and Materials: In a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) National Data Reports, mean number of myringotomy and tympanostomy tube cases logged in the Resident Case Log System from 2006 to 2019 were collated and plotted against years to identify monotonic trends. Mann-Whitney U test was used to compare pre-PCV13 era and post-PCV13 era data. Results: Since the introduction of PCV13, there is a national decreasing trend in the myringotomy and tympanostomy tube placement by otolaryngology residents ( P = .001). Conclusions: Otologic surgeries are an important part of resident education and historically have served as one of the initial surgical training experiences for residents. There has been a significant reduction in the number of myringotomy and tympanostomy procedures performed by otolaryngology residents in the past decade. While multiple factors influence resident experience, it is possible that introduction of PCV13 has impacted resident exposure to myringotomy and tympanostomy tube placement. Resident proficiency with this procedure has likely not been affected by introduction of PCV13. Data should be reassessed in 5 years to determine if an impact of the PCV13 vaccine on resident training is evident.

Behavioral Strategies to Minimize Procedural Distress During In-Office Pediatric Tympanostomy Tube Placement Without Sedation or Restraint

The purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% ‘Other’ race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children’s distress. Mean FPS-R score for tube placement was 3.30, in the “mild’ pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5–12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5–12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints.

Outcomes of Mastoidectomy With Antibiotic Catheter Irrigation for Patients With Draining Ventilation Tubes

Objectives: To evaluate the effectiveness of mastoidectomy with antibiotic catheter irrigation in patients with chronic tympanostomy tube otorrhea. Methods: A chart review of adult and pediatric patients with persistent tympanostomy tube otorrhea who had failed outpatient medical management and underwent mastoidectomy with placement of a temporary indwelling catheter for antibiotic instillation was performed. Patients were retrospectively followed for recurrent drainage after 2 months and outcomes were categorized as resolution (0-1 episodes of otorrhea or otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes). Results: There were 22 patients and 23 operated ears. Median age was 46 years (interquartile range, IQR = 29-65). The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had episodic. The observed percentage of resolved/improved ears (87%) was significant ( P = .0005, 95% CI = 67.9%-95.5%). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages improved (difference of medians = −3.3 dB, P = .02) with no significant difference in word recognition scores ( P = .68). Methicillin-resistant Staphylococcus aureus was the most common isolated microbe while no growth was most frequently noted on intraoperative cultures. Conclusions: Mastoidectomy with antibiotic catheter irrigation may be an effective surgical strategy, and single stage alternative to intravenous antibiotics, for select patients with persistent tube otorrhea who have failed topical and oral antibiotics.