Posterior vs. Anterior Tympanostomy Tube Placement

Randomized Clinical Trial of Post-operative Outcomes Following Posterior Versus Anterior Tympanostomy Tube Placement

The goal of this randomized clinical trial is to compare the results of ear tube placement in two different parts of the ear drum. The ear drum can be divided into four parts (called quadrants). Ear tubes are usually placed in one section of the ear drum, called the anterior-inferior quadrant. However, tubes can also be placed in another section, called the posterior-inferior quadrant. Ear tubes usually fall out of the ear drum on their own. In most patients, the hole in the ear drum where the tube used to be closes on its own. Sometimes (in about 2% of patients), the hole does not close on its own and might need surgery. We want to study ear tube placement in the posterior-inferior quadrant because surgery to repair a hole in the eardrum is easier in this location.

For this study, children will receive an ear tube in the usual location (anterior-inferior quadrant) in one ear and the new location (posterior-inferior quadrant) in the other ear. Researchers will determine which ear has the new location using random assignment (like flipping a coin). Researchers will collect information about hearing tests, whether there is ear drainage (otorrhea), if the tube is blocked (occluded), and how the ear drum looks for up to 37 months after tube placement. Participants will answer study questions at 2-12 weeks and 6, 12, 18, 24, 30, and 36 months after surgery. These questions will ask about whether tubes have fallen out of the ear drum, whether there is a hole in the ear drum, whether there has been drainage from the ear or other ear symptoms, and whether there have been any visits to the doctor for ear problems.

Researchers will use this information to compare ears with anterior-inferior tube placement and ears with posterior-inferior tube placement to see if there are differences in common complications following tube placement.

Study Overview

• Status: Recruiting
• Conditions: Recurrent Acute Otitis Media; Chronic Otitis Media With Effusion; Otitis Media in Children
• Intervention / Treatment: Device: Tympanostomy tube

Detailed Description

The tympanic membrane can be divided into quadrants: posterior superior, anterior superior, posterior inferior, and anterior inferior. Traditional training dictates that tympanostomy tubes should be placed in the anterior-inferior quadrant, with the thought that this would lead to longer indwelling time in the tympanic membrane, avoidance of damage to the ossicular chain, and prevention of hearing loss due to residual perforation over the round window following tympanostomy tube extrusion. However, more recent work has challenged these assumptions. Notably, there is a 2-16% risk of chronic perforation following tympanostomy tube extrusion, with a proposed annual incidence of more than 40,000 post-tympanostomy tube perforations in the United States each year. While perforations in the posterior tympanic membrane can often be repaired using transcanal approaches, anterior perforations are more likely to require more invasive postauricular or endoaural approaches or canalplasty. To our knowledge, there are no studies reporting outcomes following tympanostomy tube placement in the posterior-inferior quadrant. If this study demonstrates no difference in hearing, tube indwelling time, and sequelae following posterior-inferior placement compared with anterior-inferior, it would allow otolaryngologists greater flexibility to consider patient characteristics such as factors placing them at increased risk for perforation or anatomy of the auditory canal when selecting the section of tympanic membrane in which to place tubes.

Upon completion of screening, patients will be randomized using a random number generator in order to have an equal distribution of left and right ears with tympanostomy tubes placed in the anterior and posterior quadrants. Consented patients will receive an ear tube in the usual location (anterior-inferior) in one ear and a new location (posterior-inferior) in the other ear during surgery. Follow-up will include standard-of-care post-operative visits and may be completed at 2-12 weeks and 5-7 months. Clinicians will examine the child's ears and determine whether otorrhea and occlusion are present. During the visit, audiologists may conduct standard of care ear-specific pure tone average, air-bone gap, and sound field audiometry. At these follow-up visits, otolaryngology providers will complete a form describing the status of the tympanic membrane. This will add <1 minute to the visit. Caregivers will also complete a form asking about the status of their child's tympanostomy tubes and any ear problems their child has experienced since surgery. This will take <5 minutes to complete. Results of audiology testing will be collected from the electronic medical record. Additional follow-up will include administration of the caregiver questions via phone, mail, or REDCap email at 12, 18, 24, 30, and 36 months. If the child has other follow-up clinic visits prior to 37 months post-surgery, the provider form will be completed again during these visits. Further research activities will include viewing medical charts of the included subjects.

