Myringotomy and Tympanostomy Tube

Number: 0418

Policy

Aetna considers myringotomy and tympanostomy tube (also known as ventilation tube and grommet) insertion medically necessary for any of the following indications: 

  1. Autophony due to patulous eustachian tube; or 
  2. Barotitis media control; or
  3. Children with cleft palate and history of otitis media with effusion and persistent hearing loss; or
  4. Cholesteatoma; or
  5. Chronic retraction of tympanic membrane or pars flaccida; or
  6. Complications of otitis media such as meningitis, facial nerve paralysis, coalescent mastoiditis, or brain abscess; or
  7. Otitis media with effusion after 3 months or longer and bilateral hearing impairment (defined as 20 dB hearing threshold level or worse in both ears) (tympanostomy tube); or 
  8. Recurrent episodes of acute otitis media (more than 3 episodes in 6 months or more than 4 episodes in 12 months) (tympanostomy tube); or
  9. Severe otalgia in acute otitis media (myringotomy); or 
  10. To obtain a culture (diagnostic tympanocentesis/myringotomy) of the middle ear fluid prior to beginning or changing antimicrobial therapy (this may be necessary in situations such as otitis media that has failed to respond to appropriate antimicrobial therapy, or for otitis media in individuals or neonates who are immunocompromised). 

Notes:

OtoScan laser-assisted myringotomy (also called tympano-laserostomy, laser-assisted tympanostomy [LAT] or OtoLAM) is considered to be as effective as traditional myringotomy and is safe.  The same selection criteria apply to both laser myringotomy and the traditional myringotomy.

Tympanostomy tube insertion is considered not medically necessary for children with a single episode of otitis media with effusion (OME) of less than 3 months’ duration

Tympanostomy tube insertion is considered not medically necessary for children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy.

Aetna considers myringotomy and tympanostomy tube insertion experimental and investigational for all other indications (e.g., the prevention of hearing impairment in children with Cornelia de Lange syndrome without above-listed indications for tube placement) because its effectiveness for indications other than the ones listed above has not been established.

Aetna considers the use of soft-tissue fillers (e.g., hyaluronic acid and Prolaryn gel) experimental and investigational for the treatment of patulous Eustachian tube because their effectiveness has not been established.

Aetna considers the use of
  1. phosphorylcholine-coated tympanostomy tube; and
  2. vancomycin-coated tympanostomy tube experimental and investigational because their effectiveness has not been established.

Aetna considers the EarPopper device for the treatment of otitis media with effusion and all other conditions (e.g., eustachian tube dysfunction and negative pressure as a consequence of elevation changes from airline travel, diving, and sinusitis surgery, etc.) experimental and investigational because of insufficient evidence of its effectiveness.

Aetna considers endoscopic balloon dilation of the Eustachian tube for the treatment of Eustachian tube dysfunction experimental and investigational because of insufficient evidence of its effectiveness.

Aetna considers trans-tympanic balloon dilatation of the Eustachian tube experimental and investigational for the treatment of chronic ear disease because the effectiveness of this approach has not been established.

Aetna considers the Tubes Under Local Anesthesia (Tula) System experimental and investigational for the treatment of otitis media because its effectiveness has not been established.

Background

Myringotomy and Tympanostomy Tube

A myringotomy is an incision of the tympanic membrane to allow ventilation of the middle ear, drainage of middle ear fluid, or to obtain cultures from an infected middle ear.  In children with middle-ear effusions, initial treatment often consists of observation or antibiotic therapy even though recent evidence indicated that the benefit of antibiotics for otitis media with effusion (Lous et al, 2005) and acute otitis media (Schilder et al, 2004) is limited.  Most cases of otitis media with effusion resolve spontaneously within 3 months of onset.

An alternative to myringotomy with tube placement is a new tympanostomy procedure by CO2 laser without ventilation tubes, (also called tympanolaserostomy or laser-assisted tympanostomy [LAT]).  OtoLAM (ESC Medical Systems, Needham, MA) is performed with a computer-driven laser and a video monitor to pinpoint the exact location for the hole.  It programs the precise size of the hole into the computer.  The laser then takes just 1/10 of a second to create the opening, without damaging surrounding skin or structures in the ear.  The hole stays open for several weeks and this provides ventilation of the middle ear without the need for tube placement.  Studies showed that the CO2 laser was especially effective in vaporizing the tympanic membrane, especially when there was fluid behind the tympanic membrane to protect the promontory.  Laser myringotomies maintain patency slightly longer than that produced by cold-knife myringotomy (3 to 6 weeks versus 48 to 72 hours) but have not been proven to be more efficacious in the management of effusion than simple myringotomy.  A randomized controlled study (n = 208) found that laser myringotomy is safe but less effective than ventilation tube in the treatment of chronic otitis media with effusion (Koopman et al, 2004).

In an update of the 1994 clinical practice guideline Otitis Media With Effusion in Young Children, developed by the AHCPR, the American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Pediatrics Subcommittee on otitis media with effusion (2004) recommended that clinicians should manage children with otitis media with effusion (OME, aged 2 months through 12 years) who are not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown).  Children with persistent OME who are not at risk should be re-examined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected.  When a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure.  Candidates for surgery include children with OME lasting 4 months or longer with persistent hearing loss or other signs and symptoms, recurrent or persistent OME in children at risk regardless of hearing status, and OME and structural damage to the tympanic membrane or middle ear.  The tube usually remains in place for several months, although it may be rejected sooner or remain in place for years.  Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery should consist of adenoidectomy plus myringotomy, with or without tube insertion.  Furthermore, tonsillectomy alone or myringotomy alone should not be used to treat OME (Rosenfeld et al, 2004).

A Cochrane review (Lous et al, 2005) stated that the most common medical treatment options for OME include the use of decongestants, mucolytics, steroids, anti-histamines and antibiotics.  The effectiveness of these therapies, however, has not been established.  Surgical treatment options include grommet (ventilation or tympanostomy tube) insertion, adenoidectomy or both.  Moreover, the benefits of grommets in children appear small.  The effect of grommets on hearing diminished during the first year.  Potentially adverse effects on the tympanic membrane are common after grommet insertion.  Thus, an initial period of watchful waiting seems to be an appropriate management strategy for most children with OME.  Randomised controlled studies are needed before more detailed conclusions about the effectiveness of grommets can be drawn.

In a multi-center, randomized controlled study (n = 395), Paradise et al (2005) concluded that in otherwise healthy children younger than 3 years of age who have persistent middle-ear effusion within the duration of effusion (9 months) that these patients were studied, prompt insertion of tympanostomy tubes does not improve developmental outcomes at 6 years of age.

In a "follow-up" study, Paradise et al (2007) examined tympanostomy tubes and developmental outcomes at 9 to 11 years of age.  These researchers enrolled 6,350 infants soon after birth and evaluated them regularly for middle-ear effusion.  Before 3 years of age, 429 children with persistent effusion were randomly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if effusion persisted.  They assessed literacy, attention, social skills, and academic achievement in 391 of these children at 9 to 11 years of age.  Mean (+/- SD) scores on 48 developmental measures in the group of children who were assigned to undergo early insertion of tympanostomy tubes did not differ significantly from the scores in the group that was assigned to undergo delayed insertion.  These measures included the Passage Comprehension subtest of the Woodcock Reading Mastery Tests (mean score, 98 +/- 12 in the early-treatment group and 99 +/- 12 in the delayed-treatment group); the Spelling, Writing Samples, and Calculation subtests of the Woodcock-Johnson III Tests of Achievement (96 +/- 13 and 97 +/- 16; 104 +/- 14 and 105 +/- 15; and 99 +/- 13 and 99 +/- 13, respectively); and inattention ratings on visual and auditory continuous performance tests.  The authors concluded that in otherwise healthy young children who have persistent middle-ear effusion, as defined in this study, prompt insertion of tympanostomy tubes does not improve developmental outcomes up to 9 to 11 years of age.

In an editorial that accompanied the study by Paradise and associates, Berman (2007) stated that the consistency of the findings of Paradise et al during prolonged follow-up periods provided convincing evidence that persistent middle-ear effusion in otherwise normal children does not cause developmental impairments.

