Dale W. Steele, MD, MS,​a,​b,​c,​d Gaelen P. Adam, MLIS,​a Mengyang Di, MD, PhD,a​ Christopher H. Halladay,Effectiveness ScM,a​ Ethan M. Balk, MD, MPH,a,​ b​ Thomasof Tympanostomy A. Trikalinos, MD, PhDa,b​ Tubes for Otitis Media: A Meta-analysis CONTEXT: abstract

Tympanostomy tube placement is the most common ambulatory surgery performed OBJECTIVES: on children in the United States. The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute DATA SOURCES: otitis media. Searches were conducted in Medline, the Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews, Embase, and the Cumulative Index to Nursing and STUDY SELECTION: Allied Health Literature. Abstracts and full-text articles were independently screened by 2 DATA EXTRACTION: investigators. A total of 147 articles were included. When feasible, random effects network RESULTS: meta-analyses were performed. Children with chronic otitis media with effusion treated with tympanostomy tubes − − compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB − (95% credible interval: 14.0 to 3.4) at 1 to 3 months and 0.0 (95% credible interval: 4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly LIMITATIONS: defined and reported. CONCLUSIONS: Sparse evidence is available, applicable only to otherwise healthy children. Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.

aEvidence-based Practice Center, Center for Evidence Synthesis in Health, bDepartment of Health Services, Policy and Practice, School of Public Health, cDepartment of Emergency Medicine, Section of Pediatrics–Hasbro Children’s Hospital, and dDepartment of Pediatrics, Alpert Medical School, Brown University, Providence, Rhode Island Dr Steele conceptualized and designed the review, designed data collection instruments and supervised data collection, performed data analysis and interpretation of data, and drafted and revised the manuscript; Ms Adam performed the literature search, participated in data collection, performed analysis and interpretation of data, and critically reviewed the manuscript; Dr Di and Mr Halliday participated in data collection, analysis, and interpretation of data, and reviewed and revised the manuscript; Dr Balk assisted in conceptualization and design, reviewed data collection, collected data, and critically reviewed the manuscript; and Dr Trikalinos oversaw protocol conception and design and analysis and interpretation of data, performed supplemental analysis, and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

To cite: Steele DW, Adam GP, Di M, et al. Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis. Pediatrics. 2017;139(6):e20170125

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017:e20170125 REVIEW ARTICLE Myringotomy with tympanostomy to clear middle ear4 fluid after an studies) with at least 1000 subjects tube placement is the most common episode of AOM. were included. ambulatory surgery performed on 1 In the present systematic review, Literature searches without language children in the United States,​ with we synthesized the available restrictions were conducted in 667000 children aged <15 years evidence regarding the effectiveness Medline, the Cochrane Central Trials undergoing tympanostomy tube 2 of tympanostomy tubes (with or Registry and Cochrane Database of placement in 2006. The effectiveness without adenoidectomy) compared Systematic Reviews, Embase, and of tympanostomy tubes for chronic with watchful waiting in children the Cumulative Index to Nursing otitis media with effusion (OME) and with chronic OME and children with and Allied Health Literature (from recurrent acute otitis media (AOM) recurrent AOM. We also summarized inception) to identify primary is likely influenced by the many the frequency of adverse events research studies meeting the study factors that affect the prognosis associated with tympanostomy tubes. criteria. Citations found by literature for middle ear disease in children. searches were independently These factors include current age, This review is derived from an – screened by 2 researchers, using age at first diagnosis, frequency of Agency for Healthcare Research and the open-source, online software respiratory tract infections, and day Quality commissioned comparative 3 abstrackr (http://​abstrackr.​cebm.​ care exposure. effectiveness review (Tympanostomy 7 brown.​edu/​). Conflicts were – Tubes in Children With Otitis Media) The American Academy of resolved by discussion until a group conducted by the Brown Evidence- Otolaryngology Head and Neck consensus was reached. based Practice Center. The full review Data Extraction and Analysis Surgery clinical practice guideline and review protocol (PROSPERO recommends that clinicians should registry number: CRD42015029623) offer bilateral tympanostomy tube ≥ are available at http://​www.​ Each study was extracted by 1 insertion to children with bilateral effectivehealthcare.​ ahrq.​ ​gov. methodologist; the extractions were OME for 3 months and who have reviewed and confirmed by at least 1 documented hearing difficulties. They Methods other methodologist. We conducted may offer tympanostomy tubes to quantitative analysis for outcomes children with unilateral or bilateral with at least 5 studies which report OME with symptoms that are likely The approaches outlined in the ’ results that could be combined in attributable to OME which include, Agency for Healthcare Research a meta-analysis. Bayesian network but are not limited to, vestibular and Quality s Methods Guide for gemtc meta-analysis was performed problems, poor school performance, Comparative Effectiveness Reviews 8 6 by using the R package. behavioral problems, ear discomfort, were followed. 4 Search Strategy and Study Selection Estimation was performed with or reduced quality of life. ’ Markov chain Monte Carlo9 methods The American Academy of Pediatrics via the JAGS software,​ using initial clinical practice guideline for This study evaluated published, peer- values drawn randomly from the diagnosis and management of reviewed studies in which at least marginal distributions of the priors AOM states that clinicians may 1 arm included children receiving of respective parameters. We fit 4 offer tympanostomy tubes for tympanostomy tubes; conference Markov chain Monte Carlo chains. recurrent AOM (3 episodes in 6 abstracts were excluded. We included After a burn-in of 5000 iterations, months or 4 episodes in 1 year randomized controlled trials (RCTs) we monitored the convergence with 1 episode in the preceding 6 and nonrandomized comparative of random effects means and 5 – months). The American Academy studies (NRCS), prospective and variances automatically by checking of Otolaryngology Head and Neck retrospective, in which treatment every 10000 iterations whether Surgery clinical practice guideline with tympanostomy tubes was the Gelman-Rubin diagnostic was further recommends that clinicians assigned on a per-patient basis. <1.05 with 95% probability for not perform tympanostomy tube Studies with per-ear assignment all monitored parameters. After insertion when middle ear effusion is were excluded (eg, tympanostomy convergence was reached, an not present at the time of assessment tubes placed by design in 1 ear only). additional 10000 iterations were for tube placement; they argue that For adverse events, prospective run. All models converged within the presence of effusion