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Hearing Loss Due to Myringotomy and Tube Placement and the Role of Preoperative Audiograms

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Hearing Loss Due to Myringotomy and Tube Placement and the Role of Preoperative Audiograms ORIGINAL ARTICLE Hearing Loss Due to Myringotomy and Tube Placement and the Role of Preoperative Audiograms Mark Emery, MD; Peter C. Weber, MD Background: Postoperative complications of myrin- erative and postoperative sensorineural and conductive gotomy and tube placement often include otorrhea, tym- hearing loss. panosclerosis, and tympanic membrane perforation. How- ever, the incidence of sensorineural or conductive hearing Results: No patient developed a postoperative sensori- loss has not been documented. Recent efforts to curb the neural or conductive hearing loss. All patients resolved use of preoperative audiometric testing requires docu- their conductive hearing loss after myringotomy and tube mentation of this incidence. placement. There was a 1.3% incidence of preexisting sen- sorineural hearing loss. Objective: To define the incidence of conductive and sensorineural hearing loss associated with myrin- Conclusions: The incidence of sensorineural or con- gotomy and tube placement. ductive hearing loss after myringotomy and tube place- ment is negligible and the use of preoperative audiomet- Materials and Methods: A retrospective chart re- ric evaluation may be unnecessary in selected patients, view of 550 patients undergoing myringotomy and tube but further studies need to be done to corroborate this placement was performed. A total of 520 patients under- small data set. going 602 procedures (1204 ears), including myrin- gotomy and tube placement, were assessed for preop- Arch Otolaryngol Head Neck Surg. 1998;124:421-424 TITIS MEDIA (OM) is one erative hearing status and whether it has of the most frequent dis- either improved or remained stable after eases of childhood, af- MTT. A recent report by Manning et al11 fecting at least 80% of demonstrated a 1% incidence of preop- children prior to school erative sensorineural hearing loss (SNHL) Oentry.1-4 Because of the high incidence of in children undergoing MTT. However, no OM in children, each year billions of dol- postoperative analysis was discussed. To lars are spent in the medical and surgical our knowledge, no large study has been treatment of OM. Surgical treatment of done to document the incidence of post- chronic OM via myringotomy and tym- operative SNHL or conductive hearing loss panostomy tube insertion (MTT) is one of (CHL) with MTT. the most commonly performed opera- Recent concerns about the rising costs tions in the United States.2,5,6 The poten- of health care have challenged physicians tial risks, complications, and benefits of to continue to provide outstanding medi- MTT are well documented in the litera- cal care for their patients, while at the same ture.5,7-10 The 3 most common risks asso- time trying to reduce costs to the patient. ciated with MTT are postoperative otor- Currently, preoperative audiograms for rhea, tympanosclerosis, and persistent MTT are obtained for various reasons, the tympanic membrane perforation. The risk most common being the desire to docu- of hearing loss is routinely discussed with ment the hearing level, the medical and/or any patient (or parent) about to undergo legal implications if it is not obtained and an otologic procedure, including MTT. Al- the patient is found to have a hearing loss though the risk of hearing loss is largely postoperatively, and the recent guidelines From the Department of considered theoretical for MTT, many oto- published for when MTT is appropri- 12,13 Otolaryngology, Medical laryngologists routinely perform preop- ate. If it can be demonstrated that the University of South Carolina, erative and postoperative audiometric incidence of hearing loss following MTT is Charleston. studies to document the patient’s preop- indeed negligible, then a postoperative ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 124, APR 1998 421 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 1. Sound Field Awareness (SFA) Testing Results MATERIALS AND METHODS No. (%) of Patients A retrospective chart review was performed at the Total No. Preoperative Postoperative Medical University of South Carolina in Charleston Age, mo of Patients SFA .20 dB SFA #20 dB on all patients who had undergone bilateral MTT from 4-18 184 95 (51.6) 83 (45.1) April 1, 1990, through July 3, 1996. A total of 1225 19-36 190 63 (33.2) 60 (31.6) cases were documented from operating room rec- .36 22 17 (77.3) 12 (54.5) ords. A retrospective review of 550 charts was ana- Total 396 175 (44.2) 155 (39.1) lyzed. Only patients who had both preoperative