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Tympanic membrane retraction & atelectasis

Tympanic membrane retraction & atelectasis. The ugly truth!. … in 2 years time?. Better? Same? Worse?. Worse. 2 years later. Cholesteatoma. 2 years later. 2 years later. Same. 6 years later (no treatment). Better. 5 years later (no treatment). Points to debate. Known. Unknown.

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Tympanic membrane retraction & atelectasis

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  1. Tympanic membrane retraction & atelectasis The ugly truth!

  2. … in 2 yearstime? Better? Same? Worse?

  3. Worse 2 years later

  4. Cholesteatoma 2 years later

  5. 2 years later

  6. Same 6 years later (no treatment)

  7. Better 5 years later (no treatment)

  8. Points to debate Known Unknown Prognosis Assessment Severity Adherence Effectiveness of interventions • Potential outcomes • Same • Better • Worse • Risk factors • Age • CL&P • (Contra-lateral disease)

  9. Efficacy of intervention • Natural history • Risk of cholesteatoma • Tube insertion • Cartilage tympanoplasty

  10. What’s the risk of cholesteatoma? Cleft palate • 1 in 20 severe retraction • 1 in 2000 cholesteatoma / yr Estimate: 1 in 100 severe retractions cholesteatoma / year Int J PediatrOtorhinolaryngol 2013 Laryngoscope 2012

  11. Do tubes influence disease progression?

  12. Tubes & the risk of cholesteatoma? Cleft palate • Half life • Tubes 0.6 yr • Sub-annular 3 yr • 1 in 20 severe retraction • 1 in 2000 cholesteatoma / yr Estimate 1 in 100 severe retractions get cholesteatoma / year How many tubes to prevent one cholesteatoma? Saliba et al 2012

  13. Cartilage tympanoplasty 4 years post op

  14. Cartilage tympanoplasty Does it influence disease progression? Cholesteatoma after cartilage tympanoplasty 20 severe atelectasis • Mean FU 3 years • 0 retraction • 1 worse hearing Severe atelectasis Small cholesteatoma

  15. My non-EBM algorithm (2013) • Assessment: • Photo • Audiogram • If low risk & normal hearing • Observe • Consider intervention : • High risk • Hearing loss (NB contralateral ear) • Parental enthusiasm • Likely high risk • Deteriorating retraction • Other risks eg CL&P • Risk of stapes erosion • “Pre-cholesteatoma”

  16. My non-EBM algorithm (2013) • Assessment: • Photo • Audiogram • If low risk & normal hearing • Observe • Consider intervention : • High risk • Hearing loss (NB contralateral ear) • Parental enthusiasm • Likely high risk • Deteriorating retraction • Other risks eg CL&P • Risk of stapes erosion • “Pre-cholesteatoma”

  17. Choice of intervention • Tubes • OME • Not if multiple tubes / rapid extrusion • Sub-annular tubes • OME + multiple tubes / rapid extrusion • High risk • Cartilage tympanoplasty • “Pre-cholesteatoma” • Parents keen on intervention Consider • Insufflation • Hearing aid • Adenoidectomy

  18. BP algorithm / comment

  19. Key messages • Prognosis is uncertain • Treatment efficacy is uncertain • Digital image capture good for monitoring • Remain open-minded: Is one treatment algorithm better than another? Is it better than no treatment? … can you really tell?

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