serves as surgical studies enrolling at least 10000 iterations. Model fit was ≥ both a marker for the accuracy of the 50 subjects (including arms of RCTs assessed by comparing the posterior diagnosis of AOM and an indicator or NRCS with 50 patients) and mean of the residual deviance versus of underlying Eustachian tube population-based retrospective the number of data points. The ratio dysfunction with decreased ability single-group studies (registry of residual deviance to number of Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 Steele et al adenoidectomy alone, oral antibiotic prophylaxis, and watchful waiting). Hearing thresholds were measured in 16 RCTs. In 10 of these RCTs, mean hearing thresholds were reported according to study arm at various time points. For the network meta- analysis of these RCTs, we classified “ ” hearing thresholds obtained at 1 to 3 months as early ; hearing “ ” thresholds obtained between 12 and 24 months were classified as late. Not all studies had interventions at both early and late time points. Thus, the network of comparators differs for early and late comparisons. ‍Figure 2 illustrates the effectiveness of various interventions at 1 to 3 months compared with watchful waiting. Mean hearing thresholds improved (ie, decreased) by an FIGURE 1 Literature flow diagram. CINAHL, Cumulative Index to Nursing and Allied Health Literature. average of 9.1 dB after insertion of the tympanostomy tubes and by 10 dB after tympanostomy tube

11 insertion with adenoidectomy. As data points ranged from 0.97 to 1.06, used. The strength of evidence was shown in Table 1, the strategies ’ suggesting an adequate model fit. graded according to the Agency for with the highest probability of Healthcare Research and Quality s being among the 3 most effective Network meta-analysis is an methods guide on assessing the interventions with respect to extension of pairwise meta-analyses 12 strength of evidence. early improvements in hearing that simultaneously combines direct thresholds were tympanostomy Results (when interventions are compared tubes, tympanostomy tubes with head-to-head) and indirect (when adenoidectomy, and myringotomy interventions are compared through with adenoidectomy. other reference interventions) ‍Figure 1 displays the results of evidence. Combining the direct Five RCTs reported hearing the literature search and selection and indirect evidence not only thresholds at 12 to 24 months. As process. improves the precision of estimates Effectiveness of Tympanostomy shown in Fig 3, by 12 to 24 months, but also provides estimates for all Tubes in Children With OME the mean difference in hearing pairwise comparisons, including thresholds for tympanostomy tubes alone, compared with watchful those missing10 from the direct − evidence. Statistical heterogeneity waiting, was 0 dB (95% credible A total of 54 publications were – was explored qualitatively. Because interval: 4 to 3). As can be seen identified. Of these, 29 articles of the relatively small number of 13 41 in Table 2, tympanostomy tube reported the results of 16 RCTs. ‍ ‍ studies, and the little variability in insertion with adenoidectomy and Twenty-four publications reported characteristics, meta-regression myringotomy with adenoidectomy the results of 24 NRCS that assessed analyses were not performed. were the 2 most effective strategies Assessment of Study Risk of Bias the effectiveness of tympanostomy – with respect to late hearing and Strength of Evidence tubes in pediatric patients with 42 65 thresholds. Tympanostomy tubes chronic middle ear effusion. ‍ ‍ alone, antibiotic prophylaxis, and These studies evaluated multiple watchful waiting were among the 3 The methodologic quality of each interventions (tympanostomy least effective strategies. study was assessed on the basis tubes, tympanostomy tubes with of predefined criteria. For RCTs, adenoidectomy, myringotomy with Eight studies (5 RCTs, 3 NRCS, and the Cochrane risk of bias tool was adenoidectomy, myringotomy alone, 1 that combined both designs) in 12 Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017 3 articles reported on 119 quality of life and patient-centered outcomes (cognitive, language, and behavioral) in 1665 children over multiple time points and arms. In general, the results were not significant (only 14 of 119 had significant results), and they varied in magnitude and direction, even across subscales of Etheffectiveness same test. of Tympanostomy Tubes in Children With Recurrent AOM FIGURE 2 Early (1–3 months) decrease (improvement) in mean hearing thresholds compared with watchful waiting. CrI, credible interval; TT, tympanostomy tubes. –

We identified 8 publications, 66 72 reporting results from 7 RCTs ‍ ‍ 69,73​ TABLE 1 Probabilities That an Intervention Is Among the 3 Most Effective With Respect to Early and 2 NRCS ‍ that reported Hearing Thresholds outcomes for children with recurrent Intervention Probability (%) of Being Among the 3 Probability (%) of Being Among the 3 AOM. Most Effective Interventions Least Effective Interventions Three RCTs compared tympanostomy TT 97 3 tubes with placebo or no treatment. TT + adenoidectomy 96 4 The first trial reported that 3 of 20 Myringotomy 8 92 Myringotomy + 91 9 children in the placebo group had no adenoidectomy further episodesP of AOM, compared Antibiotic prophylaxis 6 94 with 12 of 22 in the tympanostomy Watchful waiting 1 99 tube group ( = .01), with an attack TT, tympanostomy tubes. rate of 2.0 infections per child in the placeboP group, compared with 0.86 in the tympanostomy tube group ( = .006). The authors reported a ≥ post hoc subgroup comparison of treatment failure ( 2 episodes in 3 months) rates. Children without middleP ear effusion at study entry had significantly fewer bouts of AOM ( < .05) and lower attack rates than children with middle ear effusion. However, in a logistic model of treatment failure, adjusted for presence of middle ear effusion, the FIGURE 3 treatment according to subgroup P Late (12–24 months) decrease (improvement) in mean hearing thresholds compared with watchful interaction termn is nonsignificant waiting. CrI, credible interval; TT, tympanostomy tubes. ( = .69). This analysis relies on a small sample ( = 42) and is therefore underpowered, but it provides no evidence that the presence or absence of middle ear In the placebo group, 40% had no The third, most recent trial reported further episodes of AOM, compared failure rates (defined as at least 2 effusion at study entry influenced66 the efficacy of tympanostomy tubes. with 35% in the tympanostomy tube episodes of AOM in 2 months, 3 in group. However, tympanostomy tube 6 months, or persistent effusion A second trial reported that the rate placement significantly decreased the lasting at least 2 months), percentage of new episodes per arm wasP 1.08 in Ppercentage of time with AOM (6.6%) of children with no recurrent AOM, the placebo group versus 1.02 in the compared67 with placebo (15.0%; cumulative number of AOM episodes, tympanostomy tube group ( = .25). < .001). and 1-year incidence rates. There Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 Steele et al TABLE 2 Probabilities That an Intervention Is Among the 2 Most Effective With Respect to Late Hearing − Thresholds was an absolute difference in the − Intervention Probability (%) of Being Among the 2 Probability (%) of Being Among the 3 proportion of failures of 13% − Most Effective Interventions Least Effective Interventions (95% confidence interval: 25 to TT 5 95 1) between the tympanostomy TT + adenoidectomy 92 8 tube and control groups, favoring Myringotomy + 88 12 tympanostomy tubes. The 1-year adenoidectomy incidence rate (infections per child Antibiotic prophylaxis 10 90 Watchful waiting 4 96 per year) was 0.55 (95% confidence interval: 0.93 to 0.17) lower in the TT, tympanostomy tubes. tympanostomy tube group71 compared with the control group. We were unable to provide pooled variable between studies. Not all studies that evaluated parental stress results due to the small number of cohorts followed up all patients and health-related quality of life studies, multiple interventions, and until extrusion of the tube, nor was found significant improvements in heterogeneity in reported outcomes. follow-up complete in all studies. surgically treated children compared The limited available evidence Several adverse event categories with watchful waiting. suggests that tympanostomy tube (eg, otorrhea, premature extrusion, placement decreases the risk of myringosclerosis) have very wide Tympanostomy tubes did not consistently improve cognition, recurrent66 AOM. Aside from the first interquartile ranges, likely due to study,​ we found no direct evidence highly variable definitions. Other behavior, or quality of life, but low to evaluate whether the presence adverse events, such as hearing statistical power prevents any of middle ear effusion at the time loss and cholesteatoma, are likely definitive conclusions, and the results of surgical evaluation modifies the confounded by the severity of apply to otherwise healthy children effectiveness of tympanostomy preexisting and ongoing middle ear with no baseline disorders or delays tube placement for recurrent disease. in language, cognition, or behavior. AOM because the other 2 studies With the exception of a few NRCS, The main conclusions and specifically excluded patients with comparative trials systematically 67,71​ interpretations, including strength of current middle ear effusion. ‍ exclude patients with cleft palate and evidence assessments based on our Down syndrome, thus limiting the Three RCTs evaluated tympanostomy meta-analysis, are summarized in applicability of the evidence for these tubes alone versus adenoidectomy Supplemental Table 3. and other similar subgroups who and tympanostomy tubes. Of –these Discussion experience a higher burden of middle trials, none reported a difference69 71 in ear disease. Similarly, patients at recurrent episodes of AOM. ‍‍ increased risk of developmental or Risk of bias across outcomes ranged Tympanostomy tube placement behavioral sequelae from middle ear Adversefrom moderate Events toAssociated high. With (compared with watchful waiting) disease have not been included (or at Tympanostomy Tubes in children with chronic middle ear least identified) in trials to date. effusion, results in improved average Given the sparse data and limitations hearing thresholds at 1 to 3 months inherent to the synthesis of aggregate We extracted data on the occurrence after surgery (a period when the data, we were unable to perform of 11 adverse events from 85 majority of tubes are functioning). an analysis of factors which would cohorts and from the tympanostomy Mean hearing thresholds after ∼ predict those children more likely tube arms of included RCTs and tube placement with or without to benefit from tympanostomy NRCS. The number of publications adenoidectomy improved by 10 dB tubes for chronic middle ear reporting each event and the median when assessed at 1 to 3 months. effusion. Additional insight was (with 25th and 75th percentiles) By 1 to 2 years after surgery, when provided by an individual patient percentage of patients and ears are most tubes have extruded, hearing data meta-analysis that focused on summarized in Supplemental thresholds are no longer different, interactions between treatment Table 4; references for these 159 – likely reflecting the usually favorable and baseline characteristics. The adverse events are also 13,19,​ 21,​ 30,​ 39,​ 52,​ 67,​ 71,​ 74​ 158 natural history of spontaneous meta-analysis found significant supplied. ‍ ‍ ‍ ‍ ‍ ‍ ‍ ‍‍ ≤ resolution of middle ear effusion in interactions between day care In general, the study-specific most children in both groups. There attendance in children aged 3 ≥ definitions of adverse events were is limited evidence regarding quality years, and in children >4 years of poorly reported and/or highly of life outcomes, but neither of the 2 age with a hearing level of 25 dB Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017 5 in both ears, and concluded that Our systematic review of Assessing the effectiveness of tympanostomy tubes might be most adverse events associated with tympanostomy tubes in children effective in young children attending tympanostomy tube placement with recurrent AOM is particularly day care, or in older children with provides a descriptive summary of challenging because an episode of persistent hearing impairments at the observed frequency in published AOM in control children (with an least 12 weeks. However, average cohorts. However, the study-specific intact tympanic membrane) results hearing level at baseline did not definitions of adverse events are in otalgia and inflammatory changes, obviously modify effectiveness. Our highly variable and poorly reported. whereas children with a functioning meta-analysis of hearing levels used Some adverse events, such as tympanostomy tube may present average pure tone hearing levels hearing loss and cholesteatoma, are with varying degrees of otorrhea. (typically reported as an average likely confounded by the severity of Outcomes that rely on simple over frequencies of 500, 1000, 2000, preexisting and ongoing middle ear counts or rates of otorrhea fail to and 4000 Hz). This single outcome Ldisease.imitations account for the variable character of measure is likely insufficient to fully otorrhea with respect to duration, elucidate the complex relationships character, and patient impact. For between hearing, speech perception, example, otorrhea may be transient and development in children. The available evidence base is (of little to no concern), recurrent composed of studies that evaluate Our network meta-analysis suggests (of more concern but usually multiple interventions. Several of readily managed), or chronic (of a trend toward improved hearing these (eg, myringotomy alone and thresholds in children undergoing considerable concern and difficult to oral antibiotic prophylaxis)5 are rarely manage). adenoidectomy, but credible intervals used or not recommended in current Future Research Needs are wide and include the null effect. practice. We used indirect evidence An individual patient data meta- from a network meta-analysis to analysis of children with persistent ≥ augment the direct evidence relating Pragmatic trials are needed, OME concluded that adenoidectomy to the comparisons of current particularly in children with is most beneficial in children aged 4 interest. The key assumption of the recurrent AOM, but also in children years, with no significant benefit of network meta-analysis is that of with chronic OME or some adenoidectomy160 in children <4 years consistency