Allen (2007) conducted a retrospective chart review to determine if intravenous access is necessary during the performance of myringotomy with tube insertion.  The study included 50 pediatric patients divided equally into 2 groups: group 1, who did not have intravenous access established before the procedure, and group 2, who did have intravenous access established.  To be enrolled, patients in both groups had to be less 12 years of age or younger, have an American Society of Anesthesiologists physical status classification of P1 or P2, and had to have undergone no adjunctive procedure with the myringotomy.  Induction time was significantly shorter in group 1 (average: 6.96 +/- 2.72 mins) than in group 2 (average: 9.80 +/- 3.82 mins; p = 0.004).  Operating time and total operating room time were not significantly different between the 2 groups.  Additionally, 24 of 25 patients in group 1 had their pain managed with acetaminophen or no medication at all, while 9 of 25 group 2 patients received acetaminophen and 13 received intravenous pain medication.  Interestingly, no patients in group 1 required anti-emetics, whereas 4 patients in group 2, who were given intravenous or intramuscular narcotics, received anti-emetic medications.  These findings indicate that myringotomy with tube insertion can be safely accomplished without establishing intravenous access.  Induction times and time under general anesthesia were significantly increased when intravenous access was obtained.  The findings also suggest that acetaminophen provides adequate post-operative pain control in this patient population and that the use of intravenous or intramuscular narcotics increases the risk of post-operative nausea.

Spielmann et al (2008) stated that there is a paucity of evidence to guide the post-operative follow-up of patients undergoing middle-ear ventilation tube insertion for the first time.  This study was undertaken to identify current practice at the authors' institution and to inform subsequent change in their follow-up procedure.  Two cycles of data collection and analysis were performed.  All pediatric patients undergoing ventilation tube insertion for the first time were identified.  Patients who had previously undergone ventilation tube insertion or additional procedures such as adenoidectomy or tonsillectomy were excluded.  The first data collection period comprised all of the year 2000, and the second 18 months over 2003 to 2004.  A minimum of 20 months' follow-up was allowed for.  Data regarding clinical findings and audiometry were recorded at each follow-up appointment.  A total of 50 patients meeting the criteria for inclusion in the first cohort were identified.  There were a total of 156 appointments between surgery and data collection (a mean of 3.12 per child).  A total of 113 (72 %) appointments lead to no medical intervention.  The only statistically significant difference between patients requiring further ventilation tube insertion (n = 10) and those not requiring further treatment during the study period (n = 40) was the average hearing threshold (p < 0.01).  These findings prompted a change in the post-operative regime; all patients undergoing ventilation tube insertion were subsequently seen at 3 months for a pure tone audiogram, and further review depended on clinical and audiometric findings.  Records for 84 children were identified and collected for the second cohort, there were a total of 154 appointments (a mean of 1.83 per child).  In only 18 appointments (12 %) were normal findings and hearing recorded and children given a further review appointment.  Sixteen of 29 (55 %) children with abnormal clinical findings (otorrhea, tube blockage or extrusion) required some form of intervention (p < 0.05).  Twenty-six had a mean hearing threshold worse than 20 dB at first review.  Nineteen (73 %) required further intervention of some sort (p < 0.01).  The authors concluded that these findings demonstrated that the vast majority of review appointments resulted in no clinical intervention.  Thus, these investigators question the need for regular follow-up in this patient group.  Twenty per cent (10 of 50 and 18 of 84) of the patients required further ventilation tube insertion within the study periods.  This is consistent with rates reported in the literature.  Children with abnormal clinical findings or a mean hearing threshold greater than 20 dB were significantly more likely to require further intervention.  The authors recommended one post-operative review with audiometry, 3 months after surgery.  At this initial appointment, further review should be offered to those children with poor hearing, early extrusion, blockage or infection, as they are more likely to require further ventilation tube insertion.

In a Cochrane review on grommets (ventilation tubes) for recurrent acute otitis media in children, McDonald et al (2008) concluded that ventilation tubes have a significant role in maintaining a "disease-free" state in the first 6 months after insertion.  They stated that more research is needed to investigate the effect beyond 6 months.  Furthermore, clinicians should consider the possible adverse effects of grommet insertion before surgery is undertaken.

Campbell and colleagues (2009) stated that primary ciliary dyskinesia is an autosomal recessively inherited group of disorders of ciliary ultra-structure.  Otolaryngologists are frequently involved in the management of some of the most common symptoms of primary ciliary dyskinesia including chronic rhinitis, sinusitis, and OME.  A dilemma for otorhinolaryngologists is whether ventilation tubes are of benefit in children with primary ciliary dyskinesia and OME and what effective alternatives exist.  The authors addressed this issue via a literature review and case presentation.  An extensive review of the literature was undertaken and a discussion of the advantages and disadvantages of ventilation tubes in the management of OME in these children was presented and compared with that of the general population.  These investigators presented a case of a 9-month old boy with Kartagener's syndrome and chronic bilateral OME to illustrate their findings.  A total of 8 papers were identified, all with small study numbers.  The main outcome measures were hearing, otorrhea and tympanic membrane structural changes.  The natural history of OME and hearing loss in primary ciliary dyskinesia appears to be fluctuant into adulthood.  Thus, OME in primary ciliary dyskinesia does not resolve by the age of 9 years, regardless of treatment, as previously assumed.  Ventilation tube insertion  (VTI) improves hearing in primary ciliary dyskinesia, but may lead to a higher rate of otorrhea when compared to the general population.  Tympanic membrane changes were clinically insignificant.  The patient eventually underwent successful insertion of bilateral ventilation tubes with a marked improvement in hearing and language with minimal otorrhea.  The authors concluded that the highest level of evidence found for the management of OME in children with primary ciliary dyskinesia was level IV.  Currently, the evidence is inconclusive and conflicting.  While these findings are promising, clearly higher quality research on a larger number of patients is required to definitively evaluate the management options for OME in these children.

Coated Tympanostomy Tubes

Methicillin-resistant staphylococcus aureus (MRSA) infections and colonization in children have increased in recent years.  Moreover, bacterial biofilm formation has been implicated in the high incidence of persistent otorrhea following tympanostomy tube insertion.  It has been suggested that the tube material may be an important factor in the persistence of such otorrhea.  Development of MRSA otorrhea after tympanostomy tube placement is a growing concern.  Jang and associates (2010) evaluated the effect of using vancomycin and chitosan coated tympanostomy tubes on the incidence of MRSA biofilm formation in-vitro.  Three sets each of vancomycin-coated silicone tubes (n = 5), commercial silver oxide-coated silicone tubes (n = 5) and uncoated tympanostomy tubes (as controls; n = 5) were compared as regards resistance to MRSA biofilm formation after in vitro incubation.  Scanning electron microscopy showed that the surfaces of the silver oxide-coated tubes supported the formation of thick biofilms with crusts, comparable to the appearance of the uncoated tubes.  In contrast, the surface of the vancomycin-coated tympanostomy tubes was virtually devoid of MRSA biofilm.  The authors concluded that vancomycin-coated tympanostomy tubes resist MRSA biofilm formation.  They noted that pending further study, such tubes show promise in assisting the control of MRSA biofilm formation.

In a prospective, randomized, double-blind controlled trial, Hong et al (2011) compared the post-operative complication rates of phosphorylcholine-coated fluoroplastic tympanostomy tubes versus uncoated fluoroplastic tympanostomy tubes.  A total of 240 children with recurrent acute otitis media and chronic otitis media with effusion were randomized to receive a phosphorylcholine-coated tube in one ear and an uncoated tube in the other.  Post-operatively, patients were assessed at 2 weeks and 4, 8, 12, 18, and 24 months to ascertain the incidence of otorrhea, tube lumen blockage, and early extrusion.  Out of 240 children, 5 withdrew and 16 were lost to early follow-up.  The mean age was 43.8 months.  There were no statistically significant differences in the incidence of post-operative otorrhea, tube blockage, and extrusion.  The authors concluded that phosphorylcholine-coated fluoroplastic ventilation tubes do not offer any advantages over uncoated standard fluoroplastic tympanostomy tubes.

The EarPopper Device

The EarPopper is a non-invasive device for treating conditions such as otitis media with effusion, middle ear effusion, aerotitis/barotitis and eustachian tube dysfunction, without the need for surgery or antibiotics.  It delivers a constant, regulated stream of air into the nasal cavity through the nostril with a 1-oz infant nasal syringe equipped with a plastic tip.  During the moment of swallowing, the air is diverted up the eustachian tube clearing and ventilating the middle ear.  The EarPopper relieves the negative ear pressure allowing any accumulated fluids to drain.  The Australia and New Zealand Horizon Scanning Network's assessment on "EarPopper for the treatment of otitis media in children" (2007) deemed this technology as "yet to emerge"; and it does not receive approval from the Australian Therapeutic Goods Administration.  The assessment noted that the evidence suggested that the EarPopper may provide a safe and effective treatment option in the short-term with minimal clinical impact on health practitioners as it can be used at home; and recommended that this technology be monitored.

