B-ENT, 2016, 12, 131-135

Subannular T-tubes for the treatment of adhesive otitis: how we do it

F. Ciodaro, G. Cammaroto, B. Galletti and F. Galletti
Department of Otorhinolaryngology, University of Messina, Messina, Italy

Key-words. Adhesive otitis media; tympanic drainage; tympanotomy

Abstract. Subannular T-tubes for the treatment of adhesive otitis: how we do it. Objectives: Adhesive otitis is a chronic
otitis media (OM) that consists of the adhesion of the tympanic membrane (TM) to the promontory.
The aim of our study is to evaluate a new way of positioning subannular T-tubes (SATs) in patients affected by adhesive
otitis.
Methodology: This study enrolled 22 patients (average age: 36.7 yo, 2.5 SD; M/F ratio: 14/8) affected by unilateral
chronic adhesive otitis. All of the patients underwent the positioning of a SAT and a Silastic® sheet in the tympanic
cavity. The clinical course was evaluated, considering otoscopic and audiological variations.
Results: In our series, only one case of extrusion of tubes with residual perforation of TM was recorded. Auditory
outcomes were satisfying in 18/22 patients (81.8%).
Conclusions: The proposed addition of a Silastic disk seems to avoid a new adhesion of the tympanic membrane to the
promontory and, therefore, prevents treatment failures. A longer follow-up and a larger case series are needed to prove
the efficacy of this surgical variation. Finally, the positioning of SATs can be considered as a valid and safe procedure
for the treatment of adhesive otitis.