• Study Type: Interventional
• Enrollment (Estimated): 386
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Amber D Shaffer, PhD; Phone Number: 412-692-6874; Email: shafferad@upmc.edu
• Study Contact Backup: Name: Marina V Rushchak, BA; Phone Number: 412-692-9879; Email: rushchakmv4@upmc.edu

Study Locations

• United States
  • Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15224
      • Recruiting
      • UPMC Children's Hospital of Pittsburgh
      • Contact: Amber D Shaffer, PhD; Phone Number: 412-692-6874; Email: shafferad@upmc.edu
      • Contact: Marina V Rushchak, BA; Phone Number: 412-692-9879; Email: rushchakmv4@upmc.edu
    • Sewickley, Pennsylvania, United States, 15143
      • Recruiting
      • UPMC Children's Hospital of Pittsburgh North
      • Contact: Amber D Shaffer, PhD; Phone Number: 412-692-6874; Email: shafferad@upmc.edu
      • Contact: Marina V Rushchak, BA; Phone Number: 412-692-9879; Email: rushchakmv4@upmc.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Ages 6 months -14 years
2. Bilateral tympanostomy tube placement
3. First tympanostomy tubes placement
4. Indication for tympanostomy tube placement is otitis media

Exclusion Criteria:

1. Undergoing tympanostomy tube placement for indication other than otitis media
2. Receiving tubes other than Armstrong grommet.
3. Genetic disorder that impacts the craniofacial structure, immune system, or mucosal secretions such as Downs syndrome, Stickler syndrome, Treacher Collins syndrome, other genetic disorder associated with craniofacial anomalies, Severe Combined Immunodeficiency disorder, Cystic Fibrosis, or Primary Ciliary Dyskinesia
4. Patients with craniofacial abnormalities other than plagiocephaly or submucous cleft palate (SMCP)
5. Caregivers who cannot speak, read, or write in English proficiently
6. Prior or current otologic surgery other than tympanostomy tube placement
7. On systemic corticosteroids at the time of enrollment
8. Immunodeficiency (acquired or congenital)
9. Current retraction, cholesteatoma, or middle ear mass
10. Atresia
11. Sensorineural hearing loss
12. Known ossicular chain anomaly

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Posterior Tympanostomy Tube Left; Patients in whom the left ear is randomized to receive a tympanostomy tube in the posterior-inferior quadrant (new location).	Device: Tympanostomy tube; Participants will receive an ear tube in the usual location (anterior-inferior) in one ear and a new location (posterior-inferior) in the other ear during surgery.; Other Names: Myringotomy with tubes; pressure equalization tubes; ventilation tubes
Experimental: Posterior Tympanostomy Tube Right; Patients in whom the right ear is randomized to receive a tympanostomy tube in the posterior-inferior quadrant (new location).	Device: Tympanostomy tube; Participants will receive an ear tube in the usual location (anterior-inferior) in one ear and a new location (posterior-inferior) in the other ear during surgery.; Other Names: Myringotomy with tubes; pressure equalization tubes; ventilation tubes

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Perforation	Percentage of ears with persistent (>3 month) perforation of the tympanic membrane	Within 36 months +/- 30 days following tympanostomy tube placement

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Parent-reported otorrhea at 2-12 weeks	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	2-12 weeks following tympanostomy tube placement
Parent-reported otorrhea at 6 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	6 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 2-12 weeks	Percentage of ears with tubes occluded	2-12 weeks following tympanostomy tube placement
Provider-observed tube occlusion at 6 months	Percentage of ears with tubes occluded	6 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 2-12 weeks	Percentage of ears with tympanostomy tubes in place and patent	2-12 weeks following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 6 months	Percentage of ears with tympanostomy tubes in place and patent	6 months±30 days following tympanostomy tube placement
Retained tubes requiring surgical intervention	Percentage of ears requiring surgical tympanostomy tube removal	Within 36 months +/- 30 days following tympanostomy tube placement
Perforation requiring surgical intervention	Percentage of ears with surgical repair of perforation	Within 36 months +/- 30 days following tympanostomy tube placement
Atrophy or retraction at tube site	Percentage of ears with atrophy or retraction at tube site	Within 36 months +/- 30 days following tympanostomy tube placement
Cholesteatoma	Percentage of ears with cholesteatoma	Within 36 months +/- 30 days following tympanostomy tube placement
Hearing loss	Percentage of ears with pure tone average >20 dB or absent otoacoustic emissions	Within 36 months +/- 30 days following tympanostomy tube placement
Tube indwelling time before extrusion	Months from tympanostomy tube placement to extrusion estimated from parent-report and provider observations	Within 36 months +/- 30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 2-12 weeks	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	2-12 weeks following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 6 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	6 months±30 days following tympanostomy tube placement