An Agency for Healthcare Research and Quality’s report on “Otitis media with effusion: Comparative effectiveness of treatments” (AHRQ, 2012) stated that “Though not in widespread use, the technique of autoinflation [which is what EarPopper tries to accomplish] has been used as a treatment for OME.  The goal of autoinflation is to use either a Valsalva maneuver or external device to equalize middle ear and oropharyngeal pressure, essentially transiently opening the Eustachian tube.  A 2006 Cochrane Collaboration study included 6 randomized controlled trials (RCTs) examining the use of autoinflation versus no treatment for hearing loss associated with OME.  Studies included children, adults, and special populations and concluded that the evidence for the use of autoinflation in the short-term was favorable; however, given the small number of studies and lack of long-term follow-up, the long-term effects could not be determined”.

In a randomized, single-blinded, controlled trial, Banigo et al (2016) provided an independent evaluation of the safety and effectiveness of the EarPopper in improving hearing outcomes in children with OME and reducing the ventilation tube insertion rate. A total of 29 children aged between 4 and 11 years diagnosed with persistent OME lasting at least 3 months with an average hearing of 25 decibels Hearing Leve (dBHL) or worse in the better ear were randomized to a treatment or control group for 7 weeks using random computer-generated codes.  Syndromic children, children with developmental delay, previous grommets and cleft palate were excluded.  The audiologists were blinded at the final post-treatment audiogram.  After the 7-week period, the mean improvement in air conduction across all frequencies was 10.9 dBHL in the treatment group (p < 0.001) and 3.6 dBHL in the control group (p = 0.201).  At every frequency, the treatment group had larger improvements in air conduction, the largest being at 4 kHz where the mean air conduction in both ears improved by 14.8 dBHL.  Compliance with the EarPopper was over 90 %, the only side-effect reported being discomfort in the ears immediately after use, which resolved and did not affect compliance.  The ventilation tube insertion rate was 53.3 % in the treatment group and 78.6 % in the control group.  Median follow-up time for all patients is 47.7 months.  The authors concluded that the findings of this study showed that the EarPopper is a safe and effective therapeutic option for children with hearing loss from persistent OME, and it reduces the rate of ventilation tube insertion; they stated that more studies with larger sample sizes are needed to support their findings.

Tympanostomy Tube Insertion in Children with Cleft Palate

Hornigold et al (2008) noted that between July 1984 and March 1987, all children that underwent repair for primary cleft palate at the Queen Victoria Hospital were enrolled in a clinical trial.  Those found to have OME at time of surgery had a t-tube inserted into 1 randomized ear, while the other ear received no treatment.  The object of the study was to re-assess patients from the original trial to discover the impact of the unilateral t-tube 20 years later.  A total of 22 patients were identified as potential study participants.  Of this group, 14 were contactable and 7 agreed to participate in the follow-up study.  Main outcome measures were persistent symptomatology, otoscopy, pure tone audiometry and tympanometry.  Follow-up results were compared within the original treatment groups from the primary study, on an intention-to-treat basis.  Otoscopically the ears were normal in 2 of the 7 treated ears compared with 4 of the 7 non-treated ears.  All the other ear ears had various types of chronic otitis media.  Four of the 7 had hearing of greater than 10 dB in the treated ear compared with the non-treated ear.  The authors concluded that these findings would indicate need for caution in the use of t-tubes in the cleft population and raises the question of long-term follow-up to assess for secondary cholesteatoma.

In a systematic review, Ponduri et al (2009) examined if early routine grommet insertion in children with cleft palate has a beneficial effect on hearing and speech and language development compared with conservative management.  The main outcome measure was the effect of early routine grommet placement on the degree of conductive hearing loss.  Secondary outcome measures included differences in hearing level, possible side effects, speech and language development, and quality of life.  These researchers identified 368 citations for review.  From a review of the titles, 34 potentially relevant papers were selected.  Of these, 18 studies met the inclusion criteria, including 8 case series, 6 historical cohort studies, 3 prospective cohort studies, and 1 randomized trial.  Most studies were either small or of poor quality or both.  The results of the studies were contradictory, with some studies suggesting early placement of grommets was beneficial and others reporting there was no benefit.  The authors concluded that there is currently insufficient evidence on which to base the clinical practice of early routine grommet placement in children with cleft palate.

Boonacker et al (2014) stated that otitis media (OM) is a leading cause of medical consultations, antibiotic prescription and surgery in children.  The surgical procedures offered to children with recurrent or persistent OM are insertion of grommets, adenoidectomy or a combination of the two.  There is clear National Institute for Health and Care Excellence guidance for the use of grommets in subgroups of children with persistent OME, but similar guidance is not available for adenoidectomy, either in persistent OME or in recurrent AOM.  These researchers (I) developed a model to predict the risk of children referred for adenoidectomy having a prolonged duration of their OM; (IIa) evaluated the overall effect of adenoidectomy, with or without grommets, on OM using individual patient data (IPD); and (IIb) identified those subgroups of children who are most likely to benefit from adenoidectomy with or without grommets.  A number of electronic databases were searched from their inception including the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), metaRegister of Current Controlled Trials (mRCT), ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), ClinicalStudyResults.org and Google.  Studies eligible for inclusion in this IPD meta-analysis were RCTs in children up to 12 years of age diagnosed with recurrent AOM and/or persistent OME in which adenoidectomy (with or without grommets) was compared with non-surgical treatment or grommets alone.  The final selection of eligible studies and the quality assessment were carried out according to standard methods and disagreement was resolved by discussion.  A total of 503 articles were identified of which 10 trials were included in the meta-analysis; 8 of these were at a low risk of bias and 2 were at moderate risk.  The primary outcome was failure at 12 months, defined by a set of persisting symptoms and signs.  In the prognostic analysis 56 % of those children referred for adenoidectomy (but randomized to the non-surgical group) failed to improve (38 % of the children with recurrent AOM and 89 % of the children with persistent OME).  Children who had adenoidectomy had a greater chance of clinical improvement.  The size of that effect is, in general, small but persists for at least 2 years.  Two subgroups of children are most likely to benefit from adenoidectomy:
  1. children aged less than 2 years with recurrent AOM -- 16 % of those who had adenoidectomy failed at 12 months whereas 27 % of those who did not have adenoidectomy failed [rate difference (RD) 12 %, 95 % Cl: 6 % to 18 %; number needed to treat (NNT) = 9];
  2. children aged greater than or equal to 4 years with persistent OME -- 51 % of those who had adenoidectomy failed at 12 months whereas 70 % of those who did not have adenoidectomy failed (RD 19 %, 95 % Cl: 12 % to 26 %; NNT = 6).
No significant benefit of adenoidectomy was found in children aged greater than or equal to 2 years with recurrent AOM and children aged less than 4 years with persistent OME.  The authors concluded that adenoidectomy is most beneficial in children with persistent OME aged greater than or equal to 4 years.  A smaller beneficial effect was found in children with recurrent AOM aged less than 2 years.  Consideration must be given to the balance between benefits and harms.  Future research is required in a number of key areas, including defining the best methods of selecting, developing and administering patient-reported outcome measures to assess the value of treatments for children with persistent OME and recurrent AOM and upper respiratory infections; investigating the clinical effectiveness and cost-effectiveness of hearing aids (air or bone conduction) and the use of interventions to improve classroom acoustics for children with different degrees of persistence and severity of hearing loss associated with OME; and investigating why professionals' and parents'/carers' treatment preferences vary so much both nationally and internationally.  The authors did not understand why adenoidectomy works in different subgroups at different ages, nor its effects in special populations, such as children with Down syndrome.  They stated that there is also a need for further research on the impact and optimal management of otitis media in these special situations and others, such as in children with a cleft palate or developmental problems.

Kuo and colleagues (2014) stated that no consensus has yet been reached with regard to the link between OME, hearing loss, and language development in children with cleft palate.  These researchers examined the effectiveness of VTI for OME in children with cleft palate.  A dual review process was used to assess eligible studies drawn from PubMed, Medline via Ovid, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, and reference lists between 1948 and November 2013.  Potentially relevant papers were selected according to the full text of the articles.  Relevant data were extracted onto a data extraction sheet.  A total of 9 high- or moderate-quality cohort studies were included in this study.  Ventilation tube insertion was administered in 38 % to 53 % of the OME cases, and more severe cases appeared more likely to undergo VTI.  Compared with conservative forms of management (e.g., watchful waiting), VTI has been shown to be beneficial to the recovery of hearing in children with cleft palate and OME.  A growing body of evidence demonstrated the benefits of VTI in the development of speech and language in children with cleft palate and OME.  These children face a higher risk of complications than those undergoing conservative treatments, the most common of which are eardrum retraction and tympano-sclerosis, with an incidence of approximately 11 % to 37 %.  The authors concluded that this review provided evidence-based information related to the selection of treatment for OME in children with cleft palate.  They stated that additional RCTs are needed to obtain bias-resistant evidence capable of reliably guiding treatment decisions.