of direct and indirect combination of both. Because old. This evidence is reflected in effects. Consistency is likely to hold tympanostomy tubes are no longer a recently updated clinical practice when the distribution of effect effective after extrusion, future guideline for OME, which promotes modifiers is similar across trials. If trials should record per-ear and tympanostomy tubes as the primary this assumption is violated, there surgical intervention for younger per-patient outcomes conditional on ≥ may be inconsistency between the whether the tympanostomy tube has children and reserves adenoidectomy direct evidence and indirect evidence been extruded. Future studies should for children 4 years or those with a of treatment comparisons. also conduct appropriate analyses distinct indication161 for the procedure other than OME. Reporting of possible to estimate the causal effects of tympanostomy tubes among children In children with recurrent AOM, the sociodemographic risk factors is who still have the tubes in place. limited available evidence suggests sparse and inconsistent, which limits Future trials would benefit from that tympanostomy tubes decrease our ability to draw conclusions standardization of disease definitions the number of additional episodes about which of these factors might and consistent definition of core and the overall number of episodes of influence the relative effectiveness of outcomes and adverse events. recurrent AOM. The degree to which tympanostomy tubes. the presence of middle ear fluid at Current recommended indications Exploring treatment effect the time of evaluation for surgery for tympanostomy tube placement heterogeneity (ie, differential effects will affect the effectiveness of the largely reflect the inclusion criteria of interventions in populations at tympanostomy tubes is unclear. used in existing clinical trials. different risk levels for outcomes of Three RCTs consistently found no Given the usually favorable natural interest) should be a priority. There difference in recurrent episodes of history of middle ear effusion, well- is particular need for randomized AOM in children who underwent validated prognostic models are studies evaluating tympanostomy tympanostomy tube placement with urgently needed to stratify the risk of tubes in higher risk groups, such adenoidectomy– compared with individual children in terms of their as patients with cleft palate, Down tympanostomy69 71 tube placement risk for persistence of middle ear syndrome, and children with alone. ‍‍ effusion and/or recurrent AOM. neurodevelopmental disorders. Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 Steele et al Conclusions — — improve cognition, behavior, or events associated with although Overall, the evidence suggests that quality of life. However, the evidence not necessarily caused by this tympanostomy tubes in children is sparse and prevents any definitive treatment. with persistent middle-ear effusion conclusions. The results apply to Acknowledgments result in short-term improvements otherwise healthy children without in hearing compared with watchful baseline disorders or delays in waiting. However, there is no language or cognition. They provide Special thanks to Joseph Lau for his evidence of a sustained benefit. little guidance for the treatment of advice and guidance; Ian Pan and children who may be at increased Nathan Coopersmith for assistance Our network meta-analysis of hearing risk for speech, language, or learning with screening and extraction; and thresholds suggests the possibility problems because of baseline Jenni Quiroz and Jenna Legault and of a more sustained improvement sensory, physical, cognitive, or for their assistance throughout the in hearing thresholds in at least behavioral factors. systematic review process. some children who undergo Abbreviations adenoidectomy and tympanostomy Children with recurrent AOM tube placement. A nuanced may have fewer episodes after understanding of which children tympanostomy tube placement, but AOM: acute otitis media may benefit from adenoidectomy is the evidence base is severely limited. NRCS: nonrandomized compara- limited by the small evidence base It is unclear whether quality of life tive studies and our use of aggregate data. outcomes are improved. The benefits OME: otitis media with effusion The evidence suggests that treatment of tympanostomy tubes must be RCT: randomized controlled trial with tympanostomy tubes did not weighed against a variety of adverse DOI: https://​doi.​org/​10.​1542/​peds.​2017-​0125 Accepted for publication Mar 15, 2017 Address correspondence to Dale W. Steele, MD, MS, Center for Evidence Synthesis in Health, Box G-S121-8, Brown University, Providence, RI 02912. E-mail: dale_ [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: All authors received funding for this project under Contract HHSA290-2015-00002-I from the Agency for Healthcare Research and Quality, US Department of Health and Human Services. FUNDING: Supported by the Agency for Healthcare Research and Quality (contract: HHSA290-2015-00002-I). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

References 1. Rettig E, Tunkel DE. Contemporary 5. Lieber thal AS, Carroll AE, Chonmaitree Informatics Symposium. Miami, FL: concepts in management of acute T, et al. The diagnosis and management ACM; 2012:819–824 otitis media in children. Otolaryngol of acute otitis media. Pediatrics. 8. van Valkenhoef G, Lu G, de Brock Clin North Am. 2014;47(5):651 672 2013;131(3). Available at: www.​ – B, Hillege H, Ades AE, Welton NJ. pediatrics.​org/​cgi/​content/​full/​131/​3/​ 2. Cullen KA, Hall MJ, Golosinskiy A. Automating network meta-analysis. e964 Ambulatory surgery in the United Res Synth Methods. 2012;3(4):285–299 States, 2006. Natl Health Stat Rep. 6. Agency for Healthcare Research 9. Plummer M. JAGS: a program for 2009;(11):1 25 – and Quality. Methods Guide for analysis of Bayesian graphical models 3. Hoffman HJ, Daly KA, Bainbridge KE, Effectiveness and Comparative using Gibbs sampling. In: Proceedings et al. Panel 1: epidemiology, natural Effectiveness Reviews. Rockville, MD: of the 3rd International Workshop history, and risk factors. Otolaryngol Agency for Healthcare Research and on Distributed Statistical Computing Head Neck Surg. 2013;148(suppl Quality; 2014 (DSC); March 20–22, 2003; Vienna, 4):E1 E25 Austria – 7. Wallace BC, Small K, Brodley CE, 4. Rosenfeld RM, Schwartz SR, Pynnonen Lau J, Trikalinos TA. Deploying an 10. Dias S, Sutton AJ, Ades AE, Welton MA, et al. Clinical practice guideline: interactive machine learning system NJ. Evidence synthesis for decision tympanostomy tubes in children. in an evidence-based practice center: making 2: a generalized linear Otolaryngol Head Neck Surg. abstrackr. In: Proceedings of the modeling framework for pairwise and 2013;149(suppl 1):S1–S35 2nd ACM SIGHIT International Health network meta-analysis of randomized

