Difference between revisions of "Myringotomy for ear tubes"
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| monitors = Standard ASA monitors | | monitors = Standard ASA monitors | ||
| considerations_preoperative = Assessment of upper respiratory infection | | considerations_preoperative = Assessment of upper respiratory infection | ||
| considerations_intraoperative = | | considerations_intraoperative = Laryngospasm | ||
| considerations_postoperative = Laryngospasm | | considerations_postoperative = Laryngospasm, PONV, emergence delirium | ||
}} | }}'''Myringotomy for ear tubes''' is a commonly performed procedure in pediatrics. The procedure involves placement of tubes within the middle ear to provide better drainage decreasing the risk of otitis media. Indication for the procedure includes recurrent otitis media episodes of six or more in one year, chronic serous otitis media, eustachian tube dysfunction and hearing loss <ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>. The procedure begins with an incision of the tympanic membrane. A tympanostomy tube is placed within the incision allowing for equalization of pressure and drainage of fluid in the middle ear<ref>{{Cite journal|last=Robinson|first=Hal|last2=Engelhardt|first2=Thomas|date=2017-04-19|title=Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives|url=https://www.dovepress.com/ambulatory-anesthetic-care-in-children-undergoing-myringotomy-and-tube-peer-reviewed-fulltext-article-LRA|journal=Local and Regional Anesthesia|language=English|volume=10|pages=41–49|doi=10.2147/LRA.S113591|pmc=PMC5403003|pmid=28458577}}</ref>. | ||
==Preoperative management== | |||
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | |||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
| Line 19: | Line 17: | ||
!Considerations | !Considerations | ||
|- | |- | ||
| | |Pulmonary | ||
|Assess for upper respiratory infection(URI), often patients have brief intervals between URI, if febrile illness is due to otitis media, may proceed with anesthesia. However, if febrile illness with lower respiratory tract infection, patient should not proceed with anesthesia | |Assess for upper respiratory infection(URI), often patients have brief intervals between URI, if febrile illness is due to otitis media, may proceed with anesthesia. However, if febrile illness with lower respiratory tract infection, patient should not proceed with anesthesia | ||
|- | |- | ||
|Other | |Other | ||
|Assess for conductive hearing loss | |Assess for conductive hearing loss | ||
|} | |} | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
* | *Oral [[midazolam]] for anxiety | ||
* | *consider intranasal [[dexmedetomidine]] for anxiety and emergence delirium (alternatively, can administer intraoperatively) | ||
* PO acetaminophen for pain | *PO acetaminophen for pain | ||
== Intraoperative management == | ==Intraoperative management== | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
* Standard ASA monitors | *Standard ASA monitors | ||
* | *Typically, no IV is placed. May consider placing PIV pending patient comorbidities | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
* Mask induction with sevoflurane +/- | *Mask induction with [[sevoflurane]] +/- [[nitrous oxide]] | ||
* Anesthesia mask | *Anesthesia mask kept on for the duration of the procedure | ||
* LMA | **Rarely place LMA (severe obstruction not relieved by oral airway placement), ETT (laryngospasm) | ||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
* Supine with head turned away from surgical site | *Supine with head turned away from surgical site | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
* Maintained on volatile anesthetic | *Maintained on volatile anesthetic via facemask | ||
*Consider intramuscular [[fentanyl]], [[ketorolac]]<ref name=":0">{{Cite journal|last=Stricker|first=Paul A.|last2=Muhly|first2=Wallis T.|last3=Jantzen|first3=Ellen C.|last4=Li|first4=Yue|last5=Jawad|first5=Abbas F.|last6=Long|first6=Alexander S.|last7=Polansky|first7=Marcia|last8=Cook-Sather|first8=Scott D.|date=2017-01|title=Intramuscular Fentanyl and Ketorolac Associated with Superior Pain Control After Pediatric Bilateral Myringotomy and Tube Placement Surgery: A Retrospective Cohort Study|url=https://pubmed.ncbi.nlm.nih.gov/27861435/|journal=Anesthesia and Analgesia|volume=124|issue=1|pages=245–253|doi=10.1213/ANE.0000000000001722|issn=1526-7598|pmid=27861435}}</ref> | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* Emergence delirium | *Emergence delirium common | ||
== Postoperative management == | ==Postoperative management== | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ||
* PACU | *PACU | ||
* Most cases discharged home | *Most cases discharged home | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Minimal post-operative pain | *Minimal post-operative pain, preferably avoiding longer acting opioids | ||