Introduction depression, which can lead to TM retraction.3

Adhesive otitis is a chronic otitis media (OM) that
consists of the adhesion of the tympanic membrane
(TM) to the promontory. Fibrosis of the tympanic
cavity can be found. This pathology may present in
two stages: the fibro-inflammatory phase (the
middle ear contains fibrous tissue with cystic spaces
full of mucus) and the fibro-adhesive phase (the
middle ear contains fibrous tissue and cholesterol
granulomas without cystic spaces). Sadè and Berco
described four stages of TM retraction: stage I
(simple retraction), stage II (retracted TM in contact
with the incus), stage III (middle ear atelectasis)
and stage IV (adhesive otitis).1
Adhesive otitis represents 3% of all chronic
OMs. It can affect patients of different ages but, in
general, it occurs in young adults. This disease is
bilateral in 8-21% of cases.2
Cholesteatoma is an important complication of
adhesive otitis and may originate from the deep
retraction pockets of pars flaccida or tensa of
atelectasic ears.
Tubaric dysfunction seems to be the principle
cause of adhesive otitis and several authors have
investigated this issue.1,2 In particular, an obstruction
of the Eustachian tube causes an endotympanic
Moreover, Sadé underlines the importance of gas
exchange between the middle ear mucosa, endo­
tympanic air and venous blood of mucosal capillars.4
Other factors contribute to TM retraction. Tos et al.
argue that the disaggregation of the fibrous layer of
the TM leads to adhesive otitis.5 Mechanic and
inflammatory mechanisms have been thought to
cause the disaggregation of collagen fibres.5-7
Furthermore, in many cases, the positioning of
transtympanic tubes seems to resolve endotympanic
depression. 8,9
Simonton described a technique that was first
developed by Ersner and Alexander, using sub­
annular tubes (SATs).10,11 This technique allowed a
longer intubation time of the middle ear without
needing to be replaced. Other authors have used
this approach to treat TM adhesion and atelectasis.12-14
The aim of our study is to evaluate the effect of a
new way of positioning SATs in patients affected
by adhesive otitis.
Materials and methods
This study enrolled 22 patients (average age:
36.7 yo, 2.5 SD; M/F ratio: 14/8) affected by uni­
lateral chronic adhesive otitis.
132 F. Ciodaro et al.
The patients were treated between January 2011
and June 2012. The mean follow-up was 25.5 months
(range 24 to 28 months).
All of the patients underwent an otoscopic
examination and audiological evaluation.
The diagnosis of adhesive otitis was obtained on
the basis of otoscopic and audiological findings.
In the present study, the term adhesive otitis
refers to stage IV of the Sade´ classification for TM
retraction. 2
TM was not mobilized by Valsalva’s manoeuvre.
Moreover, Type B tympanograms, absence of
stapedial reflexes and conductive hearing loss were
found in all of the patients.
All of the patients underwent the positioning of a
SAT and a Silastic® sheet in the tympanic cavity.
A Silastic® disk of 6 mm diameter and 0.5 mm
thick with a small hole in the centre was prepared
and a silicon T-Tube (10-12 mm Length- 1.14 mm
Lumen) was inserted through the hole.
The whole system was then positioned.
The procedure was performed using a trans-
canal approach, as follows:
1. Local or general anaesthesia (17/22 patients
underwent general anaesthesia)
2. Creation of the tympanomeatal flap
3. Opening of tympanic cavity
4. Lysing of adhesions in the middle ear
5. Positioning of T-tube and Silastic disk in the
postero-inferior portion of the TM between the
annulus and the bony wall of the middle ear
6. Placement of Gelfoam in the middle ear
7. Closing and packing of external auditory canal
Silastic sheets were placed in contact with the
eardrum and their posterior-superior portion just
beneath the manubrium of malleus.
All of the patients underwent post-operative oral
antibiotic prophylaxis (amoxicillin 500mg every
eight hours for at least seven days).
Finally, the removal of SATs associated with
Silastic was performed surgically.
The clinical course was evaluated, considering
the otoscopic and audiological variations.
An audiological evaluation was carried out
according to the guidelines of the Committee on
Hearing and Equilibrium of the American Academy
of Otolaryngology-Head and Neck Surgery
Foundation, Inc.15 In all of the patients, a 4-frequency
pure tone average (4-PTA) was measured for both
air and bone conduction. Air Bone Gap [ABG;
(airconducted threshold) – (bone-conducted thresh­
old)] was calculated at 500, 1.000, 2.000 and
3.000 Hz.
Pure-tone audiometric tests were performed
using an Amplaid 300 clinical audiometer in a
soundproof room (Amplaid, Biomedical Division
of Amplifon S.p.A, Milan, Italy).
All of the audiological evaluations were carried
out by operators who were not informed of the
surgical procedures that were performed on the
patients. Pre-audiometry otoscopic examinations
were performed by other operators.
The auditory outcome was considered excellent
when the post-operative improvement of ABG was
≥ 30 dB, good when the improvement was 20-
30 dB, sufficient when the improvement was 10-
20 dB and insufficient when the improvement was
≤ 10 dB.
The first audiological and otoscopic evaluations
were performed when the packing of EAC was
removed (between four and six days after surgery).
Further otoscopic and audiological investigations
were done at 10 days, 30 days, one year and two
years after surgery (the median follow-up time was
25.5 months and the range follow-up time was 24-
28 months).
The onset of complications (otorrhoea, extrusions
and replacements of tubes, lumen tube blockage
and perforations of the tympanic membrane) was
also recorded.