Guidance from the National Institute for Health and Clinical Excellence (NICE, 2008) states that the care of children with cleft palate who are suspected of having OME should be undertaken by the local otological and audiological services with expertise in assessing and treating these children in liaison with the regional multidisciplinary cleft lip and palate team. Insertion of ventilation tubes at primary closure of the cleft palate should be performed only after careful otological and audiological assessment. Insertion of ventilation tubes should be offered as an alternative to hearing aids in children with cleft palate who have OME and persistent hearing loss.

In a case-series with chart-review study, Kim and colleagues (2017) examined the effect of VTI on long-term hearing outcomes in children with cleft palate.  Children with cleft palate diagnosis who underwent surgery at Rady Children's Hospital-San Diego between 1995 and 2002 were included in this analysis.  The primary outcome studied was hearing acuity at 10 years of age.  Independent variables studied included gender, age at palate repair and first VTI, total number of VTs, number of complications, and presence of tympanic membrane perforation.  An increased number of tubes was associated with a greater incidence of hearing loss at age 10, even after adjusting for total number of otologic complications.  The timing of initial VTI did not have a significant effect on long-term hearing outcome in this study.  The authors concluded that while children with worse middle ear disease were more likely to receive more tubes and have long-term conductive hearing loss as a result of ear disease, the results of this study suggested that multiple VTI may not contribute to improved long-term hearing outcomes.  They stated that further research focusing on long-term outcomes is needed to establish patient-centered criteria guiding decision making for VTI in children with cleft palate.

Miscellaneous Information

The American Academy of Otolaryngology-Head & Neck Surgery's clinical practice guideline on "Tympanostomy tubes in children" (Rosenfeld et al, 2013) provided the following recommendations:

  • Clinicians should not perform tympanostomy tube insertion in children with a single episode of OME of less than 3 months’ duration
  • Clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion
  • Clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties
  • Clinicians should re-evaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected
  • Clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy
  • Clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy
  • Clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors
  • In the perioperative period, clinicians should educate care-givers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications
  • Clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes.
Youssef and Ahmed (2013) compared long-term follow-up results of laser versus classical myringotomy with ventilation tube insertion over 5 years.  A total of 86 patients with bilateral OME were divided into 2 groups:
  1. laser myringotomy group and
  2. myringotomy with ventilation tube insertion group, with follow-up in hearing results and recurrence rates over 5 years.
The mean patency time of myringotomy in laser group was 23 days, while the mean patency time of the ventilation tubes ears was 4.0 months in myringotomy group.  Twelve patients in laser group (13.9 %) showed a recurrent OME compared to 9 patients in myringotomy group (10.4 %).  The authors concluded that laser fenestration is a less effective alternative to myringotomy and tube placement.  The recurrence rates after both procedures did not show statistical significance over long follow-up.  It might be considered as an effective alternative to classical surgery and ideal for short-term ventilation.

Follow-Up Care After Grommet Insertion

Mughal and colleagues (2016) stated that grommet insertion is a common procedure in children.  A lengthy otolaryngology follow-up can have an adverse impact on clinic waiting times, new patient appointment availability, and pecuniary disadvantage for the hospital.  These investigators consolidated research and opinion concerning follow-up care following grommet insertion in a pediatric population.  The literature between January 1990 and September 2015 was searched on Medline (Ovid), Google Scholar, PubMed and Web of Science databases.  Guidelines and consensus of opinion from the United States advocate that an initial post-operative review should take place within 4 weeks, and subsequent appointments every 6 months until grommet extrusion.  Recent audit reports from the United Kingdom have shown that some groups arrange their first post-operative review at 3 months, and subsequent appointments vary considerably from no further follow-up to up to 24 months.  Up to 75 % of follow-up appointments were scheduled despite normal audiometry and clinical findings after grommet insertion, suggesting a large cohort of patients may undergo unnecessary specialist clinic reviews.  General practitioners (GPs), audiologists or specialist nurses are potential alternative providers of regular reviews to ensure normal hearing thresholds and an adequate tympanic membrane healing course.  The authors concluded that follow-up schedules are largely driven by consensus of opinion.  They noted that a significant number of follow-up appointments in otolaryngology clinic appear to be redundant.  Recently attention has been drawn to earlier discharge from otolaryngology clinic with subsequent follow-up in less resource- and cost-intensive clinics coordinated by GPs, audiologist or nurses, which may help alleviate some out-patient workload on acute hospital trusts.

Treatment of Hearing Impairment in Children with Cornelia de Lange Syndrome

Jung and colleagues (2016) noted that Cornelia de Lange syndrome (CdLS) is a multiple developmental disorder including hearing loss.  The hearing impairment in CdLS patients is not only sensori-neural hearing loss (SNHL), but also conductive hearing loss (CHL).  The authors examined hearing loss causes in CdLS patients and evaluated the effect of VTI in the cases of CHL.  A total of 32 patients clinically diagnosed with CdLS were included in this retrospective case review.  Audiological evaluations and imaging studies such as a temporal bone computed tomogram or brain magnetic resonance imaging (MRI) were performed for all patients.  Hearing rehabilitation (e.g., VTI, hearing aid fitting, or cochlear implantation) was chosen depending on the audiological condition.  Among the 32 CdLS patients who underwent auditory brainstem response test, 81.2 % presented hearing loss.  Imaging studies showed that only middle ear lesions without inner ear anomalies were identified in 56.3 %.  Notably, the soft tissue lesion in middle ear was identified even in the neonatal MRI.  When 7 patients were thought to have CHL due to OME, VTI was applied first.  However, VTI rarely improved CHL post-operatively.  Moreover, middle ear lesion was not fluid effusion but soft tissue lesion according to the intra-operative finding.  These lesions were not eradicated even after revision surgery of VTI.  The authors concluded that VTI was ineffective to improve hearing or eradicate OME in CdLS patients.

Janek and associates (2016) stated that patients with CdLS are reported to have CHL and SNHL, but there is little information pertaining to the progression of hearing loss over time.  These investigators examined the prevalence of CHL and SNHL in adults and children with CdLS and looked for changes in SNHL over time.  They carried out a retrospective chart review of patients with CdLS presenting to a CdLS clinic.  Also, a written survey of clinical concerns was collected from additional patients/families seen in the clinic and through the Cornelia de Lange Foundation.  A total of 78 patients (50 % female) were included in the chart-review.  Mean age was 16.8 ± 11.4 years (range of 0.6 to 50 years) and mean age at diagnosis of hearing loss was 4.6 ± 10.6 years (n = 26); 5 patients (6.4 %) had severe to profound SNHL that improved with time, including 2 who had complete normalization of audiogram results; 35 families/patients completed the clinical survey, and 45.5 % of the families reported a noticeable improvement of hearing over time.  The authors concluded that CHL and SNHL are common in CdLS; and more than 50 % of the patients seen in an adult CdLS clinic reported improvement in hearing loss over time, and a subset of patients had an improvement in SNHL.  In light of these findings, the authors recommended longitudinal evaluations of hearing loss in these patients with both auditory brainstem response and oto-acoustic emissions testing if SNHL is identified.

Endoscopic Balloon Dilation of the Eustachian Tube

Catalano and colleagues (2012) stated that Eustachian tube dysfunction is a common problem and trans-nasal endoscopic balloon dilation of the Eustachian tube (ET) is a new surgical technique.  These researchers reviewed the evolution of this novel technique and studied the preliminary outcomes.  Balloon catheter dilation of the 100 Eustachian tubes in 70 adults was performed at a tertiary medical center from January 2009 to January 2011.  A 5-mm sinus balloon catheter was endoscopically placed trans-nasally into the proximal ET to dilate the cartilaginous ET.  Cases were reviewed with respect to indications, outcomes, and complications.  Of the 100 ETs, ear fullness and pressure were improved in 71 % of patients studied for 26.3 weeks (± 3.6).  Of 8 patients followed for a minimum of 34 months, 87 % reported persistent improvement; 1 complication was reported.  The authors concluded that endoscopic trans-nasal ET balloon dilation is a novel approach to treating ET dysfunction.  Benefits can be durable up to 3 years.  Moreover, they stated that this technique holds much promise and merits further investigation.

