Myringotomy for ear tubes

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	Comprehensive
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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 . 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.

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

• Maintained on volatile anesthetic via facemask
• Consider intramuscular fentanyl, ketorolac

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
    • IM/IN fentanyl
  • If PIV
    • PO/IV acetaminophen
    • IV ketorolac
    • IV fentanyl

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