Chapter 45. Myringotomy and Tympanostomy Tube Insertion

• • Otitis media with effusion (OME) persisting longer than 3 months.

  • Hearing loss > 30 dB in patients with OME.

  • Recurrent episodes of acute otitis media.

  • • More than 3 episodes in 6 months.

    • More than 4 episodes in 12 months.

  • Barotrauma and patients undergoing hyperbaric oxygen therapy.

Absolute

• • Aural atresia.

  • Ectopic or aberrant carotid artery into the middle ear space.

Relative

• • Otitis externa causing stenosis of the external auditory meatus.

  • High-riding jugular bulb into the middle ear space.

  • Mass behind the tympanic membrane.

• • Microscope.

  • Ear speculum.

  • Cerumen curette.

  • Myringotomy knife.

  • Suction cannula (3F, 5F, and 7F) with suction canister and apparatus for cultures.

  • Tympanostomy tube.

  • • For children aged 6 months to 2 years, use short-term ventilation tubes (eg, straight tube, grommet tube, Reuter collar button tube).

    • For children aged 3–5 years with chronic eustachian dysfunction (such as children with cleft palates), use long-term ventilation tubes (eg, T-tubes or large inner-flanged tubes).

  • Alligator forceps.

  • Ear pick.

• • Risks of anesthesia.

  • Bleeding.

  • • Temporary; usually resolves spontaneously within 24 hours.

    • Due to outer ear or ear canal laceration.

    • Due to myringotomy incision.

    • Due to inflamed middle ear mucosa.

  • Otorrhea occurs in approximately 20–30% of patients with tympanostomy tubes.

  • • Postoperative otorrhea (16%): Most likely related to the presence of purulent fluid or inflamed middle ear mucosa.

    • Recurrent otorrhea (7–26%): Usually occurs due to another episode of acute otitis media.

    • Persistent or chronic otorrhea (3.8%): Can occur from reactive inflammation to the tube itself and may require tube removal.

  • Tympanic membrane perforation occurs in 5–15% of patients.

  • • Short-term ventilation tubes: Less than 5%.

    • Long-term ventilation tubes: Higher rate of perforation at approximately 15%.

    • Less than 3% require surgical closure of the perforation.

  • Tube that is retained for longer than 5 years, with or without granuloma formation, can act as a foreign body.

  • • If the patient has chronic unresolving otorrhea or granulation tissue around the tympanostomy tube, it should be removed.

    • Granulation tissue formation occurs in approximately 5% of patients.

  • Medial displacement of the tympanostomy tube (0.5%); not a problem.

  • Myringosclerosis is the submucosal hyaline degeneration in the fibrous layer of the tympanic membrane, resulting in a whitish “plaque.”

  • • Can occur in as many as 30–40% of patients with tympanostomy tubes.

    • In most cases, there is no clinical significance.

  • Other structural changes of the tympanic membrane.

  • • Flaccid tympanic membrane (25%).

    • Retracted tympanic membrane (3.1%).

  • Cholesteatoma.

  • • Occurs in less than 1% of patients.

    • May result from squamous debris being trapped in the middle ear around the tympanostomy tube.

• • Clinicians should use pneumatic otoscopy as the primary method to diagnose OME.

  • During the myringotomy and tube insertion, be careful ...