Jurkiewicz et al (2013) noted that the development of minimally invasive procedures such as the balloon dilation Eustachian tuboplasty (BET) is an alternative to the grommet tympanum membrane.  BET is applied in the cases where, after elimination of all factors influencing the ET and middle ear functioning, no sufficient improvement is observed.  These investigators presented the therapeutic benefits of the BET method in the treatment of Eustachian tube dysfunction (ETD) caused by disorders in the middle ear ventilation.  The BET procedure was offered to 4 patients (3 men and 1 woman) after subjective, physical, otorhino-laryngological and audiometric examinations including pure tone audiometry, tympanometry and pressure-swallow test.  As the method was novel, pre-interventional CT angiography of the carotid arteries was performed in all patients.  Any complications were noticed during and after the procedure (bleeding or damage of regional mucosa) in any patients.  These clinical studies assessed the feasibility and safety of the BET during a short-term period -- only a 6-week observation.  The authors concluded that although patients revealed a significant improvement of ET score, longer long-term studies are needed to determine whether this method will demonstrate lasting benefits and safety in the treatment of chronic Eustachian tube dysfunction.

Moller et al (2014) stated that balloon dilation of Eustachian tube is a novel method for managing chronic ventilatory dysfunction in patients with chronic otitis media, as an alternative to classic grommet insertion.  Although few retrospective studies have been conducted the method seems to be rapid, simple and safe with promising short-term results.  These researchers presented the method and summarized the results of available studies.  Optimization of patient selection is needed and the authors discussed the development of better objective measurement methods as well as the need for randomized prospective studies, which are currently being conducted.

In a retrospective, cohort study, Gurtler et al (2015) assessed Eustachian tube balloon dilation in the treatment of Eustachian tube dysfunction by objective analysis, especially tubomanometry.  Patients undergoing Eustachian tube balloon dilation for treatment of Eustachian tube dysfunction were enrolled in this study.  Main outcome measures included subjective improvement, otomicroscopic findings, tympanogram, air-bone gap in pure-tone audiogram, R-value in tubomanometry at 3 pressure measurements (30, 40, and 50 mbar) and the Eustachian Tube Score (ETS).  Eustachian tube balloon dilation was performed in 21 patients.  The ETS including the R-values, tympanogram, and air-bone gap all showed a statistically positive outcome (p < 0.005) after Eustachian tube balloon dilation.  Subjective improvement was seen in 76 %.  Normal R-values were achieved in 57 %.  Retraction processes of the tympanic membrane improved in 18 % of patients.  Only 1 minor bleeding complication occurred.  The authors concluded that Eustachian tube balloon dilation constitutes a safe and very promising treatment option for patients with Eustachian tube dysfunction based on early-outcome analysis; ETS and specifically tubomanometry appeared promising as assessment tools but await validation for use in the diagnostic workup and outcome analysis after ETBD.  The pathophysiologic mechanism of Eustachian tube balloon dilation remains unclear.  They stated that long-term analysis and stratification of patients are needed to better evaluate the definite value of Eustachian tube balloon dilation.

In a retrospective analysis, Maier et al (2015) evaluated the role of balloon dilation of the Eustachian tube in a large cohort of children with Eustachian tube dysfunction who did not respond to other treatments and in whom a tumor could be ruled out as the cause.  These researchers retrospectively analyzed the medical records of 66 children (mean age of 8.12 years, range of 4 to 14 years) who underwent balloon dilation of the Eustachian tube using the Bielefeld balloon catheter.  There were no complications during surgery.  Clinical symptoms improved in more than 80 % of the patients.  No patient reported a deterioration of symptoms.  Of the participating parents, over 80 % were very satisfied or satisfied with the treatment outcome.  The authors concluded that balloon dilation is a rapid, simple, and safe method for treatment of both adults and children with Eustachian tube dysfunction who did not respond to other treatments.  Moreover, they stated that further studies, ideally multi-center studies, are needed to optimize the definition of existing and potential new indications for this treatment approach, as well as to establish this treatment in the management of children with refractory chronic Eustachian tube dysfunction.

Randrup and Ovesen (2015) performed a systematic review and meta-analysis of the evidence on balloon Eustachian tuboplasty (BET) as a treatment modality for ETD.  These investigators followed the PRISMA guideline and registered with PROSPERO No. CRD42014009461.  They searched 12 databases including PubMed and Embase from January 1, 2010 to April 7, 2014 for studies of BET.  Main outcome measures included change in symptoms, middle ear pathology, eardrum status, Eustachian tube function tests, hearing, adverse events, complications, and health-related quality of life.  Study quality was assessed using the modified Delphi technique quality appraisal tool for case series studies.  Risk of bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias.  A total of 9 case-series studies with 443 patients (642 tubes) were included; population size ranged from n = 4 (7 tubes) to n = 210 (320 tubes).  All studies were of poor quality and featured a high risk of bias.  These researchers found reduction of patient symptoms in ETD questionnaire (p < 0.001), post-operative normalization of the tympanic membrane, conversion of type B or type C into type A tympanograms, reduced mucosal inflammation, increased number of positive Valsalva test and Swallowing tests, improvement in Eustachian tube score, reduction in Sino-Nasal Outcome Test (SNOT)-22 score (p = 0.001), and increased quality of life (p = 0.001).  No serious adverse events were found.  The authors concluded that the evidence of BET is poor and biased.  No firm conclusions can be made to identify patients who will benefit from the procedure or to accurately predict surgical results.  They stated that randomized controlled trials or case-control trials are needed.

Hwang et al (2016) stated that Eustachian tube dysfunction is a disorder for which there are limited medical and surgical treatments.  Recently, Eustachian tube balloon dilation has been proposed as a potential solution.  These investigators performed a systematic literature review.  Abstracts were selected for relevance, and pooled data analysis and qualitative analysis was conducted.  A total of 9 prospective studies, describing 713 Eustachian tube balloon dilations in 474 patients (aged 18 to 86 years), were identified.  Follow-up duration ranged from 1.5 to 18 months.  Ability to perform a Valsalva maneuver improved from 20 to 177 out of 245 ears following Eustachian tube balloon dilation and, where data were reported in terms of patient numbers, from 15 to 189 out of 210 patients.  Tympanograms were classified as type A in 7 out of 141 ears pre-operatively and in 86 out of 141 ears post-operatively.  The authors concluded that prospective case series can confirm the safety of Eustachian tube balloon dilation.  As a potential solution for chronic Eustachian tube dysfunction, further investigations are needed to establish a higher level of evidence of efficacy.

Williams et al (2016) measured the success of Eustachian tube balloon dilation by comparing pre- and post-operative middle ear pressures using tympanometric testing.  A retrospective chart review was performed on all patients who underwent balloon dilation of the Eustachian tube by authors from 2010 to 2014.  Pre and post-operative tympanograms were analyzed and categorized based on type (Type A, Type B, Type C).  Success was defined by an improvement in tympanogram type: Type B or C to Type A, or Type B to type C.  Pre- and post-operative tympanograms were further analyzed using middle ear pressure values.  Follow-up ranged from 3 to 15 months.  A total of 25 ears (18 patients) were included in the study.  Overall 36 % of ears had improvement in tympanogram type, and 32 % had normalization of tympanogram post-operatively.  The Jerger tympanogram type improved significantly following the procedure (p = 0.04).  Patients also had statistically significant improvement in measured middle ear pressure post-operatively (p = 0.003).  The authors concluded that the natural history of Eustachian tube dysfunction is poorly understood, and evidence for current treatments are limited.  Eustachian tube balloon dilation is a safe procedure, and produces significant improvement in tympanogram values up to 15 months post-operatively.  They stated that further refinement of patient selection and standardization of technique is needed to optimize the effect of this therapy; long-term follow-up data will clarify the persistence of the effect.

Furthermore, an UpToDate review on “Eustachian tube dysfunction” (Poe and Hanna, 2017) states that “The choice of management strategies for isolated Eustachian tube dysfunction remains controversial as randomized trial data are limited, study outcomes vary widely between studies, and much of what is known about the treatment of Eustachian tube dysfunction comes from animal rather than human studies … Balloon dilation is a novel tuboplasty method to increase the patency of the cartilaginous Eustachian tube.  Similar to the concept of balloon sinuplasty for the treatment of chronic sinusitis, a balloon catheter is used to dilate the cartilaginous portion through a minimally invasive transnasal endoscopic approach.  Initial cadaveric studies and clinical trials are promising.  A 2015 systematic review including 9 case series (443 patients) concluded that balloon tuboplasty is a safe procedure but is still lacking good evidence of benefit”.