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017 7 controlled trials. Med Decis Making. 19. Ingels K, Rovers MM, van der Wilt 28. Paradise JL, Campbell TF, Dollaghan 2013;33(5):607–617 GJ, Zielhuis GA. Ventilation tubes CA, et al. Developmental outcomes in infants increase the risk of after early or delayed insertion of 11. Higgins JP, Altman DG, G tzsche PC, ø otorrhoea and antibiotic usage. B-ENT. tympanostomy tubes. N Engl J Med. et al; Cochrane Bias Methods Group; 2005;1(4):173 176 2005;353(6):576 586 Cochrane Statistical Methods Group. – – The Cochrane Collaboration’s tool for 20. Johnston LC, Feldman HM, Paradise 29. Paradise JL, Dollaghan CA, Campbell TF, assessing risk of bias in randomised JL, et al. Tympanic membrane et al. Otitis media and tympanostomy trials. BMJ. 2011;343:d5928 abnormalities and hearing levels at tube insertion during the first three the ages of 5 and 6 years in relation years of life: developmental outcomes 12. Berkman ND, Lohr KN, Ansari M, to persistent otitis media and at the age of four years. Pediatrics. et al; AHRQ Methods for Effective tympanostomy tube insertion in the 2003;112(2):265–277 Health Care. Grading the Strength of first 3 years of life: a prospective study a Body of Evidence When Assessing 30. Paradise JL, Feldman HM, Campbell incorporating a randomized clinical TF, et al. Effect of early or delayed Health Care Interventions for the trial. Pediatrics. 2004;114(1). Available Effective Health Care Program of the insertion of tympanostomy tubes at: www.​pediatrics.​org/​cgi/​content/​ for persistent otitis media on Agency for Healthcare Research and full/​114/​1/​e58 Quality: An Update. Methods Guide developmental outcomes at the for Effectiveness and Comparative 21. Mandel EM, Rockette HE, Bluestone CD, age of three years. N Engl J Med. Effectiveness Reviews. Rockville, MD: Paradise JL, Nozza RJ. Myringotomy 2001;344(16):1179–1187 Agency for Healthcare Research and with and without tympanostomy tubes 31. Paradise JL, Feldman HM, Campbell TF, Quality; 2008 for chronic otitis media with effusion. et al. Early versus delayed insertion Arch Otolaryngol Head Neck Surg. of tympanostomy tubes for persistent 13. Bernard PA, Stenstrom RJ, Feldman 1989;115(10):1217–1224 W, Durieux-Smith A. Randomized, otitis media: developmental outcomes controlled trial comparing long-term 22. Mandel EM, Rockette HE, Bluestone at the age of three years in relation sulfonamide therapy to ventilation CD, Paradise JL, Nozza RJ. Efficacy to prerandomization illness patterns tubes for otitis media with effusion. of myringotomy with and without and hearing levels. Pediatr Infect Dis J. tympanostomy tubes for chronic otitis 2003;22(4):309 314 Pediatrics. 1991;88(2):215–222 – media with effusion. Pediatr Infect Dis 32. Paradise JL, Feldman HM, Campbell 14. Casselbrant ML, Mandel EM, Rockette J. 1992;11(4):270–277 TF, et al. Tympanostomy tubes HE, Kurs-Lasky M, Fall PA, Bluestone 23. Maw R, Wilks J, Harvey I, Peters TJ, and developmental outcomes at 9 CD. Adenoidectomy for otitis media Golding J. Early surgery compared to 11 years of age. N Engl J Med. with effusion in 2-3-year-old children. with watchful waiting for glue ear and 2007;356(3):248 261 Int J Pediatr Otorhinolaryngol. – effect on language development in 2009;73(12):1718–1724 33. Popova D, Varbanova S, Popov TM. preschool children: a randomised trial. Comparison between myringotomy 15. Chaudhuri GR, Bandyopadhyay SN, Lancet. 1999;353(9157):960–963 and tympanostomy tubes in Basu SK. Role of grommet in otitis 24. MRC Multicentre Otitis Media Study combination with adenoidectomy media with effusion: a necessity Group. The role of ventilation tube in 3-7-year-old children with otitis or nuisance? A comparative study. status in the hearing levels in children media with effusion. Int J Pediatr Indian J Otolaryngol Head Neck Surg. managed for bilateral persistent otitis Otorhinolaryngol. 2010;74(7):777–780 2006;58(3):271–273 media with effusion. Clin Otolaryngol 34. Rach GH, Zielhuis GA, van Baarle 16. D’Eredità R, Shah UK. Contact Allied Sci. 2003;28(2):146–153 PW, van den Broek P. The effect of diode laser myringotomy for 25. MRC Multicentre Otitis Media Study treatment with ventilating tubes on medium-duration middle ear Group. Speech reception in noise: an language development in preschool ventilation in children. Int indicator of benefit from otitis media children with otitis media with J Pediatr Otorhinolaryngol. with effusion surgery. Clin Otolaryngol effusion. Clin Otolaryngol Allied Sci. 2006;70(6):1077–1080 Allied Sci. 2004;29(5):497–504 1991;16(2):128–132 17. Hall AJ, Maw AR, Steer CD. 26. MRC Multicentre Otitis Media Study 35. Rovers MM, Krabbe PF, Straatman H, Developmental outcomes in early Group. Adjuvant adenoidectomy in Ingels K, Zielhuis GA, van der Wilt GJ. compared with delayed surgery persistent bilateral otitis media Randomised controlled trial of the for glue ear up to age 7 years: a with effusion: hearing and revision effect of ventilation tubes (grommets) randomised controlled trial. Clin surgery outcomes through 2 years on quality of life at age 1-2 years. Arch Otolaryngol. 2009;34(1):12–20 in the TARGET randomised trial. Clin Dis Child. 2001;84(1):45–49 18. Har tman M, Rovers MM, Ingels K, Otolaryngol. 2012;37(2):107–116 36. Rovers MM, Straatman H, Ingels K, Zielhuis GA, Severens JL, van der Wilt 27. Nguyen LH, Manoukian JJ, Yoskovitch van der Wilt GJ, van den Broek P, GJ. Economic evaluation of ventilation A, Al-Sebeih KH. Adenoidectomy: Zielhuis GA. The effect of ventilation tubes in otitis media with effusion. selection criteria for surgical cases tubes on language development in Arch Otolaryngol Head Neck Surg. of otitis media. Laryngoscope. infants with otitis media with effusion: 2001;127(12):1471–1476 2004;114(5):863–866 a randomized trial. Pediatrics.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 8 Steele et al 2000;106(3). Available at: www.​ 45. For quer BD, Linthicum FH Jr. Middle and otitis media [in Italian]. Acta pediatrics.​org/​cgi/​content/​full/​106/​3/​ ear effusion in children: a report of Otorhinolaryngol Ital. 2006;26(5 suppl e42 treatment in 500 cases. West J Med. 84):30–55 1982;137(5):370–374 37. Rovers MM, Straatman H, Ingels 56. Reiter R, Haase S, Brosch S. Repaired K, van der Wilt GJ, van den Broek 46. Marshak G, Neriah ZB. Adenoidectomy cleft palate and ventilation tubes and P, Zielhuis GA. Generalizability of versus tympanostomy in chronic their associations with cholesteatoma trial results based on randomized secretory otitis media. Ann Otol in children and adults. Cleft Palate versus nonrandomized allocation of Rhinol Laryngol Suppl. 1980;89(3 pt Craniofac J. 2009;46(6):598–602 OME infants to ventilation tubes or 2):316–318 57. Kobayashi H, Sakuma T, Yamada watchful waiting. J Clin Epidemiol. 47. Peters SA, Grievink EH, van Bon WH, N, Suzaki H. Clinical outcomes of 2001;54(8):789–794 Schilder AG. The effects of early ventilation tube placement in children bilateral otitis media with effusion on with cleft palate. Int J Pediatr 38. Rovers MM, Straatman H, Ingels K, educational attainment: a prospective Otorhinolaryngol. 2012;76(5):718 721 van der Wilt GJ, van den Broek P, – cohort study. J Learn Disabil. Zielhuis GA. The effect of short-term 58. Wolter NE, Dell SD, James AL, Campisi 1994;27(2):111 121 ventilation tubes versus watchful – P. Middle ear ventilation in children waiting on hearing in young children 48. Grievink EH, Peters SA, van Bon WH, with primary ciliary dyskinesia. with persistent otitis media with Schilder AG. The effects of early Int J Pediatr Otorhinolaryngol. effusion: a randomized trial. Ear Hear. bilateral otitis media with effusion 2012;76(11):1565–1568 2001;22(3):191–199 on language ability: a prospective 59. Yousaf M, Inayatullah, Khan F. Medical cohort study. J Speech Hear Res. 39. Velepic M, Starcevic R, Bonifacic versus surgical management of otitis 1993;36(5):1004–1012 M, et al. The clinical status of the media with effusion in children. J Ayub eardrum: an inclusion criterion for 49. Schilder AG, Hak E, Straatman H, Med Coll Abbottabad. 