Pediatric Otolaryngologic Surgery Swapna K Chandran, Matthew B Hirsch
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1Otology
Chapters
  • Tympanostomy and Tube Placement
    Matthew B Hirsch
  • Repair of the Perforated Tympanic Membrane
    Matthew B Hirsch, Arun K Gadre
  • Repair of Ossicular Chain Abnormalities
    Beth N McNulty, Arun K Gadre
  • Surgical Treatment of Chronic Otitis Media
    Matthew B Hirsch
  • Cochlear Implantation
    Arun K Gadre, Lynzee N Alworth, Katie L Austin
    Paul A Tennant
2

Tympanostomy and Tube PlacementCHAPTER 1

Matthew B Hirsch
 
INTRODUCTION
Tympanostomy with pressure equalization (PE) tube placement is the most common surgical procedure performed under general anesthesia in the United States. The procedure can be performed under topical anesthesia (i.e. phenol) in co-operative adults, but in children, general anesthesia via mask or inhalational agent is the most common anesthetic technique.
Indications for this procedure include chronic otitis media with effusion, recurrent acute otitis media, symptomatic relief of acute otitis media, complicated (i.e. facial nerve paresis, brain abscess, simple mastoiditis) acute otitis media, anticipated hyperbaric oxygen therapy, and Eustachian tube (ET) dysfunction.
Tympanostomy with PE tube placement is indicated for chronic otitis media with effusion when bilateral effusions are present for greater than 3 months despite medical therapy, a unilateral effusion is present for 6 months despite medical therapy, or a hearing loss of 20 dB or greater is demonstrated. If a child has had a prior set of PE tubes placed and again meets these indications, adenoidectomy along with replacement of PE tubes should be strongly considered.
The type of tube chosen depends on the indications for the procedure. Generally, the longer T-tubes remain in place in the tympanic membrane (TM) longer than the shorter grommet-style tubes. Thus, for patients with chronic ET tube dysfunction that is not likely to resolve in the short term, consideration should be made for T-tube placement. PE tubes with wider diameter or bore tend to leave more persistent perforations when they extrude and may result in the need for myringoplasty or tympanoplasty.
There is no set definition of “premature” extrusion of PE tubes, as the length of need varies from patient to patient and among different indications. Generally, the rate of extrusion prior to the cessation of need for ventilation is felt to be about 5%.1
There is no evidence supporting the recommendation to avoid swimming with PE tubes in place. Children in whom we place PE tubes are generally allowed to swim in shallow, chlorinated water but are recommended to avoid swimming in lakes, rivers, etc.
 
DETAILS OF PROCEDURE
  1. General anesthesia is induced via mask. Alternatively, a laryngeal mask airway can be placed or endotracheal intubation can be performed. Intravenous access is rarely required for this procedure, especially in young children less than the age of seven.
  2. The patient's head is rotated away from the side of the operated ear. The largest speculum that can be inserted atraumatically is placed in the external auditory canal (EAC).
  3. The otomicroscope is used to inspect the EAC. A #5 or #7 Frazier tip suction or a cerumen loop is used to gently remove debris (cerumen, desquamated epithelium, etc.) from the EAC to allow the TM to be visualized.
  4. The TM is visualized and a note is made of any abnormalities.
  5. An incision is made with the myringotomy knife in the anterior-inferior quadrant in a location that ensures the tube will be seen on postoperative otoscopic examinations. The incision can be made parallel to the annulus fibrosis or parallel to the radial fibers of the TM (Figs. 1.1A to C).4
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    Figs. 1.1A to C: Demonstration of the steps of tympanostomy tube placement. Care is taken to place the incision in an anterior-inferior location to avoid injury to the ossicles and other middle ear structures. (A) Incision into tympanic membrane; (B) Placement of tube with forceps; (C) Tube in place.
  6. Any middle ear fluid present is suctioned with the #3 or #5 suction. Care is taken to avoid trauma to any middle ear components. If necessary, an inline fluid reservoir can be used to collect middle ear aspirate for culture.
  7. When the middle ear space is free of fluid, the alligator forceps and Rosen needle are used to place the PE tube into the myringotomy and ensure that the inner flange is well-seated. Depending on the tube type, rotation of the tube helps to ensure its position within the TM (Fig. 1.2).
    zoom view
    Fig. 1.2: Adequate placement of a tympanostomy tube in the tympanic membrane.
  8. Ototopical antibiotic drops are instilled in the EAC and the tragal pump maneuver is performed (the tragus is digitally squeezed onto the concha 2–3 times). The speculum is removed, and a cotton ball is placed in the EAC.
REFERENCES
  1. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001;124(4):374–80.