Guidelines for Ventricular Tube Insertion in Pediatric Patients
Ventricular tube (VT) insertion is the most common treatment for otitis media with effusion (OME) in pediatric patients, with specific guidelines for optimal timing, technique, and management to reduce complications and improve outcomes.
Indications for VT Tube Insertion
- VT insertion is primarily indicated for children with recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME) 1, 2
- VT insertion is often recommended before cochlear implantation in pediatric cochlear implant candidates with recurrent AOM or chronic OME 1
Risk Factors to Consider Before VT Insertion
- Age is a significant factor, with bimodal risk distribution (highest in infants and adolescents) 3
- Central venous access devices (CVAD) increase risk of complications 3
- Other risk factors include surgical history, malignancy, infection/sepsis, major trauma, immobility, and certain medical conditions (cardiac disease, inflammatory bowel disease, sickle cell disease) 3
- Mechanical ventilation and use of recombinant factor VIIa may increase risk 3
Procedural Guidelines
- For children who can tolerate it, local anesthesia is an effective option with no significant difference in tube extrusion timing compared to general anesthesia 2
- General anesthesia may be preferred for younger children or those unable to cooperate 2
- Full sterile barrier precautions should be used during insertion to prevent infectious complications 4
- Post-procedure radiographic confirmation is recommended to verify proper tube placement 4
Duration of VT Placement
- The retention period of VT should be at least 2 years for optimal outcomes 2
- VT removal at approximately age 7 years might be a viable strategy 2
- Shorter duration of VT retention is associated with significantly higher rates of OME recurrence 2
- For children undergoing cochlear implantation who already have VTs in place, retaining the tube during CI rather than removing it may decrease the incidence of AOM within 6 months after CI 1
Management of Complications
- Common complications include occlusion, infiltration, leaking, and dislodgement 5
- The OME recurrence rate is approximately 29% after first VT insertion 2
- Persistent tympanic membrane perforation occurs in approximately 17% of cases after first insertion 2
- Multiple VT insertions are recommended for patients with recurrent OME 2
- Spontaneous removal of VTs is associated with higher OME recurrence compared to intentional removal 2
- Male sex is significantly associated with higher rates of persistent tympanic membrane perforation 2
Special Considerations
- For children with cancer undergoing major surgery with a history of DVT, pharmacologic antithrombotic prophylaxis is recommended if not contraindicated 3
- Low molecular weight heparin (LMWH) is the preferred agent for thromboprophylaxis in these high-risk cases 3
- Strict protocols for post-insertion care should be implemented to reduce infection risk 4
- VTs should be removed as soon as they are no longer needed, but there is no recommendation for routine replacement on a predetermined schedule 4
Follow-up Recommendations
- Regular monitoring for complications including occlusion, infiltration, and dislodgement 5
- Screening for persistent tympanic membrane perforation after VT extrusion or removal 2
- Monitoring for OME recurrence, particularly in cases of spontaneous tube extrusion 2
- Consider additional VT insertions for patients with recurrent OME, as multiple insertions have shown good safety profiles 2