2012;24(1):83–85 the treatment of chronic secretory Zielhuis GA, van Bon WH, van den Broek 60. Youssef TF, Ahmed MR. Laser-assisted otitis media in children. Int J Pediatr P. Long-term effects of ventilation myringotomy versus conventional tubes for persistent otitis media with Otorhinolaryngol. 2011;75(5):686–690 myringotomy with ventilation tube effusion in children. Clin Otolaryngol insertion in treatment of otitis media 40. Vlastos IM, Houlakis M, Kandiloros D, Allied Sci. 1997;22(5):423–429 with effusion: long-term follow-up. Manolopoulos L, Ferekidis E, Yiotakis 50. Coyte PC, Croxford R, McIsaac W, Interv Med Appl Sci. 2013;5(1):16 20 I. Adenoidectomy plus tympanostomy – Feldman W, Friedberg J. The role tube insertion versus adenoidectomy 61. Tian L, Chen X, Li G. The clinical curative of adjuvant adenoidectomy and plus myringotomy in children with effect of the low temperature plasma tonsillectomy in the outcome of the obstructive sleep apnoea syndrome. ablation adenoidectomy and tympanic insertion of tympanostomy tubes. N J Laryngol Otol. 2011;125(3):274–278 membrane indwelling catheter in Engl J Med. 2001;344(16):1188–1195 parallel or not used on childhood 41. Wilks J, Maw R, Peters TJ, Harvey I, 51. Xu HF, Xu LR, He Y, Zheng Q, Zheng Y, patients with secretory otitis media [in Golding J. Randomised controlled Liao XY. [Treatment of cleft palate with Chinese]. Lin Chuang Er Bi Yan Hou Tou trial of early surgery versus watchful secretory otitis media]. Zhonghua Kou Jing Wai Ke Za Zhi. 2015;29(5):415–417 waiting for glue ear: the effect on Qiang Yi Xue Za Zhi. 2003;38(4):269–270 behavioural problems in pre-school 62. Li S, Zhang H, Wei Y, et al. Clinical children. Clin Otolaryngol Allied Sci. 52. de Beer BA, Schilder AG, Ingels K, comparative study on the treatment Snik AF, Zielhuis GA, Graamans K. characteristics of secretory otitis 2000;25(3):209–214 Hearing loss in young adults who media between cleft and non-cleft 42. Yagi HI. The surgical treatment of had ventilation tube insertion in palate patients [in Chinese]. Hua Xi Kou secretory otitis media in children. childhood. Ann Otol Rhinol Laryngol. Qiang Yi Xue Za Zhi. 2015;33(3):259–262 J Laryngol Otol. 1977;91(3):267 270 – 2004;113(6):438–444 63. Hu S, Patel NA, Shinhar S. 43. Robson AK, Blanshard JD, Jones 53. Stenstrom R, Pless IB, Bernard P. Follow-up audiometry after K, Albery EH, Smith IM, Maw AR. Hearing thresholds and tympanic bilateral myringotomy and A conservative approach to the membrane sequelae in children tympanostomy tube insertion. management of otitis media with managed medically or surgically for Int J Pediatr Otorhinolaryngol. effusion in cleft palate children. otitis media with effusion. Arch Pediatr 2015;79(12):2068–2071 J Laryngol Otol. 1992;106(9):788–792 Adolesc Med. 2005;159(12):1151–1156 64. Kuscu O, Gunaydin RO, Icen M, et al. 54. Kadhim AL, Spilsbury K, Semmens JB, The effect of early routine grommet 44. Hubbard TW, Paradise JL, McWilliams Coates HL, Lannigan FJ. Adenoidectomy insertion on management of otitis BJ, Elster BA, Taylor FH. Consequences for middle ear effusion: a study media with effusion in children with of unremitting middle-ear disease in of 50,000​ children over 24 years. cleft palate. J Craniomaxillofac Surg. early life. Otologic, audiologic, and Laryngoscope. 2007;117(3):427 433 2015;43(10):2112 2115 developmental findings in children – – with cleft palate. N Engl J Med. 55. Motta G, Esposito E, Motta S, et al. 65. Niclasen J, Obel C, Homøe P, 1985;312(24):1529–1534 Acute recurrent pharyngotonsillitis Kørvel-Hanquist A, Dammeyer J.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017 9 Associations between otitis media fenestration. Laryngoscope. 86. Rothera MP, Grant HR. Long-term and child behavioural and learning 1999;109(12):2009–2014 ventilation of the middle ear using difficulties: results from a Danish 75. Hoffmann KK, Thompson GK, Burke BL, the Goode T-tube. J Laryngol Otol. cohort. Int J Pediatr Otorhinolaryngol. Derkay CS. Anesthetic complications 1985;99(4):335–337 2016;84:12–20 of tympanostomy tube placement in 87. Levinson SR, Gill AJ, Teich L. 66. Gonzalez C, Arnold JE, Woody EA, et al. children. Arch Otolaryngol Head Neck Semipermeable membrane tubes: a Prevention of recurrent acute otitis Surg. 2002;128(9):1040–1043 prospective study. Otolaryngol Head media: chemoprophylaxis versus 76. Isaacson G. Six Sigma tympanostomy Neck Surg. 1982;90(5):622–628 tympanostomy tubes. Laryngoscope. tube insertion: achieving the highest 88. Plotkin RP. Middle ear ventilation 1986;96(12):1330–1334 safety levels during residency with the Castelli membrane tube. 67. Casselbrant ML, Kaleida PH, Rockette training. Otolaryngol Head Neck Surg. Laryngoscope. 1981;91(7):1173–1175 2008;139(3):353 357 HE, et al. Efficacy of antimicrobial – 89. Mandel EM, Casselbrant ML, Kurs- prophylaxis and of tympanostomy tube 77. Hörmann K, Roehrs M. Middle-ear Lasky M. Acute otorrhea: bacteriology insertion for prevention of recurrent findings in young cleft lip and palate of a common complication of acute otitis media: results of a children. Comparison of two treatment tympanostomy tubes. Ann Otol Rhinol randomized clinical trial. Pediatr Infect clinics [in German]. Dtsch Z Mund Laryngol. 1994;103(9):713–718 Dis J. 1992;11(4):278 286 Kiefer Gesichtschir. 1991;15(2):149–152 – 90. Brown JA. Management of ventilation 68. El-Sayed Y. Treatment of recurrent 78. Suetake M, Kobayashi T, Takasaka tubes: preventing premature extrusion. acute otitis media chemoprophylaxis T, Shinkawa H. Is change in middle J S C Med Assoc. 1993;89(9):427–430 ear air volume following ventilation versus ventilation tubes. Aust J 91. Debruyne F, Degroote M. One-year Otolaryngol. 1996;2(4):352–355 tube insertion a reliable prognostic indicator? Acta Otolaryngol Suppl. follow-up after tympanostomy tube insertion for recurrent acute otitis 69. Mattila PS, Joki-Erkkilä VP, Kilpi 1990;471:73–80 T, Jokinen J, Herva E, Puhakka media. ORL J Otorhinolaryngol Relat 79. Gates GA, Avery CA, Cooper JC Jr, H. Prevention of otitis media by Spec. 1993;55(4):226–229 Prihoda TJ. Chronic secretory adenoidectomy in children younger otitis media: effects of surgical 92. Owen MJ, Norcross-Nechay K, Howie than 2 years. Arch Otolaryngol Head management. Ann Otol Rhinol Laryngol VM. Brainstem auditory evoked Neck Surg. 2003;129(2):163–168 potentials in young children before and Suppl. 1989;138:2–32 after tympanostomy tube placement. 70. Hammarén-Malmi S, Saxen 80. Weigel MT, Parker MY, Goldsmith Int J Pediatr Otorhinolaryngol. H, Tarkkanen J, Mattila PS. MM, Postma DS, Pillsbury HC. A 1993;25(1–3):105–117 Adenoidectomy does not significantly prospective randomized study of four reduce the incidence of otitis media commonly used tympanostomy tubes. 93. Heaton JM, Mills RP. Otorrhoea in conjunction with the insertion via ventilation tubes in adults and Laryngoscope. 