* Multimodal analgesia | *Multimodal analgesia | ||
** If no PIV: | **If no PIV: | ||
*** PO/PR acetaminophen | ***PO/PR [[acetaminophen]] | ||
*** IM | ***IM ketorolac<ref name=":0" /> | ||
*** IM/IN fentanyl | ***IM/IN fentanyl<ref name=":0" /> | ||
** If PIV | **If PIV | ||
*** PO/IV acetaminophen | ***PO/IV acetaminophen | ||
*** IV | ***IV ketorolac | ||
*** IV fentanyl | ***IV fentanyl | ||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
* Laryngospasm | *Laryngospasm | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
{| class="wikitable wikitable-horizontal-scroll" | {| class="wikitable wikitable-horizontal-scroll" | ||
|+ | |+ | ||
! | ! | ||
!Myringotomy | !Myringotomy | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | |Can be performed without IV access | ||
|- | |- | ||
|Position | |Position | ||
| Line 113: | Line 110: | ||
|} | |} | ||
== References == | ==References== | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
<references /> | |||
Latest revision as of 09:49, 27 March 2024
Myringotomy for ear tubes
| Anesthesia type |
General |
|---|---|
| Airway |
Anesthesia mask vs LMA vs ETT |
| Lines and access |
No access vs PIV x 1 |
| Monitors |
Standard ASA monitors |
| Primary anesthetic considerations | |
| Preoperative |
Assessment of upper respiratory infection |
| Intraoperative |
Laryngospasm |
| Postoperative |
Laryngospasm, PONV, emergence delirium |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Myringotomy for ear tubes is a commonly performed procedure in pediatrics. The procedure involves placement of tubes within the middle ear to provide better drainage decreasing the risk of otitis media. Indication for the procedure includes recurrent otitis media episodes of six or more in one year, chronic serous otitis media, eustachian tube dysfunction and hearing loss [1]. The procedure begins with an incision of the tympanic membrane. A tympanostomy tube is placed within the incision allowing for equalization of pressure and drainage of fluid in the middle ear[2].
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Pulmonary | Assess for upper respiratory infection(URI), often patients have brief intervals between URI, if febrile illness is due to otitis media, may proceed with anesthesia. However, if febrile illness with lower respiratory tract infection, patient should not proceed with anesthesia |
| Other | Assess for conductive hearing loss |
Patient preparation and premedication
- Oral midazolam for anxiety
- consider intranasal dexmedetomidine for anxiety and emergence delirium (alternatively, can administer intraoperatively)
- PO acetaminophen for pain
Intraoperative management
Monitoring and access
- Standard ASA monitors
- Typically, no IV is placed. May consider placing PIV pending patient comorbidities
Induction and airway management
- Mask induction with sevoflurane +/- nitrous oxide
- Anesthesia mask kept on for the duration of the procedure
- Rarely place LMA (severe obstruction not relieved by oral airway placement), ETT (laryngospasm)
Positioning
- Supine with head turned away from surgical site
Maintenance and surgical considerations
Emergence
- Emergence delirium common
Postoperative management
Disposition
- PACU
- Most cases discharged home
Pain management
- Minimal post-operative pain, preferably avoiding longer acting opioids
- Multimodal analgesia
- If no PIV:
- PO/PR acetaminophen
- IM ketorolac[3]
- IM/IN fentanyl[3]
- If PIV
- PO/IV acetaminophen
- IV ketorolac
- IV fentanyl
- If no PIV:
Potential complications
- Laryngospasm
Procedure variants
| Myringotomy | |
|---|---|
| Unique considerations | Can be performed without IV access |
| Position | Supine |
| Surgical time | 5-10 minutes |
| EBL | Minimal |
| Postoperative disposition | Home |
| Pain management | Mild, multimodal |
| Potential complications | Laryngospasm |
References
- ↑ Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (Sixth edition ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.
|edition=has extra text (help)CS1 maint: others (link) - ↑ Robinson, Hal; Engelhardt, Thomas (2017-04-19). "Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives". Local and Regional Anesthesia. 10: 41–49. doi:10.2147/LRA.S113591. PMC 5403003. PMID 28458577.CS1 maint: PMC format (link)
- ↑ 3.0 3.1 3.2 Stricker, Paul A.; Muhly, Wallis T.; Jantzen, Ellen C.; Li, Yue; Jawad, Abbas F.; Long, Alexander S.; Polansky, Marcia; Cook-Sather, Scott D. (2017-01). "Intramuscular Fentanyl and Ketorolac Associated with Superior Pain Control After Pediatric Bilateral Myringotomy and Tube Placement Surgery: A Retrospective Cohort Study". Anesthesia and Analgesia. 124 (1): 245–253. doi:10.1213/ANE.0000000000001722. ISSN 1526-7598. PMID 27861435. Check date values in:
|date=(help)
Top contributors: Cornel Chiu, Elena Brandford and Chris Rishel