This study was approved by the ethics committee
and all of the patients signed an informed consent
form.
Results
Pre-operative ABG was 50-60 dB in six cases
(27.3%), 40-50 dB in 12 cases (54.5%) and 30-
40  dB in four cases (18.2%). The mean improvement
in air-bone gap two years after the treatment was
17.4 dB (range, five to 30 dB). All of the auditory
outcomes are reported in table 1. No intraoperative
complications were recorded. Three days after
surgery, good ventilation of tympanic cavity was
noted in the anterior portion of TM of all of the
patients. This finding was more evident 10 days
after surgery.
On the 30th day, a TM with good ventilation of
the whole TM was found in 14 cases (63.6%). The
other eight patients (36.4%) still presented some
retractions of the posterior portions of TM.
Subannular T-tubes for the treatment of adhesive otitis 133
Table 1
Post-operative hearing results
Auditory Outcome Auditory Outcome
Third Day 10th Day
Excellent 0 0
Good 0 4
Sufficient 14 14
Insufficient 8 4
Two months after surgery, only two cases
(9.09%) presented with otorrhoea. These patients
were successfully treated with antibiotic therapy.
No otoscopic changes were found one year after
surgery and the tubes were still well positioned.
In one patient, the extrusion of the tube with
residual perforation of TM was noted two years
after surgery.
Discussion
Today, treatment planning for adhesive otitis still
remains a controversial issue.
Some studies have reported discordant results
on the efficacy of wall up and wall down mastoi­
dectomies.1,2,7,16 In particular, palisade cartilage
tympanoplasty has been considered a reliable
surgical method in the management of this
patology.18
A valid option could be represented by the use of
SATs, which were introduced several years ago.10,11
SATs were used by O’Hare and Goebel and,
later, by Elluru et al., during tympanoplasty in
patients with Eustachian tube dysfunction, adhesive
OM and chronic OM.19,20
The same type of T-tube was used by Carr and
Robinson, with a modified procedure.21
Daudia et al. used SATs to treat different forms
of chronic OM. The mean duration of ventilation for
tubes was 22 months, the mean improvement in air-
bone gap was 14 dB (range, 14 to 35 dB) and a low
incidence of complications was recorded in their
series.22
Some authors compared SATs with repetitive
transtympanic tubes in paediatric patients: lower
incidence of complications (otorrhoea, extrusions
and replacements of tubes, lumen tube blockage
and perforations of the tympanic membrane) and
better outcomes were shown in patients that were
treated with SATs. These authors opted for the use
of SATs in all cases of adhesive otitis.13
Auditory Outcome Auditory Outcome Auditory Outcome
30th Day First Year Second Year
0 0 0
6 8 8
12 10 10
4 4 4
Moreover Cloutier et al. compared subannular
T-tubes and subannular fluoroplastic tubes in the
treatment of adhesive otitis and atelectasis. Better
outcomes were reported in patients who underwent
the positioning of T-tubes. These authors found that
T-tubes that were inserted in patients affected by
adhesive otitis lasted, an average, 20.7 months. The
same tubes lasted 25.3 months in patients presenting
with atelectasis. Moreover, an average audiometric
gain of 13.7 for pure tone average audiometry was
recorded in their series.14
Furthermore, Jassar stated that SATs outweigh
the benefits when compared with transtympanic
T-tubes, considering the high extrusion rate and
high incidence of complications registered in
patients who were affected by chronic OM.23
Our team opted for the use of SATs for the
treatment of adhesive otitis.
The proposed addition of a Silastic disk seems to
decrease the formation of adhesions between the
TM and promontory. Therefore, it prevents
treatment failures.
In our series, only one patient experienced the
extrusion of a tube with Silastic with a residual
perforation of TM. This was characterized by
minimal and partial disruption of the annulus.
The auditory results were satisfactory, which is
in line with the experience of other authors.14,22
In particular, slightly higher ABG gain was
reported compared to other authors’ series (17 dB
vs 13.4 dB and 14 dB).
Only 4/22 patients (18.18%) did not experience a
satisfying auditory recovery. These patients
presented with the worst post-operative otoscopic
pattern, suggesting an irreversible fibrotic process
and a severe tubaric dysfunction.
In this sense, previous treatment of tubaric
dysfunction with balloon dilatation of Eustachian
tube could help to obtain better post-operative
outcomes in patients who are affected by adhesive
otitis.24
134 F. Ciodaro et al.
However, considering the short follow-up (a
mean of 25 months) of our series, and taking into
account the average duration of T-tubes (30-
36 months), a longer follow-up would be useful to
demonstrate the benefits of the proposed technique
and evaluate the risk of possible complications such
as cholesteatoma.
Conclusions
Despite the promising results, a larger case series is
needed to prove the efficacy of this surgical
variation. Moreover, a longer follow-up is needed
to evaluate auditory outcomes and complications,
especially those related to an eventual migration of
epithelial tissue, as well as the correct timing of
removal.
Furthermore, a multiple-harms paper that com-
pares the effects of myringoplasty with cartilage
graft,25 palisade cartilage tympanoplasty and SATs
may help us to understand how to tailor the gold
standard treatment for adhesive otitis.
However, considering the discordant results and
pitfalls related to tympanoplasties, the positioning
of SAT could be considered a valid, safe and less
invasive procedure for the treatment of adhesive
otitis.
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