1989;99(3):252–256 of tympanostomy tubes in children children. Clin Otolaryngol Allied Sci. 81. Gates GA, Avery C, Prihoda TJ, Holt who are younger than 4 years: 1993;18(6):496–499 a randomized trial. Pediatrics. GR. Delayed onset post-tympanotomy 94. Siddiqui N, Toynton S, Mangat KS. 2005;116(1):185–189 otorrhea. Otolaryngol Head Neck Surg. 1988;98(2):111–115 Results of middle ear ventilation 71. Kujala T, Alho OP, Luotonen J, et al. with ‘Mangat’ T-tubes. Int J Pediatr 82. Debruyne F, Jorissen M, Tympanostomy with and without Otorhinolaryngol. 1997;40(2–3):91–96 Poelmans J. Otorrhea during adenoidectomy for the prevention of transtympanal ventilation. Am J Otol. 95. Golz A, Netzer A, Joachims HZ, recurrences of acute otitis media: a 1988;9(4):316–317 Westerman ST, Gilbert LM. Ventilation randomized controlled trial. Pediatr tubes and persisting tympanic 83. Tavin ME, Gordon M, Ruben RJ. Hearing Infect Dis J. 2012;31(6):565–569 membrane perforations. Otolaryngol results with the use of different Head Neck Surg. 1999;120(4):524 527 72. Kujala T, Alho OP, Kristo A, et al. Quality tympanostomy tubes: a prospective – of life after surgery for recurrent otitis study. Int J Pediatr Otorhinolaryngol. 96. Valtonen H, Qvarnberg Y, Nuutinen media in a randomized controlled trial. 1988;15(1):39–50 J. Tympanostomy in young children Pediatr Infect Dis J. 2014;33(7):715–719 with recurrent otitis media. A long- 84. Gates GA, Avery CA, Prihoda TJ, term follow-up study. J Laryngol Otol. 73. Grindler DJ, Blank SJ, Schulz KA, Cooper JC Jr. Effectiveness of 1999;113(3):207 211 Witsell DL, Lieu JE. Impact of otitis adenoidectomy and tympanostomy – media severity on children’s quality tubes in the treatment of chronic otitis 97. Rosenfeld RM, Bhaya MH, Bower CM, of life. Otolaryngol Head Neck Surg. media with effusion. N Engl J Med. et al. Impact of tympanostomy tubes 2014;151(2):333–340 1987;317(23):1444–1451 on child quality of life. Arch Otolaryngol Head Neck Surg. 2000;126(5):585 592 74. Brodsky L, Brookhauser P, Chait 85. Debruyne F, Jorissen M, Poelmans – D, et al. Office-based insertion of J. Follow-up of trans-tympanum tubes 98. Ah-Tye C, Paradise JL, Colborn DK. pressure equalization tubes: the role [in Dutch]. Acta Otorhinolaryngol Belg. Otorrhea in young children after of laser-assisted tympanic membrane 1986;40(4):666–677 tympanostomy-tube placement

Downloaded from www.aappublications.org/news by guest on October 2, 2021 10 Steele et al for persistent middle-ear effusion: children with tympanostomy tubes: 119. Wallace HC, Newbegin CJ. Does ENT prevalence, incidence, and duration. incidence and predictors. PLoS One. outpatient review at 1-week post Pediatrics. 2001;107(6):1251–1258 2013;8(7):e69062 ventilation tube insertion improve outcome at 1 month in paediatric 99. Valtonen H, Dietz A, Qvarnberg 109. Saki N, Nikakhlagh S, Salehe patients? Clin Otolaryngol Allied Sci. Y. Long-term clinical, audiologic, F, Darabifard A. Incidence of 2004;29(6):595 597 and radiologic outcomes in complications developed after the – palate cleft children treated with insertion of ventilation tube in children 120. Allen J, Morton RP, Ahmad Z. Early early tympanostomy for otitis under 6 years old in 2008-2009. Iran post-operative morbidity after media with effusion: a controlled J Otorhinolaryngol. 2012;24(66):15–18 tympanostomy tube insertion. prospective study. Laryngoscope. J Laryngol Otol. 2005;119(9):699–703 110. Smillie I, Robertson S, Yule A, Wynne 2005;115(8):1512–1516 DM, Russell CJ. Complications of 121. Dohar J, Giles W, Roland P, et al. Topical 100. Pereira MB, Pereira DR, Costa SS. ventilation tube insertion in children ciprofloxacin/dexamethasone superior Tympanostomy tube sequelae in with and without cleft palate: a to oral amoxicillin/clavulanic acid children with otitis media with nested case-control comparison. in acute otitis media with otorrhea effusion: a three-year follow-up study. JAMA Otolaryngol Head Neck Surg. through tympanostomy tubes. Rev Bras Otorrinolaringol (Engl Ed). 2014;140(10):940–943 Pediatrics. 2006;118(3). Available at: 2005;71(4):415–420 www.​pediatrics.​org/​cgi/​content/​full/​ 111. Luo HN, Ma SJ, Sheng Y, et al. 118/​3/​e561 101. Spielmann PM, McKee H, Adamson RM, Pepsin deteriorates prognosis of Thiel G, Schenk D, Hussain SS. Follow children with otitis media with 122. Muenker G. Results after treatment up after middle-ear ventilation tube effusion who undergo myringotomy of otitis media with effusion. Ann Otol insertion: what is needed and when? or tympanostomy tube insertion. Rhinol Laryngol Suppl. 1980;89(3 pt J Laryngol Otol. 2008;122(6):580–583 Int J Pediatr Otorhinolaryngol. 2):308–311 102. O’Reilly RC, He Z, Bloedon E, et al. 2014;78(12):2250–2254 123. van Baarle PW, Wentges RT. Extrusion of transtympanic ventilating tubes, The role of extraesophageal reflux in 112. Powell J, Powell S, Lennon M, Ho A, relative to the site of insertion. otitis media in infants and children. Murrant N. Paediatric ventilation tube ORL J Otorhinolaryngol Relat Spec. Laryngoscope. 2008;118(7 pt 2 suppl insertion: our experience of seventy- 1975;37(1):35 40 116):1–9 five children in audiology-led follow-up. – 103. Ida JB, Worley NK, Amedee RG. Gold Clin Otolaryngol. 2015;40(4):385–389 124. Kokko E, Palva T. Clinical results and laser adenoidectomy: long-term safety complications of tympanostomy. Ann 113. Birck HG, Mravec JJ. Myringostomy for and efficacy results. Int J Pediatr Otol Rhinol Laryngol. 1976;85(2 suppl middle ear effusions. Results of a two- Otorhinolaryngol. 2009;73(6):829 831 25 pt 2):277 279 – year study. Ann Otol Rhinol Laryngol. – 104. Jung H, Lee SK, Cha SH, Byun JY, Park 1976;85(2 suppl 25 pt 2):263–267 125. Paradise JL, Bluestone CD, Rogers MS, Yeo SG. Current bacteriology of KD, et al. Efficacy of adenoidectomy 114. Mackenzie IJ. Factors affecting the chronic otitis media with effusion: for recurrent otitis media in children extrusion rates of ventilation tubes. high rate of nosocomial infection and previously treated with tympanostomy- J R Soc Med. 1984;77(9):751 753 decreased antibiotic sensitivity. – tube placement. Results of parallel J Infect. 2009;59(5):308–316 115. Eliachar I, Joachims HZ, Goldsher M, randomized and nonrandomized trials. JAMA. 1990;263(15):2066 2073 105. Kinnari TJ, Aarnisalo AA, Rihkanen H, Golz A. Assessment of long-term middle – Lundin J, Jero J. Can head position ear ventilation. Acta Otolaryngol. 126. MacKinnon DM. The sequel to after anesthesia cause occlusion of 1983;96(1–2):105–112 myringotomy for exudative the tympanostomy tube? J Otolaryngol 116. Jamal TS. Avoidance of postoperative otitis media. J Laryngol Otol. Head Neck Surg. 2010;39(1):1–4 blockage of ventilation tubes. 1971;85(8):773–794 106. Marzouk HA, Nathawad R, Laryngoscope. 1995;105(8 pt 1): 127. Daly KA, Hunter LL, Lindgren BR, Hammerschlag MR, Weedon J, 833–834 Margolis R, Giebink GS. Chronic Bachman D, Goldstein NA. Methicillin- 117. Walker P. Ventilation tube duration otitis media with effusion sequelae resistant Staphylococcus aureus versus site of placement. Aust N Z J in children treated with tubes. colonization in otitis-prone children. Arch Otolaryngol Head Neck Surg. Surg. 1997;67(8):571–572 Arch Otolaryngol Head Neck Surg. 2003;129(5):517–522 118. Roland PS, Kreisler LS, Reese B, et al. 2011;137(12):1217–1222 128. Praveen CV, Terry RM. Does passive Topical ciprofloxacin/dexamethasone smoking affect the outcome of 107. Tuli BS, Parmar TL, Singh B. Evaluation otic suspension is superior to grommet insertion in children? of tympanostomy tubes in middle ear ofloxacin otic solution in the treatment J Laryngol Otol. 2005;119(6):448 454 affections. Indian J Otolaryngol Head of children with acute otitis media – Neck Surg. 2001;53(3):217–220 with otorrhea through tympanostomy 129. Khan F, Asif M, Farooqi GH, Shah SA, 108. van Dongen TM, van der Heijden GJ, tubes. Pediatrics. 2004;113(1 pt 1). Sajid T, Ghani R. Management outcome Freling HG, Venekamp RP, Schilder Available at: www.​pediatrics.​org/​cgi/​ of secretory otitis media. J Ayub Med AG. Parent-reported otorrhea in content/​full/​113/​1/​e40 Coll Abbottabad. 2006;18(1):55–58

