First conceived by Politzer and Cassells1 in 1868, ventilating tubes were not popular until the 1950s, when Armstrong² introduced them in 1954. The tympanostomy tube has since become one of the most commonly employed yet contentious devices in modern medicine. In children, otitis media is the most frequent reason for nonwell visits to a physician. Often it is recurrent and medically refractory. Vent tube placement has become an important weapon in the otolaryngologist’s war on this problem. In fact, myringotomy with vent tube placement has become the most common operation in children requiring general anesthesia in the United States. Enthusiasm for the procedure has been moderated, however, in both otolaryngologists and pediatricians by complications, the most common of which is post-tympanostomy otorrhea (PTO).

Although vent tube placement is a safe and effective treatment strategy that has significantly reduced the incidence of chronic mastoiditis and acquired cholesteatoma, PTO occurs within a range of 3.1 to 37.9%. Luxford and Sheehy’s³ reported incidence of 21% is typical. This literature is well summarized by Goldstein et al.⁴ Higher rates of PTO have been associated with large-bore vent tubes (41% and 69% in two studies^{5, 6}). PTO is not thought to be more common in patients who have undergone prior myringotomy with intubation.⁷ In children with cleft palates, reflux of nasopharyngeal secretions into the middle ear has been associated with higher rates of PTO (67%).^{8, 9} Patients undergoing concomitant adenoidectomy do not represent higher PTO risks.¹⁰

PTO can occur early, at 2 weeks after surgery, or at some time later. The etiology of both scenarios is different.¹¹ Early PTO is thought to be a function of the underlying disease or to represent surgical contamination. Early PTO is clearly related to the conditions in the middle ear cleft at surgery.¹² Dry or serous effusions are rarely associated with PTOs, whereas mucoid or mucopurulent effusions and/or middle ear mucosal disease is statistically correlated with PTO. An enormous literature has been dedicated to surgical PTO prophylaxis. Although contradictory, consensus appears to refute the efficacy of drop therapy or canal preparation. Younger children appear to be more susceptible than older children.^{7, 10} Late PTO is more frequently associated with extrinsic contamination of the middle ear and otitis media associated with upper respiratory infection or allergic disorders.¹¹ Late PTO occurs more commonly during the summer months with water contamination.¹³ Intubation abolishes the air cushion of the middle ear. In young children, this may make bacterial reflux from the nasopharynx and eustachian tube more problematic.¹⁴ Adenoidectomy does not appear to influence late PTO.

PTO bacteriology has been reviewed by Schneider.¹⁵ In young children under age 3 years, isolates were similar to those found in acute otitis media, except that Hemophilus influenzae is more common than D. pneumoniae. The presence or absence of concurrent upper respiratory infection is significant in choosing a treatment strategy. In children older than age 3 years and in whom infectious causes are more common, Pseudomonas sp. is a common isolate (in 25%). Gram-positive species (Staphylococcus) are even more common (in 45%), many of which are penicillin resistant, even in nonhospital communities (80%). PTO management in this population is somewhat more problematic.

Most cases of PTO arise from extensive contamination of the middle ear through the open tube. The risk of otorrhea after tympanostomy tube placement is three times higher than after myringotomy alone.

Treatment Strategies

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