Chia-Huei Chu

Otitis media with effusion in children with cleft lip and palate: A narrative review

OBJECTIVE Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP. METHODS All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles. RESULTS Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference. CONCLUSIONS The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.

Migraine is a risk factor for sudden sensorineural hearing loss: A nationwide population-based study:

Background The pathophysiology of idiopathic sudden sensorineural hearing loss (SSNHL) is poorly understood. Few case reports have proposed a possible link between migraine and SSNHL. Objectives This study aimed to explore the risk of idiopathic SSNHL in patients with migraine in a nationwide, population-based cohort study. Methods We identified patients with migraine from the Taiwan National Health Insurance Research Database (NHIRD) between 2000 and 2009. Each migraine patient was matched with four randomly selected subjects without migraine for age, sex, and comorbidities. Both cohorts were followed up until the end of 2009. We compared the incidence rates of SSNHL in the two cohorts and identified the risk factors. Results A total of 10,280 migraine patients and 41,120 matched controls were enrolled with a median follow-up of five years. The migraine cohort had a greater risk of developing SSNHL than the matched cohort (81.6 vs. 45.7 per 100,000 person-years, incidence rate ratio (IRR) = 1.8; 95% confidence interval (CI) 1.22–2.61, p = 0.002). The Cox proportional hazards analysis revealed that among migraine subjects, comorbidity with hypertension was associated with a trend of developing SSNHL (hazard ratio (HR) = 1.92, 95% CI 0.97–3.79, p = 0.06). Conclusions This population-based study demonstrates that migraine is associated with an increased risk of idiopathic SSNHL, which, however, is a rare condition.

New therapeutic strategy for treating otitis media with effusion in postirradiated nasopharyngeal carcinoma patients

Background: Postirradiation otitis media with effusion (OME) is the most common radiotherapy‐associated otologic complication associated with nasopharyngeal carcinoma (NPC). This studys aim was to evaluate the efficacy of laser myringotomy followed by intratympanic steroid injection (LMIS) for treating OME in postirradiated NPC patients. Methods: From August 2002 to January 2006, 27 newly diagnosed NPC patients who developed OME after a full course of radiotherapy were enrolled. Laser myringotomy was performed followed by once‐weekly administration of steroids (0.5 mL dexamethasone at a concentration of 5.0 mg/mL) into the middle ear for 3 consecutive weeks. The success rate of dry eardrum perforation and the prognostic factors associated with OME resolution were analyzed. Results: The procedure was performed on 44 ears of 27 patients. The mean follow‐up period was 37 weeks. Of the 44 ears, 23 (52.3%) developed persistent eardrum perforation, 18 (40.9%) developed recurrent OME, and three (6.8%) were disease‐free on follow‐up. Of the 23 ears with persistent eardrum perforation, 18 (78.3%) were diagnosed as dry perforation. The absence of pretreatment mastoiditis was an independent factor associated with OME resolution (p < 0.001). Conclusion: LMIS is a quick, minimally invasive, office‐based technique that can be repeatedly performed to treat highly recurrent postirradiation OME, and it results in relatively slight pain to NPC patients. Long‐lasting dry eardrum perforation allows for adequate middle ear ventilation and drainage and guarantees sustained relief from symptoms. The absence of preoperative mastoiditis is a favorable prognostic factor associated with OME resolution.

The protective effect of adenoidectomy on pediatric tympanostomy tube re-insertions: a population-based birth cohort study.

Objectives Adenoidectomy in conjunction with tympanostomy tube insertion for treating pediatric otitis media with effusion and recurrent acute otitis media has been debated for decades. Practice differed surgeon from surgeon. This study used population-based data to determine the protective effect of adenoidectomy in preventing tympanostomy tube re-insertion and tried to provide more evidence based information for surgeons when they do decision making. Study Design Retrospective birth cohort study. Methods This study used the National Health Insurance Research Database for the period 2000–2009 in Taiwan. The tube reinsertion rate and time to tube re-insertion among children who received tympanostomy tubes with or without adenoidectomy were compared. Age stratification analysis was also done to explore the effects of age. Results Adenoidectomy showed protective effects on preventing tube re-insertion compared to tympanostomy tubes alone in children who needed tubes for the first time (tube re-insertion rate 9% versus 5.1%, p = 0.002 and longer time to re-insertions, p = 0.01), especially those aged over 4 years when they had their first tube surgery. After controlling the effect of age, adenoidectomy reduced the rate of re-insertion by 40% compared to tympanostomy tubes alone (aHR: 0.60; 95% CI: 0.41–0.89). However, the protective effect of conjunction adenoidectomy was not obvious among children with a second tympanostomy tube insertion. Children who needed their first tube surgery at the age 2–4 years were most prone to have tube re-insertions, followed by the age group of 4–6 years. Conclusions Adenoidectomy has protective effect in preventing tympanostomy tube re-insertions compared to tympanostomy tubes alone, especially for children older than 4 years old and who needed tubes for the first time. Nonetheless, clinicians should still weigh the pros and cons of the procedure for their pediatric patients.