and postoperative audiometric studies were analyzed for this study. Thus, a total of 520 patients of the origi- show the threshold value and label it an SFA (sound field nal 550 were included in our study. There was no follow-up postoperative audiogram in 30 patients be- assessment label). We evaluated 3 different age groups cause of the inability of the patients to return for ex- for SFAs: 0 to 18 months, 19 to 36 months, and those amination after the surgical procedure. Of these 520 children older than 36 months. It was thought that if the patients, 602 procedures on 1204 ears were ana- preoperative SFA level was higher than 20 dB, we would lyzed for this frequency-specific study. Audiometric consider this abnormal. This is certainly generous since data analyzed included speech sound field aware- normal can be 60 to 40 dB in infants younger than 9 ness (SFA) and SFA threshold levels for children months, 35 to 25 dB in children aged 9 months to 18 younger than 3 years. Pure tone averages (PTA), months, and 30 to 25 dB in children aged 18 to 24 speech reception thresholds, and discrimination scores months.14 Postoperatively, we were looking for an SFA for children older than 3 years were assessed. level of less than 20 dB. As Table 1 indicates, there were 95 patients in the 0- to 18-month age category who had a preoperative SFA level higher than 20 dB, but only 12 audiogram may be all that is needed to ensure that our (12.6%) did not obtain a postoperative level lower than patients have good hearing ability and these cost savings 20 dB. Of these 12 children, 9 demonstrated normal hear- could then be passed on to our patients. ing on a subsequent audiogram within the year. Of the remaining 3, 1 increased his hearing sensitivity from no response preoperatively to an SFA level of 60 dB post- RESULTS operatively. He was a child with pervasive developmen- Of the 520 patients evaluated for this study, 320 (61.5%) tal delays and on further testing was noted to have mod- were male and 200 (38.5%) were female. The ages ranged erate SNHL on auditory brainstem response. The second from 4 months to 78 years, although only 3 patients in child, aged 6 months, had an SFA level of 70 dB preop- this entire study were adults. The other 2 adults were 21 eratively and went up to an SFA of 45 dB postopera- years old. The mean age was 45 months. The male- tively; for his age, this is actually a normal response. The female ratio was approximately 3:2. The ages of the 520 same is true of our last patient who had an SFA level of patients were as follows: 45 dB preoperatively and on postoperative evaluation had No. of an SFA level of 40 dB. Age, mo Patients For the age range of 19 to 36 months, there were 63 1-18 164 children who had a preoperative SFA level higher than 20 19-23 109 dB. Postoperatively, only 3 (4.8%) of the 63 children had 24-35 81 a postoperative SFA level higher than 20 dB. Of these 3, 2 36-47 63 later tested with normal hearing: 1 with PTA scores and 48-59 33 60-71 24 the other with auditory brainstem response. The last pa- 72-83 26 tient demonstrated an SFA level of 25 dB preoperatively 84-95 16 and postoperatively, which is also within the range of nor- .96 4 mal hearing for a child aged 20 months.14 Total 520 Twenty-two patients older than 36 months re- In the 520 patients there were 602 procedures on quired SFA testing because PTA could not be per- 1204 ears that were analyzed for this study. Of these 520 formed. There were 17 patients with a preoperative SFA patients, 72 had to undergo either a second or third tube level higher than 20 dB and 12 (70.6%) resolved to lower placement. than 20 dB on SFA testing after tubes were put in. Of the Of the 602 procedures of MTT, there was not one 5 who did not improve to lower than 20 dB on their SFA incidence of a postoperative SNHL or a CHL that was not test, 2 had a known preexisting SNHL that had been docu- present preoperatively. mented with brainstem auditory evoked responses in the Speech SFA assessment levels and frequency- past. One had cerebral palsy with a preoperative 55-dB specific sound field thresholds (averaged .500, 1000, SFA level and a 40-dB SFA level postoperatively. An- and 2000 Hz) were the audiometric data used in this study other child had Down syndrome with what was thought for younger children in whom individual ear PTA scores to be a preexisting SNHL and the last patient, with Beck- could not be obtained (Table 1). In our study, the SFA with-Wiedemann syndrome, was tested 6 months later levels and thresholds correlated within 5 dB and thus we and had an SFA level lower than 20 dB. ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 124, APR 1998 422 ©1998 American Medical Association. All rights reserved.
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