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

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Myringotomy 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

  • PO midazolam for anxiety
  • IN dexetomidine for anxiety and emergence delirium
  • PO acetaminophen for pain

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • No access may be needed vs PIV x 1

Induction and airway management

  • Mask induction with sevoflurane +/- N2O
  • Anesthesia mask kept on for the duration of the procedure
  • LMA
  • ETT rarely indicated (laryngospasm)

Positioning

  • Supine with head turned away from surgical site

Maintenance and surgical considerations

  • Maintained on volatile anesthetic supplemented with analgesia

Emergence

  • PONV prophylaxis
  • Emergence delirium

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

References

  1. 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)
  2. 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)