2017 Sec 1 Green Book

M. Duval

et

al.

/ International

Journal

of Pediatric Otorhinolaryngology 79

(2015)

336–341

Table Odds

3

ratio

of

various

complications

per

age

group.

Outcome

Age

2–4 OR

(95%CI)

Age

5–7 OR

(95% CI)

Age

8–13 OR

p -Value

(overall)

perforation perforation

1.16 3.86 1.66 1.59 2.27 1.58 2.01

(0.49–2.73) (0.88–16.88) (0.77–3.59) (0.48–5.29) (0.44–11.67) (0.78–3.23) (0.88–4.60)

1.60 1.93 1.74 0.56 3.46 1.72 1.47

(0.85–3.02) (0.49–7.67) (0.96–3.16) (0.17–1.82) (0.95–12.59) (0.99–2.98) (0.75–2.91)

1.0 1.0 1.0 1.0 1.0 1.0 1.0

0.32 0.19 0.16 0.28 0.12 0.13 0.24

Persistent Recurrent

perforation

Any

Tubes

Cholesteatoma

failure

Any

surgery

Revision

examined

children analysis

age

8–13

years

old.

When

limiting months highest

the

multivariate

[22] . The

late

failure

rate observed

in

that

study and

the

to

children between

with

at

least

6

of

follow-up

the

study

suggest

a

high

rate

of

recurrent

perforation

after

current

the

lowest

and

age

group

was

successful healing

possibly due

to

an

immature

Eustachian

difference significant perforation p = 0.005) perforation significantly ( p = 0.07). weakened perforation,

initial

with

pre-school

children

having

an

incidence

of

in

younger

children.

tube

more

than

5

times

higher

(95%

CI

1.68–17.93,

meta-analysis

evaluating

the

effect

of

age

on

pediatric

A

than

that

of

children

aged

8–13

years

old. was

The not old and

included 19 articles evaluating

the effect of

tympanoplasty success

rate

in

children

aged

5–7

years aged

old

the

lowest age

limit being 6 years old

[27] . Compilation of

age, with

different

than

that

of

children

8–13

years

articles

revealed

a

linear

association

between

success

rate

these

Surgeon

acted

as

a

strong

negative

confounder

increasing

age

( p = 0.005).

Interestingly,

only

5

out

of

the

and

the

association

between

age

and

post-tympanoplasty

articles

included between

in

the

overall meta-analysis

had

reported

an

30

thus

increasing

the

odds

of

perforation

in

pre-school

age

and

tympanoplasty

success

rate. While

association

after

controlling

for

the

effect

of

surgeon.

literature

does

seem

to

indicate

that

the

success

rate

in

children

the

is

somewhat

lower

than

that

in

adults,

uncertainty

children remains

as

to what

is

the

ideal [28] .

age

to

repair

tympanic membrane

5. Discussion

in

children

The

current

results

suggest

that

perforations

should

exert

caution

when

considering

performing

surgeons

This

study

represents

the

largest

reported

evaluation

of of

on

children

less

than

5

years

of

age

since

results

tympanoplasty

tympanoplasty

assessing adjusting

specifically

the

outcome

pediatric pre-school

tympanoplasty

in

that age group

seems

to be associated with

from

children.

After

for

confounding

factors,

the

lower

success

rate.

Possible between

reasons

for

previous

failure

to

a

study

does

suggest

that

pre-school

children

have

a

current

an

association

age

and

pediatric

tympanoplasty

identify success

higher

rate

of

post-tympanoplasty

perforation

as

significantly

rate

include

exclusion

of

younger

children

(under

6

or

to older children. The higher

rate of

failure

in pre-school

compared

years

old),

lack

of

sufficient

power

to

detect

a

significant

8

seems

to

be

mostly

attributed

to

a

high

rate

of

re-

children

thus

far had case series of

less

difference as most studies published

than 6 months after

tympanoplasty, with a

perforation noted more

100

patients

and

lack

of multivariate

analysis

to

control

for

than

of

failures

due

to

reperforations

after

initial

successful successful persistent

third

confounding

factors.

possible

This

could

be

explained

by

an

initially

healing.

complete

closure

of

the

tympanic

membrane

is

the

While

and

subsequent

reperforation

due

to

tympanoplasty

goal,

significant

improvements

in

quality

of

life

can

also

desired

tube

dysfunction

or of

due

to

an

acute

otitis media.

In

Eustachian

achieved

with

a

decreased

perforation

size.

Sheahan

et

al.

be

overall

success

rate

tympanoplasty

in

this

study was

addition,

a

phone

survey

with

parents

of to

children evaluate

who

had

conducted previously satisfaction

than

those

previously

reported

in

the

literature

for

all

age

lower

undergone

a

tympanoplasty

parental percent

groups. This may be partially explained by the

significant

resident

8–60 months

after

surgery

[5] .

Seventy-nine

in

those

cases

and

the

fact

that

the procedures were

involvement performed at

parents were

satisfied with

the

outcome.

For

children with

a

of

a

tertiary

referral

centre

and

that

some

of

these

satisfied, 56%

reported

persistent perforation, 40% of parents were

referred

from other otolaryngologists

that

children may have been may have considered the

ear

infections

and

40%

reported

improvement

in

hearing.

fewer

repair

too difficult

for

them

to attempt.

It

main

confounding

factor

that

modified

the

association

The

also

be

a

reflection

of

the

patient

selection

criteria

by

the

may

between age and perforation post-tympanoplasty was the

identity

at

our

centre.

surgeons

the

surgeon

performing

the

surgical

procedure.

The

fact

that

of

of

previous

studies

evaluating

the

association

Results

association

between

the

surgeon

and

the

anatomical

success

the

age

and

success

rate

in

pediatric

tympanoplasty

have

between

in

the multivariate analysis

suggests

that

the

rate was maintained

study by Black et al which

included 14 children

been conflicting. A

effect

is

likely

attributable

to

criteria

used

for

patient

surgeon’s

years

old

revealed

a

rate

of

intact

graft

of 56%

in

that

age

age 2–7

selection by each surgeon, surgical skills and variation in

technique patient’s

as

compared

to

77%

in

children between

age the

8–10

years

old

[15] .

group

by

the

chart

review

and

not

solely

due

to

undetected

difference

in

intact

graft

age

groups

was

not

The

Individual surgeon’s success rate did

age or choice of graft material.

significant.

Kessler

et

al.

examined

tympanoplasty

statistically

to

indicate

that

surgeons

with

more

than

20

years

of

seem

in

209

children

and

reported

a

lower

long-term

success short- groups

outcome

(surgeons 1 and 2) had a higher

success

rate, which

is a

experience

in

the 37

children under 6 years old

( p < 0.05), but

the

rate

that has previously been

reported when

comparing

senior

finding

outcome

was

similar

between

the

different

age

term

Table

5

Table

4

and

post-operative

ABG

per

age

group.

Pre-

and

post-operative

SRT

per

age

group.

Pre-

Age

group

Pre-operative

ABG Post

operative

ABG

p -Value

Age

group

Pre-operative

SRT Post

operative

SRT

p -Value

2–4 5–7

15.7 16.7 21.5 0.16

9.1 9.5

0.04

2–4 5–7

23.3 21.7 25.6

16.7 16.7 18.4

0.02

< 0.001 < 0.001

< 0.001 < 0.001

8–13

11.3 0.24

8–13

p -value

ANOVA

p -value

0.23

0.61

ANOVA

122