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Parent-reported otorrhea at 12 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	12 months±30 days following tympanostomy tube placement
Parent-reported otorrhea at 18 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	18 months±30 days following tympanostomy tube placement
Parent-reported otorrhea at 24 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	24 months±30 days following tympanostomy tube placement
Parent-reported otorrhea at 30 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	30 months±30 days following tympanostomy tube placement
Parent-reported otorrhea at 36 months	Percentage of ears with ear drainage most days (67-100%), many days (33-67%), some days (1-33%) or no days (0)	36 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 2-12 weeks	Percentage of ears clogged/blocked	2-12 weeks following tympanostomy tube placement
Parent-reported blockage of tube lumen at 6 months	Percentage of ears clogged/blocked	6 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 12 months	Percentage of ears clogged/blocked	12 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 18 months	Percentage of ears clogged/blocked	18 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 24 months	Percentage of ears clogged/blocked	24 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 30 months	Percentage of ears clogged/blocked	30 months±30 days following tympanostomy tube placement
Parent-reported blockage of tube lumen at 36 months	Percentage of ears clogged/blocked	36 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 2-12 weeks	Percentage of ears with otorrhea observed by provider	2-12 weeks following tympanostomy tube placement
Provider-observed otorrhea at 6 months	Percentage of ears with otorrhea observed by provider	6 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 12 months	Percentage of ears with otorrhea observed by provider	12 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 18 months	Percentage of ears with otorrhea observed by provider	18 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 24 months	Percentage of ears with otorrhea observed by provider	24 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 30 months	Percentage of ears with otorrhea observed by provider	30 months±30 days following tympanostomy tube placement
Provider-observed otorrhea at 36 months	Percentage of ears with otorrhea observed by provider	36 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 12 months	Percentage of ears with tubes occluded	12 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 18 months	Percentage of ears with tubes occluded	18 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 24 months	Percentage of ears with tubes occluded	24 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 30 months	Percentage of ears with tubes occluded	30 months±30 days following tympanostomy tube placement
Provider-observed tube occlusion at 36 months	Percentage of ears with tubes occluded	36 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 12 months	Percentage of ears with tympanostomy tubes in place and patent	12 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 18 months	Percentage of ears with tympanostomy tubes in place and patent	18 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 24 months	Percentage of ears with tympanostomy tubes in place and patent	24 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 30 months	Percentage of ears with tympanostomy tubes in place and patent	30 months±30 days following tympanostomy tube placement
Provider-observed tympanostomy tubes in place and patent at 36 months	Percentage of ears with tympanostomy tubes in place and patent	36 months±30 days following tympanostomy tube placement
Ear-specific pure tone average	Highest (worst) pure tone average of 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz in decibels	Within 36 months +/- 30 days following tympanostomy tube placement
Ear-specific speech-response threshold	Highest (worst) speech-response threshold in decibels	36 months±30 days following tympanostomy tube placement
Ear-specific speech-awareness threshold	Highest (worst) speech-awareness threshold in decibels	Within 36 months +/- 30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 12 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	12 months±30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 18 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	18 months±30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 24 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	24 months±30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 30 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	30 months±30 days following tympanostomy tube placement
Ability to see through lumen and assess tube patency at 36 months	Percentage of ears in which the otolaryngology provider is able to see through lumen and assess tube patency	36 months±30 days following tympanostomy tube placement

Collaborators and Investigators

• Sponsor: David Chi, MD
• Investigators: Principal Investigator: David H Chi, MD, University of Pittsburgh

Publications and helpful links

General Publications

• ALBERTI PW. EPITHELIAL MIGRATION ON THE TYMPANIC MEMBRANE. J Laryngol Otol. 1964 Sep;78:808-30. doi: 10.1017/s0022215100062800. No abstract available.
• O'Donoghue GM. The kinetics of epithelial cells in relation to ventilating tubes. Acta Otolaryngol. 1984 Jul-Aug;98(1-2):105-9. doi: 10.3109/00016488409107541.
• Gibb AG, Mackenzie IJ. The extrusion rate of grommets. Otolaryngol Head Neck Surg. 1985 Dec;93(6):695-9. doi: 10.1177/019459988509300601.
• Kivekas I, Poe D. Is there an optimal location for tympanostomy tube placement? Laryngoscope. 2015 Jul;125(7):1513-4. doi: 10.1002/lary.25127. Epub 2015 Jan 13. No abstract available.
• Mehta RP, Rosowski JJ, Voss SE, O'Neil E, Merchant SN. Determinants of hearing loss in perforations of the tympanic membrane. Otol Neurotol. 2006 Feb;27(2):136-43. doi: 10.1097/01.mao.0000176177.17636.53.
• Stinson WD. Reparative processes in the membrana tympani: some interested manifestations. Arch Otolaryngol. 1936; 24(5): 600-605. doi:10.1001/archotol.1936.00640050613006.

Study record dates

Study Major Dates

• Study Start (Actual): February 29, 2024
• Primary Completion (Estimated): February 1, 2028
• Study Completion (Estimated): February 1, 2028

Study Registration Dates

• First Submitted: December 19, 2023
• First Submitted That Met QC Criteria: January 3, 2024
• First Posted (Actual): January 5, 2024

Study Record Updates

• Last Update Posted (Estimated): March 4, 2024
• Last Update Submitted That Met QC Criteria: February 29, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: Otitis media; Middle ear ventilation
• Additional Relevant MeSH Terms: Otorhinolaryngologic Diseases; Ear Diseases; Otitis; Otitis Media; Otitis Media with Effusion
• Other Study ID Numbers: STUDY22120108

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Individual participant data (IPD) that underlie the results reported in a publication may be shared, after de-identification.
• IPD Sharing Time Frame: Beginning 1 year after publication of summary data. Ending 5 years after publication.
• IPD Sharing Access Criteria: IPD will be shared with researchers who provide a methodologically sound proposal. IPD to be shared will include that necessary to achieve the aims in the approved proposal. Proposals should be directed to shafferad@upmc.edu. To gain access, data requestors will need to sign data access agreement.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes