++
An otherwise healthy 2-year-old male child presents with a history of multiple ear infections and hearing loss. He has just completed a course of amoxicillin for a recent ear infection. He has symptoms of a recent acute upper airway infection and still has a runny nose.
+++
PREOPERATIVE CONSIDERATIONS
++
Otitis media with effusion is the most common chronic condition of the ear in children. Children have small eustachian tubes and are unable to clear the mucus secreted in the mastoid and middle ear. Children with Down syndrome and craniofacial anomalies like cleft palate are more prone to develop middle ear infections. Fluid may also develop in the middle ear during an upper respiratory infection.
++
Persistent effusion can cause conductive hearing loss and predispose the child to develop recurrent acute suppurative otitis media.
++
Patients with recent upper respiratory tract infections (URI) are at increased risk for respiratory complications following general anesthesia (desaturations, laryngospasm, or bronchospasm). These can easily be treated with oxygen, positive pressure ventilation, and inhaled bronchodilators. However, some patients may have severe bronchospasm requiring postoperative intubation and intensive care unit admission or postoperative pneumonia. Deciding when to cancel cases is sometimes difficult because of a variety of factors. In general, patients who have only upper airway symptoms, no fever, and no history of pulmonary disease can be taken care of safely, but a discussion should be had with the family and the surgeon evaluating the risks and benefits of proceeding. The risks remain elevated for up to 6 weeks following an acute URI, so the timing of rescheduling a case can also be problematic.
+++
ANESTHETIC MANAGEMENT
++
Use mask induction.
Maintain anesthesia with either a mask or a laryngeal mask airway (LMA).
It may or may not be necessary to place an IV in a healthy child, since this is a short procedure that may take about 10-15 minutes.
Intranasal fentanyl 1-2 μg/kg and rectal acetaminophen 30-40 mg/kg; make sure the next dose of acetaminophen will be given no sooner than 6 hours later.
Nerve block of the auricular branch of the vagus (nerve of Arnold) behind the tragus may be performed with 0.2 mL of 0.25% bupivacaine to manage postoperative pain.
+++
POSTOPERATIVE CONSIDERATIONS
++
Nearly all patients who have had tube placement have occasional episodes of otorrhea through the tube. Patients are discharged home within 1 to 2 hours after the procedure. Tubes can also extrude prematurely, necessitating repeated insertion. Long-term complications from tube placement include persistent perforation after tube extrusion, which may require operative closure; scarring of the tympanic membrane or middle ear structures; and atrophy of the previously incised area of the tympanic membrane. The risk of cholesteatoma is higher in children who have had tubes placed.
++