Wang, et al. (2018) reported a meta-analysis examining balloon dilatation and laser tuboplasty for the treatment of eustachian tube dysfunction (ETD). PubMed, Cochrane, and Embase were searched up to April 18, 2016, with the following keywords: eustachian, middle-ear, eustachian tuboplasty, balloon tuboplasty, laser tuboplasty, laser dilatation, and balloon dilatation. Randomized controlled trials and prospective, retrospective, and 1-arm studies of patients with ETD treated with balloon dilatation or laser tuboplasty were included. Outcome measures were improvement of eustachian tube score (ETS) and tympanometry and Valsalva maneuver results. Two retrospective and 11 prospective studies were included (1063 patients; 942 treated with balloon and 121 with laser tuboplasty). Balloon tuboplasty resulted in a significant improvement of ETS (pooled standardized mean difference [SMD], 0.94; 95% confidence interval [CI], 0.23-1.66; P = .009) and, compared with laser tuboplasty, a greater tympanometry improvement rate (pooled event rate = 73% vs 13%; P = .001). Valsalva maneuver improvement rate was not different between the group results (pooled event rate = 67% vs 50%; P = .472). The maximum number of studies that provided outcome data for any one measure was only 4, and sensitivity analysis indicated ETS results may have been overly influenced by 2 studies. No balloon tuboplasty studies reported ETS data, preventing comparison between the 2 procedures. The authors concluded that both procedures can improve symptoms of ETD; however, because of the limited numbers of studies reporting data of the outcomes of interest, it remains unclear if one procedure provides greater benefits.

In a prospective, multi-center RCT, Meyer and colleagues (2018) compared BET versus continued medical therapy (control) for treating persistent ETD.  Patients with medically refractory persistent ETD were randomized 1:1 to BDET or control.  After 6 weeks, control participants had the option to undergo BET if symptoms persisted.   Primary efficacy end-point was the comparison between treatment arms in the mean change from baseline in the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score.  Primary safety end-point was complication rate.  A total of 60 participants were randomized (31 BET, 29 control).  Mean (SD) change in overall ETDQ-7 score at 6 weeks was −2.9 (1.4) for BET compared with −0.6 (1.0) for control: BET was superior to control (p < 0.0001).  No complications were reported in either study arm.  Among participants with abnormal baseline assessments, improvements in tympanogram type (p < 0.006) and tympanic membrane position (p < 0.001) were significantly better for BET than control.  Technical success was 100 % (91 successful dilations/91 attempts) and most procedures (72 %) were completed in the office under local anesthesia.  Improvements in the ETDQ-7 scores were maintained through 12 months after BET.  The authors concluded that BET was a safe and effective treatment for persistent ETD.  Based on improved ETDQ-7 scores, BET was superior to continued medical management for persistent ETD.  Symptom improvement was durable through a minimum of 12 months; procedures were well-tolerated in the office setting under local anesthesia.

The authors stated that a limitation of this study was the inability to blind the participants to their treatment.  This could lead to the placebo effect, especially with patient-reported outcomes.  However, since these researchers also observed significant improvements in objective findings such as tympanometry, otoscopy, and Valsalva maneuver in the BET-arm and not in the control-arm, they believed that any placebo effect was minimal and that the improvements observed in the ETDQ-7 scores were reliable and indicated true symptom improvement.  The physicians were also not blinded to the participant's treatment assignment.

In a prospective, multi-center RCT, Poe and associates (2018) evaluated BET with Eustachian tube balloon catheter in conjunction with medical management (MM) as treatment for ETD.  These investigators assigned, in a 2:1 ratio, patients aged 22 years and older with ETD refractory to medical therapy to undergo BET with balloon catheter in conjunction with MM or MM alone.  The primary end-point was normalization of tympanogram at 6 weeks.  Additional end-points were normalization of ETDQ-7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety.  Primary efficacy results demonstrated superiority of BET with balloon catheter + MM compared to MM alone.  Tympanogram normalization at 6-week follow-up was observed in 51.8 % (72/139) of investigational patients versus 13.9 % (10/72) of controls (p < 0.0001).  Tympanogram normalization in the treatment group was 62.2 % after 24 weeks.  Normalization of ETDQ-7 scores at 6-week follow-up was observed in 56.2 % (77/137) of investigational patients versus 8.5 % (6/71) controls (p < 0.001).  The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6-week follow-up compared to controls.  No device- or procedure-related serious adverse events (AEs) were reported for those who underwent BET.  The authors concluded that the findings of this study demonstrated superiority of BET with balloon catheter + MM compared to MM alone to treat ETD in adults.  Level of Evidence = 1b.

The authors stated that this study had several drawbacks.  First, 1/3 of the study patients were randomized to continue MM, which had previously failed to improve ETD.  Risk of low enrollment was mitigated by providing patients the option to receive BET after a 6-week follow-up visit.  The majority of patients in the control-arm (59/72; 82 %) did opt to cross-over and receive BET before their 12-week follow-up.  Thus, 6 weeks post-randomization, the MM group became relatively small and self-selecting in nature, likely biasing any statistical comparison between treatment groups.  Second, the 6-week post-treatment follow-up was rather short; therefore, longer follow-up is needed to properly evaluate the durability of these effects.  Third, the use of general anesthesia only in the BET group added a potential confounding factor, but numerous studies of intra-nasal interventions under general anesthesia have failed to show improvement in ETD.  Lastly, patients were not blinded to treatment due to the nature of study design comparing MM to surgical procedure.  The use of a quantitative primary end-point, evaluated in a blinded fashion, minimized the risk of a placebo effect.

Huisman and co-workers (2018) stated that BET is a new entity in the therapeutic approach of ETD.  In a systematic review, these investigators evaluated the success of balloon dilation of the tuba auditiva in reducing symptoms in adult patients with ETD.  Data sources included Embase, PubMed, and Cochrane Library.  The systematic literature search was conducted independently by 2 authors based on title and abstracts, and resulted in 36 articles.  These articles were screened as full text, 15 of them were eligible for critical appraisal.  Data were extracted from selected studies and presented in this article.  A meta-analysis was conducted for 4 subgroups.  The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used as a writing guideline for this systematic review.  All 15 included studies were case series.  A total of 1,155 patients were treated with balloon dilation of the tuba auditiva.  Outcome parameters were relief of symptoms, otoscopy, Valsalva maneuver or Toynbee test, audiometry, tympanometry, ETD classification, and Eustachian tube score.  All articles showed short-term improvement of original symptoms; some showed further improvement over time.  Follow-up ranged from just after therapy to 50 months.  Relatively mild and self-limiting complications were described in 36 patients.  The authors concluded that all current studies suggested that BET could be a helpful treatment in patients with ETD; however, placebo-controlled trials are still needed.

In a retrospective, cohort study, Satmis and van der Torn (2018) examined the subjective and objective short-term results and safety of trans-nasal BET in adult patients with chronic dilatory ETD.  Data collection was performed pre-operatively, 1 and 3 months after BET; the study included a cohort of 42 consecutive patients (66 ears).  ETDQ-7 score, bone conduction threshold, air-bone gap, the ability to perform Valsalva's and/or Toynbee's maneuver, tympanic membrane and middle ear conditions were collected pre- and post-operatively.  Subjective satisfaction and complications were collected post-operatively.  The ETDQ-7 score improved significantly from 4.28 to 3.09 1 month post-operatively and from 4.10 to 2.96 3 months post-operatively.  Bone conduction thresholds did not differ significantly post-operatively.  A significant improvement of air-bone gap was found post-operatively.  The tympanic membrane and middle ear condition showed improvement in 62 %.  Subjective satisfaction 1 and 3 months post-operatively was around 43 and 48 %.  A small number of minor (self-limiting) complications occurred.  The authors concluded that BET has shown to be a safe intervention, which may have a positive effect on objective and subjective indicators for chronic dilatory ETD in adult patients.  These researchers observed subjective positive effects in less than 50 % of the patients.  For certain indications, there was a measurable positive effect on the findings of the eardrum and ETDQ-7, whereas in other patients it appeared not to have any effect at all.  These investigators stated that careful patient selection may improve this success rate; and RCTs with a prolonged follow-up are needed to evaluate the value of BET in comparison to grommets.

Schmitt and associates (2018) noted that currently there is no consensus on the treatment of obstructive ETD (QETD).  In case of failure of well-conducted drug and pressure therapy, some investigators recommend balloon dilation.  In a  retrospective, single-center study, these researchers examined the safety and efficacy of BET.  They assessed clinical and tubo-manometric results of BET, complications and satisfaction in a trial carried out between June 2012 and February 2015.  Indications were based on clinical and para-clinical signs of obstructive tube dysfunction despite well-conducted MM.  A total of 45 procedures were performed in 38 patients.  Improvement in clinical symptoms was assessed as 88 %, 80 % and 80 % at 2 months, 6 months, and over 1 year, respectively.  Improved function on tubo-manometry was observed in 81 % of cases.  The procedure was well-tolerated, with a minor complications rate of only 4 %.  The authors concluded that the present findings for safety, tolerance,  and efficacy were comparable to those in the literature, despite 1st-line failure in all patients; Eustachian tube function normalized in about 1/3 of cases.  These investigators stated that despite these encouraging results, true efficacy remained to be confirmed in prospective studies with higher levels of evidence.

Anand and colleagues (2019) stated that OETD affects up to 5 % of adults; however, available treatment strategies have limitations.  It was previously reported that BET with the Eustachian tube balloon catheter + MM resulted in a significantly higher proportion of subjects with normalized tympanograms versus MM alone at 6- and 24-week follow-up.  The current analysis extended these initial findings by examining the durability of BET + MM treatment outcomes through 52 weeks.  This trial included 21 investigational sites across the United States.  These investigators reported on secondary and exploratory end-points for patients with OETD who previously failed MM and were randomized to the BET + MM cohort.  Analyses of tympanogram outcomes were reported by ear, unless specified otherwise, as a more accurate measure of durability of the procedure over time.  Among subjects randomized to BET + MM, the overall number with normalized tympanograms and ETDQ-7 scores remained comparable to those reported at 6- versus 52-week follow-up: tympanograms, 73 of 143 (51.0 %) versus 71 of 128 (55.5 %); ETDQ-7, 79 of 142 (55.6 %) versus 71 of 124 (57.3 %).  The overall number of ears with normalized tympanograms also remained comparable, with 117 of 204 (57 %) versus 119 of 187 (63.6 %).  The authors concluded that the findings of the present study suggested that the beneficial effects of BET + MM on tympanogram normalization and symptoms of subjects with refractory OETD showed significant durability that was clinically relevant through 52 weeks. The authors identified a number of study limitations:  First, because crossover to the BET + MM group was allowed after 6-week follow-up, the remaining MM group became self-selected, and this limited the ability to perform meaningful comparisons with the control group after 6-week follow-up. Moreover, because the subjects in the treatment cohort were used as their own historical control, the extent of improvement specifically attributable to treatment remains unknown. Subjects were not blinded to treatment. General anesthesia was used only in the treatment cohort and not in the control cohort and therefore is a potential confounding variable. The study was industry funded and coauthors were paid consultants to the device manufacturer. 

An UpToDate review on “Eustachian tube dysfunction” (Poe and Hanna, 2019) states that “Balloon dilation of the Eustachian tube (BDET) is a newer technology for performing a tuboplasty to increase the patency of the cartilaginous Eustachian tube and reduce inflammation.  A balloon catheter is used to dilate the cartilaginous portion through a minimally invasive trans-nasal endoscopic approach.  Initial cadaveric studies and clinical trials are promising.  Two systematic reviews (2015, 2018) concluded that BDET is a safe procedure that appears to have benefit, but all of the studies reviewed were retrospective case series with varied indications and outcome measures.  The conclusions were that although there is a consistent demonstration of benefit, randomized controlled trials with long-term results were needed.  A randomized trial in 323 patients found that 6 weeks after procedural placement of a balloon catheter, normal tympanogram results were demonstrated in 52 % of the device group compared with 14 % of the medical management (nasal spray) group, leading to approval of the device in adults by the US Food and Drug Administration (FDA) in 2016.  The results were sustained at 24 weeks postop in the treatment group.  Early results in pediatric BDET in Germany are reflected in a report of 52 children (ages 3 to 15, mean 7 years) undergoing the procedure having failed previous tympanostomy tube and adenoidectomy.  BDET was done with or without a myringotomy to aspirate effusion and improvement was reported in 71 percent by one year postop”.   Balloon dilation of the Eustachian tube (BDET) is not listed in the “Summary and Recommendations” section.

Soft-Tissue Fillers for patulous Eustachian tubes

Schröder et al (2018) stated the Eustachian tube protects against secretion, germs and sound pressure from the nasopharynx, it acts as a drain, and serves pressure equalization in both directions so that the ear drum and sound-conducting apparatus can vibrate optimally. The incidence of Eustachian tube dysfunction in adults is about 1%, in children almost 40%. Symptoms are often unspecific. For diagnosis, the Eustachian tube score (ETS-5) can be used in patients with a perforated ear drum, and the ETS-7 score in patients with intact ear drum. Adenoid hypertrophy is a frequent cause of obstructive tube dysfunction in children. Treatment of obstructive dysfunction includes steroid nasal sprays and regular performance of the Valsalva maneuver, as well as tube dilation with the Bielefelder balloon catheter. The patulous Eustachian tube is treated with saline nasal irrigation, estrogen-nasal ointment, and craniocervical manual therapy; causal treatments are evaluated.

Schröder et al (2015) stated a patulous Eustachian tube ([ET] tuba aperta) may cause symptoms as autophony, breath synchronous tinnitus, pressure sensation, and conductive hearing loss and thus lead to an enormous cutback in quality of life. In combination with "sniffing," it can trigger the development of cholesteatoma. Because of the ambiguous symptoms, the diagnosis can be challenging. A patulous ET can only be diagnosed through a well-structured examination, including patient history, physical examination with thorough observation of the movements of the tympanic membrane, and tympanometry with reflex-decay. Transnasal endoscopic injection of injectable soft-tissue bulking agent into the torus tubarius was performed in 20 patients as a new treatment option for patulous ET. All patients were followed up 6 weeks and 6 and 12 months after treatment. For each intervention, 0.8 to 2 mL of injectable soft-tissue bulking agent was used. In nine patients, more than one procedure was necessary. On follow-up, 10 out of 15 patients were satisfied with the result. Only three out of 15 patients reported no improvement of their symptoms. The procedure was minimally invasive, fast, and easy to perform. The authors concluded there is no gold standard for the therapy of patulous ET. The injection of soft-tissue bulking agent in the torus tubarius is a new minimally invasive therapeutic approach, but much more clinical experience is needed.

Luu et al (2015) determined the effectiveness of currently available medical and surgical interventions for treating symptoms of Patulous Eustachian Tube (PET) through a comprehensive search of MEDLINE (January 1948 to July 8, 2015), EMBASE (January 1974 to July 8, 2015), gray literature, hand searches, and cross-reference checking. The review included original published reports evaluating an intervention to treat the symptoms of patulous eustachian tube in patients 18 years and older. Quality-of-case reviews were assessed with the National Institute of Health (NIH) Quality Assessment Tool for Case Series Studies. The search strategy identified 1,104 unique titles; 39 articles with 533 patients are included. The available evidence consists of small case series and case reports. The most common medical treatment was nasal instillation of normal saline. Surgical treatments were categorized as mass loading of the tympanic membrane, eustachian tube plugging, and manipulation of eustachian tube musculature. The authors concluded that the available evidence for management of patients with PET is poor in quality and consists predominantly of small case series. Further research is needed to determine the comparative efficacy of the current treatments.

Trans-Tympanic Balloon Dilatation of Eustachian Tube

In a systematic review, Jufas and Patel (2016) examined the evidence for balloon dilatation of the Eustachian tube using a trans-tympanic approach.  These investigators searched several databases using the terms “dilation” or “dilatation”, and “balloon” and “Eustachian tube”.  Only studies that used a trans-tympanic approach for the procedure were included.  These studies were then assessed for risk of bias.  A total of 3 studies were included.  Each of these studies was a limited case series, with 2 performed on human subjects and 1 on human cadavers.  Results of safety and efficacy were conflicting.  There was a high risk of bias overall.  The authors concluded that there is currently a very narrow evidence base for trans-tympanic balloon dilatation of the Eustachian tube; there are a number of advantages and disadvantages of the technique.  These researchers stated that previously identified and theoretical safety concerns will need to be addressed thoroughly in future studies prior to wider clinical use.

In a cadaver pilot study, Kapadia and colleagues (2018) evaluated the safety of trans-tympanic balloon dilatation of the cartilaginous proximal Eustachian tube under endoscopic guidance as it relates to the integrity of the carotid canal.  Endoscopic guided trans-tympanic dilatations of the cartilaginous proximal end of the Eustachian tube were performed in 15 ears of 8 fresh frozen cadaver heads.  CT scans were done before and after dilatation.  Images were reviewed by 2 otologists and 1 radiologist.  Balloon catheter placement and dilatation of the proximal Eustachian tube was feasible in all specimens.  Endoscopic examination post-dilatation showed a consistent increase in the aperture of the proximal cartilaginous tube in all ears.  Review of CT images after dilatation showed no evidence of trauma to the carotid canal in all ears instrumented.  The authors concluded that endoscopically guided trans-tympanic dilatation of the proximal Eustachian tube was not associated with damage to the carotid canal in cadaver model.  Level of evidence = IV.

