Spielmann P M, McKee H, Adamson R M, Thiel G, Schenk D, Hussain S S M
Department of Otolaryngology, Raigmore Hospital, Inverness, Aberdeen, Scotland, UK.
J Laryngol Otol. 2008 Jun;122(6):580-3. doi: 10.1017/S0022215107001168. Epub 2007 Nov 30.
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 conceived to identify current practice at our institution (Ninewells Hospital, Dundee) and to inform subsequent change in our follow-up procedure.
Two cycles of data collection and analysis were performed. All paediatric 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 2003-2004. A minimum of 20 months' follow up was allowed for. Data regarding clinical findings and audiometry were recorded at each follow-up appointment.
We identified a total of 50 patients meeting our criteria for inclusion in the first cohort. There were a total of 156 appointments between surgery and data collection (a mean of 3.12 per child). A total of 113 (72 per cent) 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 three 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 per cent) were normal findings and hearing recorded and children given a further review appointment. Sixteen of 29 (55 per cent) children with abnormal clinical findings (otorrhoea, 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 per cent) required further intervention of some sort (p < 0.01).
Our study demonstrated that the vast majority of review appointments resulted in no clinical intervention. We therefore question the need for regular follow up in this patient group. Twenty per cent (10 of 50 and 18 of 84) of our 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. We would recommend one post-operative review with audiometry, three 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. This strategy is dependent on good links with community primary care providers and easy access to secondary care for further management, should this be required.
目前缺乏证据来指导首次接受中耳通气管插入术患者的术后随访。本研究旨在确定我们机构（邓迪的九井医院）的当前做法，并为后续随访程序的改变提供依据。
进行了两个周期的数据收集和分析。确定了所有首次接受通气管插入术的儿科患者。排除先前接受过通气管插入术或其他手术（如腺样体切除术或扁桃体切除术）的患者。第一个数据收集期涵盖2000年全年，第二个数据收集期涵盖2003 - 2004年的18个月。允许至少20个月的随访。每次随访预约时记录临床检查结果和听力测定数据。
我们共确定了50名符合纳入第一队列标准的患者。手术和数据收集之间共有156次预约（平均每名儿童3.12次）。共有113次（72%）预约无需医疗干预。在研究期间需要进一步插入通气管的患者（n = 10）与无需进一步治疗的患者（n = 40）之间，唯一具有统计学显著差异的是平均听力阈值（p < 0.01）。这些发现促使术后方案发生改变；所有接受通气管插入术的患者随后在三个月时进行纯音听力图检查，进一步的复查取决于临床和听力测定结果。确定并收集了第二队列84名儿童的记录，共有154次预约（平均每名儿童1.83次）。仅18次预约（12%）记录了正常的检查结果和听力，并为儿童安排了进一步的复查预约。29名临床检查结果异常（耳漏、通气管堵塞或脱出）的儿童中有16名（55%）需要某种形式的干预（p < 0.05）。26名儿童在首次复查时平均听力阈值超过20 dB。其中19名（73%）需要某种进一步的干预（p < 0.01）。
我们的研究表明，绝大多数复查预约无需临床干预。因此，我们质疑该患者群体定期随访的必要性。我们20%的患者（50名中的10名和84名中的18名）在研究期间需要进一步插入通气管。这与文献报道的发生率一致。临床检查结果异常或平均听力阈值大于20 dB的儿童更有可能需要进一步干预。我们建议在术后三个月进行一次听力测定复查。在这次初次预约时，应向听力差、通气管早期脱出、堵塞或感染的儿童提供进一步复查，因为他们更有可能需要进一步插入通气管。该策略依赖于与社区初级医疗服务提供者的良好联系，以及在需要时能够方便地获得二级医疗服务进行进一步治疗。