Decision making in the choice of surgical management for preauricular sinuses with different severities.

Objectives The preauricular sinus is a common congenital abnormality of the preauricular soft tissues. Here, we demonstrate the decision making in the choice of surgical management of preauricular sinuses based on disease severity. In addition, a method termed figure 8 incision with extended fistulectomy is introduced. Study Design Case series with chart review. Setting Tertiary care center. Subjects Between January 2003 and February 2010, a total of 90 patients (109 ears) underwent surgery for preauricular sinuses in our hospital. Methods After controlling the infection, the patients received definite surgery. They were classified into 3 groups according to the operative methods. We recorded the clinical conditions and any recurrences during the follow-up period. Results Group I patients (48 ears) had a trace inflammatory condition and underwent a simple sinusectomy. The recurrence rate was 2.08%. Group II (31 ears) and group III (30 ears) patients had more highly inflamed tissue and underwent a local wide excision and a figure 8 incision with extended fistulectomy, respectively. The recurrence rate in group II was 22.58%. Meanwhile, none of the group III cases showed a recurrence. In our study, there were 8 recurrent cases in 109 ears, yielding a recurrence rate of 7.34%. Conclusion Simple sinusectomy is an adequate surgical technique for preauricular sinuses with a mild inflammatory condition. For more severe cases, the figure 8 incision with extended fistulectomy can achieve adequate wound exposure for radical excision of the inflamed tissue and a satisfactory surgical outcome.

Re-evaluation of CO2 laser myringotomy for managing children with persistent acute otitis media

Background: This study aimed to re‐evaluate the utility of CO2 laser myringotomy in children with persistent acute otitis media (PAOM). Methods: From September 2002 to April 2008, 40 children with PAOM received CO2 laser myringotomy. PAOM was defined as continuing symptoms and signs after systemic antibiotic treatment. Before laser myringotomy, the eardrums were checked under videotelescopy, pure tone audiometry or behavior audiometry and tympanometry. Middle ear effusions were collected using our own designed bottle culture device after laser myringotomy. The patients were followed up at outpatient clinics for 3 months. Cultured middle ear pathogens, healing time of the eardrums, hospital course (for admitted patients), and the development of middle ear effusions were recorded. Results: Forty children with 53 ears with PAOM were enrolled. Eight patients (20%) had bilateral disease and underwent bilateral laser myringotomy. The overall culture rate was 28.3%, and Streptococcus pneumoniae was the most common pathogen. Eight patients (20%) were admitted for intravenous antibiotics. The average eardrum healing time was 22 days in those with positive cultures, and 16.4 days in those with negative cultures (p = 0.125). All eardrums healed in 1 month. The resolution rate was 62.5% at 1 month. Patients with bilateral PAOM were prone to have positive middle ear culture (5/8) compared with those with unilateral PAOM (8/32) (p = 0.086). Conclusion: CO2 laser myringotomy is an applicable means of treating PAOM. S pneumoniae is the most common pathogen in PAOM. CO2 laser myringotomy allows for the drainage and culture sampling of middle ear effusion, relieving the need of taking prolonged medication.

High-Dose Amoxicillin with Clavulanate for the Treatment of Acute Otitis Media in Children

Objective. This study uses the acute otitis media clinical practice guideline proposed in 2004 as a reference to evaluate whether antibiotics doses that are in line with the recommendations lead to better prognosis. The study also attempts to clarify possible factors that influence the outcome. Study Design. Retrospective cohort study. Subjects and Methods. A total of 400 children with acute otitis media were enrolled. The dosage of amoxicillin was considered to be appropriate when in accord with clinical practice guidelines, that is, 80–90 mg/kg/day. The outcome was defined according to the description of tympanic membrane on medical records. Multivariate logistic regression was used to analyze the relationship between antibiotic dosage and prognosis after adjusting for baseline factors. Results. The majority of prescriptions were under dosage (89.1%) but it was not noticeably associated with outcome (P = 0.41). The correlation between under dosage and poor prognosis was significant in children below 20 kg with bilateral acute otitis media (odds ratio 1.63; 95% CI 1.02–2.59, P = 0.04). Conclusion. Treating acute otitis media in children, high-dose amoxicillin with clavulanate as recommended in the clinical practice guideline was superior to conventional doses only in children under 20 kg with bilateral diseases.