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 139, number 6, June 2017 11 130. Hammarén-Malmi S, Saxen H, 141. Valtonen H, Tuomilehto H, Qvarnberg otolaryngology clinic. Int J Pediatr Tarkkanen J, Mattila PS. Passive Y, Nuutinen J. A 14-year prospective Otorhinolaryngol. 2001;60(3):205–211 smoking after tympanostomy and follow-up study of children treated 152. Bonding P, Lorenzen E. Chronic risk of recurrent acute otitis media. early in life with tympanostomy secretory otitis media–long-term Int J Pediatr Otorhinolaryngol. tubes: part 1: clinical outcomes. results after treatment with 2007;71(8):1305–1310 Arch Otolaryngol Head Neck Surg. grommets. ORL J Otorhinolaryngol 2005;131(4):293 298 131. Fiebach A, Matschke RG. Duration and – Relat Spec. 1974;36(4):227–235 complications following grommet 142. De Beer BA, Schilder AG, Zielhuis 153. Bonding P, Lorenzen E. Cicatricial insertion in childhood [in Dutch]. HNO. GA, Graamans K. Natural course of changes of the eardrum after 1987;35(2):61–66 tympanic membrane pathology related treatment with grommets. Acta to otitis media and ventilation tubes 132. Fior R, Veljak C. Late results and Otolaryngol. 1973;75(4):275–276 between ages 8 and 18 years. Otol complications of tympanostomy tube 154. Li Y, Hunter LL, Margolis RH, Neurotol. 2005;26(5):1016–1021 insertion for prophylaxis of recurrent et al. Prospective study of tympanic purulent otitis media in pediatric 143. Carignan M, Dorion D, Stephenson MF, membrane retraction, hearing loss, age. Int J Pediatr Otorhinolaryngol. Rouleau M. First myringotomy with and multifrequency tympanometry. 1984;8(2):139–146 insertion of a modified Goode T-Tube: Otolaryngol Head Neck Surg. changing the perforation paradigm. 133. Van Cauwenberge P, Cauwe F, 1999;121(5):514–522 J Otolaryngol. 2006;35(5):287–291 Kluyskens P. The long-term results 155. Tos M, Poulsen G. Attic retractions of the treatment with transtympanic 144. Florentzson R, Finizia C. following secretory otitis. Acta ventilation tubes in children with Transmyringeal ventilation tube Otolaryngol. 1980;89(5–6):479–486 chronic secretory otitis media. treatment: a 10-year cohort study. Int J Pediatr Otorhinolaryngol. Int J Pediatr Otorhinolaryngol. 156. Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with 1979;1(2):109–116 2012;76(8):1117–1122 ventilation tube insertion. Arch 134. Tos M, Poulsen G. Secretory otitis 145. O’Niel MB, Cassidy LD, Link Otolaryngol Head Neck Surg. media. Late results of treatment TR, Kerschner JE. Tracking 1999;125(7):754–757 with grommets. Arch Otolaryngol. tympanostomy tube outcomes in 157. Spilsbury K, Ha JF, Semmens JB, 1976;102(11):672–675 pediatric patients with otitis media Lannigan F. Cholesteatoma in cleft 135. Costa OA, Balieiro RO. Secretory otitis using an electronic database. Int J Pediatr Otorhinolaryngol. lip and palate: a population-based media in Brazilian children. Scand follow-up study of children after 2015;79(8):1275–1278 Audiol Suppl. 1986;26:93–94 ventilation tubes. Laryngoscope. 146. Gundersen T, Tonning FM. Ventilating 136. Barfoed C, Rosborg J. Secretory 2013;123(8):2024–2029 tubes in the middle ear. Arch otitis media. Long-term observations 158. Djurhuus BD, Christensen K, Skytthe Otolaryngol. 1976;102(4):198–199 after treatment with grommets. A, Faber CE. The impact of ventilation Arch Otolaryngol. 1980;106(9): 147. Tos M, Stangerup SE, Larsen P. tubes in otitis media on the risk of 553–556 Dynamics of eardrum changes cholesteatoma on a national level. 137. Levine S, Daly K, Giebink GS. Tympanic following secretory otitis. A Int J Pediatr Otorhinolaryngol. prospective study. Arch Otolaryngol membrane perforations and 2015;79(4):605–609 Head Neck Surg. 1987;113(4):380–385 tympanostomy tubes. Ann Otol Rhinol 159. Rovers MM, Black N, Browning GG, Maw Laryngol Suppl. 1994;163:27–30 148. Slack RW, Maw AR, Capper JW, Kelly S. R, Zielhuis GA, Haggard MP. Grommets 138. Hampton SM, Adams DA. Perforation Prospective study of tympanosclerosis in otitis media with effusion: an rates after ventilation tube insertion: developing after grommet insertion. individual patient data meta-analysis. J Laryngol Otol. 1984;98(8):771 774 does the positioning of the tube – Arch Dis Child. 2005;90(5):480–485 matter? Clin Otolaryngol Allied Sci. 149. Daly KA, Hunter LL, Levine SC, Lindgren 160. Boonacker CW, Rovers MM, Browning 1996;21(6):548–549 BR, Giebink GS. Relationships between GG, Hoes AW, Schilder AG, Burton 139. Postma DS, Poole MD, Wu SM, otitis media sequelae and age. MJ. Adenoidectomy with or without Tober R. The impact of day care on Laryngoscope. 1998;108(9):1306–1310 grommets for children with otitis ventilation tube insertion. Int J Pediatr 150. Koc A, Uneri C. Sex distribution in media: an individual patient data Otorhinolaryngol. 1997;41(3): children with tympanosclerosis meta-analysis. Health Technol Assess. 253–262 after insertion of a tympanostomy 2014;18(5):1–118 140. Valtonen HJ, Qvarnberg YH, Nuutinen tube. Eur Arch Otorhinolaryngol. 161. Rosenfeld RM, Shin JJ, Schwartz J. Otological and audiological 2001;258(1):16–19 SR, et al. Clinical practice guideline: outcomes five years after 151. Friedman EM, Sprecher RC, Simon S, otitis media with effusion (update). tympanostomy in early childhood. Dunn JK. Quantitation and prevalence Otolaryngol Head Neck Surg. Laryngoscope. 2002;112(4):669–675 of tympanosclerosis in a pediatric 2016;154(suppl 1):S1–S41

Downloaded from www.aappublications.org/news by guest on October 2, 2021 12 Steele et al Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis Dale W. Steele, Gaelen P. Adam, Mengyang Di, Christopher H. Halladay, Ethan M. Balk and Thomas A. Trikalinos Pediatrics originally published online May 16, 2017;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2017/05/12/peds.2 017-0125 References This article cites 157 articles, 11 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2017/05/12/peds.2 017-0125#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Ear, Nose & Throat Disorders http://www.aappublications.org/cgi/collection/ear_nose_-_throat_dis orders_sub Otitis Media http://www.aappublications.org/cgi/collection/otitis_media_sub Evidence-Based Medicine http://www.aappublications.org/cgi/collection/evidence-based_medic ine_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on October 2, 2021 Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis Dale W. Steele, Gaelen P. Adam, Mengyang Di, Christopher H. Halladay, Ethan M. Balk and Thomas A. Trikalinos Pediatrics originally published online May 16, 2017;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2017/05/12/peds.2017-0125

Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2017/05/12/peds.2017-0125.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on October 2, 2021