Myringotomy and Ear Tubes Health Article

Description

When a conventional myringotomy is performed, the ear is washed, a small incision made in the eardrum, the fluid sucked out, a tube inserted, and the ear packed with cotton to control bleeding.

Recent developments include the use of medical acupuncture to control pain during the procedure, and the use of carbon dioxide lasers to perform the myringotomy itself. Laser-assisted myringotomy can be performed in a doctor's office with only a local anesthetic. It has several advantages over the older technique: it is less painful; less frightening to children; and minimizes the need for tube insertion because the hole in the eardrum produced by the laser remains open longer than an incision done with a scalpel.

Another technique to keep the incision in the eardrum open without the need for tube insertion is application of a medication called mitomycin C, which was originally developed to treat bladder cancer. The mitomycin prevents the incision from sealing over. As of 2003, however, this approach is still in its experimental stages.

There has also been an effort to design ear tubes that are easier to insert or to remove, and to design tubes that stay in place longer. As of 2003, ear tubes come in various shapes and sizes.

Diagnosis/Preparation

The diagnosis of otitis media is based on the doctor's visual examination of the patient's ear and the patient's symptoms. Patients with otitis media complain of earache and usually have a fever, sometimes as high as 105°F (40.5°C). There may or may not be loss of hearing. Small children may have nausea and vomiting. When the doctor looks in the ear with an otoscope, the patient's eardrum will look swollen and may bulge outward. The doctor can evaluate the presence of fluid in the middle ear either by blowing air into the ear, known as insufflation, or by tympanometry, which is an indirect measurement of the mobility of the eardrum. If the eardrum has already ruptured, there may be a watery, bloody, or pus-streaked discharge.

Fluid removed from the ear can be taken to a laboratory for culture. The most common bacteria that cause otitis media are Pneumococcus, Haemophilus influenzae, and Moraxella catarrhalis. Some cases are caused by viruses, particularly respiratory syncytial virus (RSV).

A child scheduled for a myringotomy should not have food or water for four to six hours before anesthesia. Antibiotics are usually not needed.

If local anesthesia is used, a cream containing lidocaine and prilocaine is applied to the ear canal about 30 minutes before the myringotomy. If medical acupuncture is used for pain control, the acupuncture begins about 40 minutes before surgery and is continued during the procedure.

Aftercare

The use of antimicrobial drops is controversial. Water should be kept out of the ear canal until the eardrum is intact. A doctor should be notified if the tubes fall out.

Risks

The risks include:

• cutting the outer ear
• formation at the myringotomy site of granular nodes due to inflammation
• formation of a mass of skin cells and cholesterol in the middle ear that can grow and damage surrounding bone (cholesteatoma)
• permanent perforation of the eardrum

It is also possible that the incision won't heal properly, leaving a permanent hole in the eardrum. This result can cause some hearing loss and increases the risk of infection.

The ear tube may move inward and get trapped in the middle ear, rather than move out into the external ear, where it either falls out on its own or can be retrieved by a doctor. The exact incidence of tubes moving inward is not known, but it could increase the risk of further episodes of middle-ear inflammation, inflammation of the eardrum or the part of the skull directly behind the ear, formation of a mass in the middle ear, or infection due to the presence of a foreign body.

The surgery may not be a permanent cure. As many as 30% of children undergoing myringotomy with insertion of ear tubes need to undergo another procedure within five years.

The other risks include those associated with sedatives or general anesthesia. Some patients may prefer acupuncture for pain control in order to minimize these risks.

An additional element of postoperative care is the recommendation of many doctors that the child use ear plugs to keep water out of the ear during bathing or swimming to reduce the risk of infection and discharge.

Normal results

Parents often report that children talk better, hear better, are less irritable, sleep better, and behave better after myringotomy with the insertion of ear tubes. Normal results in adults include relief of ear pain and ability to resume flying or deep-sea diving without barotrauma.