In a case-series study, Kapadia and Tarabichi (2018) examined safety and feasibility of trans-tympanic dilatation of proximal (tympanic-end) of the cartilaginous segment of the Eustachian tube in patients undergoing surgery for chronic ear disease.  These investigators reviewed the charts of 40 consecutive patients undergoing chronic ear surgery in their practice with manometric evidence of obstruction who underwent attempted trans-tympanic dilatation of proximal (tympanic-end) segment of the Eustachian tube.  A range of outcome measures were reported that included pre- and post-dilatation opening pressure measurement of the Eustachian tube, closure of perforation, audiometric data, and complications.  Dilatation of proximal (tympanic-end) of the cartilaginous segment of the Eustachian tube was technically feasible in 37 of 40 patients (93 %). Post-dilatation inspection of protympanum showed increased aperture in all dilated tubes.  Opening pressure of Eustachian tube declined in 36 of 37 patients (97 %).  Residual perforation was evident in 5 of 40 patients (12 %).  No facial nerve or carotid complications were observed; 2 patients had severe dizziness (5 %) with 1 patient sustaining severe cochlear loss.  The authors concluded that trans-tympanic dilatation increased the patency of the Eustachian tube immediately after instrumentation.  No carotid complications were observed.  Continuous endoscopic control is needed to avoid subluxation of stapes.  Further study of this technique is warranted to identify its role, if any, in chronic ear surgery.

The Tubes Under Local Anesthesia (Tula) System

Cohen and colleagues (2015) stated that tympanostomy tube insertion is the most common pediatric surgery, but it typically requires general anesthesia.  To facilitate in-office tube placement without general anesthesia, 2 complementary technologies have recently been developed comprising an iontophoresis system (IPS) for delivering local anesthesia and an integrated tube delivery system (TDS).  These researchers evaluated behavioral support techniques used during a clinical study of the new technology for pediatric in-office tube placement without general anesthesia or physical restraints.  As part of an institutional review board (IRB)-approved, prospective, 9-center clinical study, pediatric patients requiring tube insertion underwent in-office treatment using the new procedure.  The behavior management techniques included preparation, distraction, coaching, and reinforcement for co-operation.  The entire procedure was videotaped and 2 independent coders used the validated FLACC (face, legs, activity, cry, consolability) scale to code behavioral distress across 5 procedural phases.  A total of 70 pediatric patients aged 8 months to 17 years (mean [M] of 7.0 years; 51 % girls) were enrolled in the study, and 68 had video recordings available for analysis.  Of the 68 recordings analyzed, 63 patients completed the procedure and had tubes placed without sedation.  Mean FLACC scores ranged from 0.05 to 2.38 (M = 1.25, SD = 0.82) and median (Mdn) FLACC scores ranged from 0 to 1 (Mdn = 0, inter-quartile range [IQR] = 0.05), which indicated "mild" distress.  During iontophoresis, eardrum tap (anesthesia assessment), and tube delivery, older children displayed lower distress and girls had higher FLACC scores during the eardrum tap procedural phase.  The authors concluded that when combined with the evidence-based behavioral techniques, office-based local anesthesia and tube delivery resulted in minimal distress, suggesting that the new procedure may be a viable method of conducting tympanostomy tube placement in children without having to use general anesthesia.

In a prospective, multi-center (9 centers), single-arm study, Zeiders and associates (2015) evaluated the safety and effectiveness of an IPS to achieve local anesthesia in combination with a TDS for tube placement in pediatric patients in an office setting.  This trial conducted at 9 otolaryngology sites in the U.S.  Subjects included pediatric patients aged 6 months to less than 22 years requiring tube placement.  They were prepared for the procedure using behavioral support techniques and tube placement was attempted under local anesthesia using the IPS in conjunction with the TDS.  No physical restraints were allowed and no anxiolytics, analgesics, or sedatives were permitted.  Safety was evaluated via the occurrence of AEs and success rates for tube placement under local anesthesia were determined.  Tolerability of the procedure was evaluated using the 5-point Wong-Baker FACES Pain Rating Scale and parental satisfaction was assessed using a post-operative survey.  A total of 70 (127 ears) were enrolled in the study [mean (SD) age of 7.0 (3.9) years].  No serious AEs were observed in the 70 enrolled patients.  Tube placement using the TDS was successful in 96.6 % (114/118) of attempted ears.  A single TDS was required in 105 ears, while more than 1 device was required in 9 ears.  Of the 70 patients enrolled in study, 63 (90.0 %) successfully received tubes in all indicated ears during their in-office visit.  The mean (SD) change in pain score from pre-anesthesia to post-surgery was +0.9 (1.8).  Favorable ratings for overall satisfaction with the in-office procedure were obtained from 96.9 % (63/65) of respondents.  Tube retention at 2 weeks was 99.1 %.  As only 15 patients were enrolled who were 3 years old or younger, the ability to generalize these results to younger patients was limited.  The authors concluded that the use of the IPS and TDS technologies enabled safe, reliable, and tolerable placement of tubes in awake, unrestrained pediatric patients.  This appeared to be the same study described above by Cohen et al (2015), with the former trial examining the use of behavioral techniques to optimize success of in-office pediatric tympanostomy tube placement without sedation.

Cofer and co-workers (2017) noted that insertion of tympanostomy tubes is a common elective pediatric surgical procedure and is typically performed under general anesthesia.  The potential to reduce general anesthetic requirements for young children has led to increased interest in alternatives for tympanostomy tube placement.  A tympanostomy tube system, developed to enable tympanostomy tube placement in a single pass on conscious patients under moderate sedation, was evaluated.  A prospective study on 128 children and 253 tympanostomy tube placements conducted at 4 centers in the U.S. demonstrated an 88.3 % success rate in performing the procedure under moderate sedation with AEs within normal rates reported in the literature.  The authors concluded that the feasibility of completing tympanostomy tube placement under moderate sedation enabled avoidance of general anesthesia and provided additional choices to physicians and parents.

On November 25, 2019, the FDA approved a new system for the delivery of tympanostomy tubes that can be inserted into the eardrum to treat otitis media.  The Tubes Under Local Anesthesia (Tula) System is the first ear tube delivery system that can be performed in young children using local anesthesia in a physician’s office setting.  The Tula System consists of the anesthetic Tymbion, Tusker Medical tympanostomy tubes, and several devices needed for the delivery of the ear tubes and the anesthetic into the ear drum.  The Tula System allows the delivery of an ear tube in the office setting, thus, avoiding the use of general anesthesia.  The Tula System employs a small electrical current to administer a local anesthetic into the ear drum before insertion of the tube.  It is approved for use in both adults and children as young as 6 months of age.  The FDA evaluated data provided by the sponsor from 222 pediatric patients to examine the effectiveness of the Tula System for the delivery of ear tubes.  The procedural success rate was 86 % and 89 % in children younger than age 5 and between ages 5 to 12 years old, respectively.  The most common AE observed was inadequate anesthesia during the procedure.  The Tula System should not be used in patients younger than 6 months of age or patients who have allergies to some local anesthetics.  This product is not intended for patients who may have pre-existing issues with their eardrum, such as a perforated eardrum.

UpToDate reviews on “Overview of tympanostomy tube placement, postoperative care, and complications in children” (Isaacson, 2019), “Acute otitis media in children: Prevention of recurrence” (Pelton and Marchisio, 2019), and “Otitis media with effusion (serous otitis media) in children: Management” (Pelton and Marom, 2019) do not mention the use of local anesthetic as a management option.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

69420 Myringotomy including aspiration and/or eustachian tube inflation
69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia
69424 Ventilating tube removal requiring general anesthesia
69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia
69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia

CPT codes not covered for indications listed in the CPB:

EarPopper, trans-tympanic balloon dilatation of the Eustachian tube - no specific code:

0583T Tympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia

Other CPT codes related to the CPB:

31000 - 31230 Incision and excision of accessory sinuses
31231 - 31297 Sinus endoscopy
42820 - 42821 Tonsillectomy and adenoidectomy
42830 - 42836 Adenoidectomy

HCPCS codes not covered for indications listed in the CPB:

C1878 Material for vocal cord medialization, synthetic implantable [Prolaryn Plus]
C9745 Nasal endoscopy, surgical; balloon dilation of eustachian tube

ICD-10 codes covered if selection criteria are met:

H65.00 - H65.93 Nonsuppurative otitis media
H66.001 - H66.93 Suppurative and unspecified otitis media
H69.00 - H69.03 Patulous Eustachian tube
H71.20 - H71.23
H71.90 - H71.93
Cholesteatoma of mastoid and unspecified part [middle ear]
H72.10 - H72.13 Attic perforation of tympanic membrane [Pars flaccida]
H90.0 - H91.93 Hearing loss
Q35.1 - Q37.9 Cleft lip and cleft palate
T70.0xx+ Otitic barotrauma

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

H69.80 - H69.83 Other specified disorders of eustachian tube
H69.90 - H69.93 Unspecified eustachian tube disorder
Q87.1 Congenital malformation syndromes predominantly associated with short stature [Cornelia de Lange syndrome]

The above policy is based on the following references:

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