Is There an Optimal Location for Tympanostomy Tube Placement?

TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

Background

Tympanostomy tube placement is the most common surgical procedure in children. It is performed on about 1 million children and 1 million adults in the United States annually. In the past decades, tympanostomy tubes have been shown to reduce the incidence of otitis media–related complications. Although it is a well-tolerated procedure with a low risk of complications, chronic perforation after tube extrusion has an incidence of 2% with short-term tubes and 16% for long-term tubes. Thus, there is an expected annual incidence that is conservatively >40,000 perforations in children and adults in the United States alone. Most perforations are readily repaired, but anteriorly located perforations may be more challenging to surgically close than posterior holes.

Originally, tubes were often placed using spinal needles for the myringotomy and involved working through an otoscope. The anterior-inferior quadrant was frequently recommended to stay maximally far from the posterior-superior quadrant under which the ossicles are located.

Most textbooks have recommended placement of tympanostomy tubes into the anterior-inferior quadrant with the hopes of:

1. Longer duration in the tympanic membrane (i.e., prolonged function);
2. Avoidance of the ossicular chain;
3. Prevention of hearing loss that could theoretically result from a perforation being located over the round window; and
4. Easier visibility through the tube to view the patency of the lumen and to see the status of the middle ear mucosa.

Best Practice

A literature review found that there is no body of evidence to suggest that there is an optimal location for placing tympanostomy tubes, yet the anterior-inferior quadrant is commonly used. In the absence of such evidence, we suggest that surgeons also consider the risk of a chronic perforation and the technical issues that may be associated with its repair. Future studies would be in order to provide evidence for rates of perforation between anterior versus posterior sites and other measures of superiority of one site over another. (Laryngoscope. 2015;125:1513–1514).