Minimally traumatic stapes surgery for otosclerosis: Risk reduction of post-operative vertigo

Background: The author (Dr. Shiao) modified traditional stapes surgery (TSS) specifically for patients with otosclerosis. The proposed technique, referred to as minimally traumatic stapes surgery (MTSS), reduces the risk of subjective discomfort (i.e. vertigo and tinnitus) following surgery. This paper compares the effectiveness of MTSS with that of TSS. Methods: The medical records of patients with otosclerosis after stapes surgery (TSS or MTSS) were analyzed. Outcome variables included post‐operative vertigo, tinnitus, and hearing success. Multivariate logistic regression analysis was used to determine the correlation between surgical technique and outcome variables. Results: TSS was performed in 23 otosclerosis ears and MTSS was performed in 33 otosclerosis ears. The risk of post‐operative vertigo was significantly lower among patients that underwent MTSS (27%) than among those that underwent TSS (83%, p < 0.001). No differences in the incidence of tinnitus were observed between the two groups. Post‐operative audiometric outcomes were also equivalent between the two groups. However, multivariate logistic regression analysis revealed a correlation between post‐operative vertigo and surgical technique (p < 0.001). Conclusion: MTSS involves a lower risk of vertigo than does TSS. MTSS helps to prevent damage to the footplate, thereby reducing the risk of footplate floating. Therefore, MTSS provides a means to overcome some of the limitations associated with the narrow surgical field in Asian patients.

Impact of pneumococcal conjugate vaccine on pediatric tympanostomy tube insertion in partial immunized population.

Objective. To investigate the impact of seven-valent pneumococcal conjugate vaccine on tube insertions in a partial immunized pediatric population. Study Design. Retrospective ecological study. Methods. This study used Taiwan National Health Insurance Research Database for the period 2000–2009. Every child under 17 years old who received tubes during this 10-year period was identified and analyzed. The tube insertion rates in different age groups and the risk to receive tubes in different birth cohorts before and after the release of the vaccine in 2005 were compared. Results. The tube insertion rates for children under 17 years of age ranged from 21.6 to 31.9 for 100,000 persons/year. The tube insertion rate of children under 2 years old decreased significantly after 2005 in period effect analysis (β = −0.074, P < 0.05, and the negative β value means a downward trend) and increased in children 2 to 9 years old throughout the study period (positive β values which mean upward trends, P < 0.05). The rate of tube insertion was lower in 2004-2005 and 2006-2007 birth cohorts than that of 2002-2003 birth cohort (RR = 0.90 and 0.21, 95% CI 0.83–0.97 and 0.19–0.23, resp.). Conclusion. The seven-valent pneumococcal conjugate vaccine may reduce the risk of tube insertion for children of later birth cohorts. The vaccine may have the protective effect on tube insertions in a partial immunized pediatric population.

Reply to 'migraine, sudden sensorineural hearing loss and autoimmune ear disease'.

We thank Drs Espinosa-Sanchez and Lopez-Escamez (1) for showing interest in this study (2). He questioned first that autoimmune inner ear diseases may explain the differences in the incidence rates of sudden sensorineural hearing loss (SSNHL) between migraine and the matched control groups. We would like to declare that it is important to ensure high validity while using a population-based claim dataset. We excluded cases with Meniere’s disease (MD) any time in the study period because the first attack of MD in some patients might be misdiagnosed as SSNHL (3). Furthermore, the comorbidity of migraine and MD has been reported (4). Therefore, we excluded MD cases to minimize the confounding effect of MD that links migraine and SSNHL. In contrast, patients with autoimmune diseases are not excluded in our study because the role of autoimmune diseases in SSNHL remains speculative and the specific immunologic markers for autoimmune inner ear disease are not determined (5). The second question is about the consideration of vestibular migraine (VM). We did not exclude patients with VM because there is no formal coding for it in the International Classification of Diseases, Ninth Revision, ModiEcation (ICD-9-CM). In fact, the diagnosis of VM is not adopted in the International Headache Classification, 2nd edition (2004) either (6). The last question is that the incidence of MD reported here seems too high. Actually, it had been reported that the annual incidence ranged from 8.2 to 157 per 100,000 (7). The incidence rate of MD in our study, 168 per 100,000 (227 MD in 13,532 migraine patients during the 10-year follow-up), was reasonable since this incidence was estimated from a migraine cohort with female predominance.