Myringotomy and ear tubes

Definition

Myringotomy is a surgical procedure in which a small incision is made in the eardrum (the tympanic membrane), usually in both ears. The English word is derived from myringa, modern Latin for drum membrane, and tome, Greek for cutting. It is also called myringocentesis, tympanotomy, tympanostomy, or paracentesis of the tympanic membrane. Fluid in the middle ear can be drawn out through the incision.

Ear tubes, or tympanostomy tubes, are small tubes open at both ends that are inserted into the incisions in the eardrums during myringotomy. They come in various shapes and sizes and are made of plastic, metal, or both. They are left in place until they fall out by themselves or until they are removed by a doctor.

Purpose

Myringotomy with the insertion of ear tubes is an optional treatment for inflammation of the middle ear
with fluid collection (effusion) that lasts longer than three months (chronic otitis media with effusion) and does not respond to drug treatment. This condition is also called glue ear. Myringotomy is the recommended treatment if the condition lasts four to six months. Effusion refers to the collection of fluid that escapes from blood vessels or the lymphatic system. In this case, the effusion collects in the middle ear.

Initially, acute inflammation of the middle ear with effusion is treated with one or two courses of antibiotics . Antihistamines and decongestants have been used, but they have not been proven effective unless there is also hay fever or some other allergic inflammation that contributes to the problem. Myringotomy with or without the insertion of ear tubes is not recommended for initial treatment of otherwise healthy children with middle ear inflammation with effusion.

In about 10% of children, the effusion lasts for three months or longer, when the disease is considered chronic. In children with chronic disease, systemic steroids may help, but the evidence is not clear, and there are risks.

When medical treatment doesn't stop the effusion after three months in a child who is one to three years old, is otherwise healthy, and has hearing loss in both ears, myringotomy with insertion of ear tubes becomes an option. If the effusion lasts for four to six months, myringotomy with insertion of ear tubes is recommended.

The purpose of myringotomy is to relieve symptoms, to restore hearing, to take a sample of the fluid to examine in the laboratory in order to identify any microorganisms present, or to insert ear tubes.

Ear tubes can be inserted into the incision during myringotomy and left there. The eardrum heals around them, securing them in place. They usually fall out on their own in six to 12 months or are removed by a doctor.

While the tubes are in place, they keep the incision from closing, keeping a channel open between the middle ear and the outer ear. This allows fresh air to reach the middle ear, allowing fluid to drain out, and preventing pressure from building up in the middle ear. The patient's hearing returns to normal immediately and the risk of recurrence diminishes.

Demographics

In the United States, myringotomy and tube placement have become a mainstay of treatment for recurrent otitis media in children. An article published in the March 1998 Consumer Reports stated that the " … number of myringotomies has risen nearly 250 percent in recent years, making the operation the sixth most common operation in the United States." According to the New York University School of Medicine, myringotomy and tube placement is the most common surgical procedure performed in children as of 2003, largely because otitis media is the most common reason for children to be taken to a doctor's office.

Myringotomy in adults is a less common procedure than in children, primarily because adults benefit from certain changes in the anatomy of the middle ear that occur after childhood. In particular, the adult ear is less likely to accumulate fluid because the Eustachian tube, which connects the middle ear to the throat area, lies at about a 45-degree angle from the horizontal. This relatively steep angle means that the force of gravity helps to keep fluids from the throat containing disease organisms out of the middle ear. In children, however, the Eustachian tube is only about 10 degrees above the horizontal, which makes it relatively easy for disease organisms to migrate from the nose and throat into the inner ear. Myringotomies in adults are usually performed as a result of barotrauma that is also known as pressure-related ear pain or barotitis media. Barotrauma refers to earache caused by unequal air pressure on the inside and outside of the eardrum. Adults with very narrow Eustachian tubes may experience barotrauma in relation to scuba diving, using elevators, or frequent flying. A myringotomy with tube insertion may be performed if the condition is not helped by decongestants or antibiotics.

Most myringotomies in children are performed in children between one and two years of age. One Canadian study found that the number of myringotomies performed was 12.8 per thousand for children 11 months old or younger; 54.2 per thousand for children between 12 and 23 months old; and 11.1 per thousand for children between three and 15 years old. Sex and race do not appear to affect the number of myringotomies in any age group, although boys are reported to have a slightly higher rate of ear infections than girls.

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.

Morbidity and mortality rates

Morbidity following myringotomy usually takes the form of either otorrhea, which is a persistent discharge from the ear, or changes in the size or texture of the eardrum. The risk of otorrhea is about 13%. If the procedure is repeated, the eardrum may shrink, retract, or become flaccid. The eardrum may also develop an area of hardened tissue. This condition is known as tympanosclerosis. The risk of hardening is 51%; its effects on hearing aren't known, but they appear to be insignificant.

A report published in 2002 indicates that morbidity following myringotomy in the United States is highest among children from families of low socioeconomic status. The study found that children from poor urban families had more episodes of otorrhea following tube insertion then children from suburban families. In addition, the episodes of otorrhea in the urban children lasted longer.

Mortality rates are extremely low; case studies of fatalities following myringotomy are rare in the medical literature, and most involve adults.

Alternatives

Preventive measures

There are several lifestyle issues related to high rates of middle ear infection. One of the most serious is parental smoking. One study of the effects of passive smoking on children's health estimated that as many as 165,000 of the myringotomies performed each year on American children are related to the use of tobacco in the household.

Another risk factor is daycare placement. A 1997 study at the University of North Carolina found that 31% of the children in a sample of 346 children in daycare required myringotomy with tube insertion as compared to 11% of 63 children cared for at home. In addition, the children in daycare who had ventilation tubes had to have the tubes reinserted three times as often as the children in home care with ventilation tubes.

A third factor that affects a child's risk of recurrent middle ear infection is breastfeeding. Researchers at the University of Arizona reported in 1993 that infants who had been breastfed exclusively for at least four months had significantly fewer middle ear infections as toddlers.

Other surgical approaches

There is some controversy among doctors as to whether removal of the adenoids helps to lower the risk of recurrent ear infections. A 2001 Canadian study reported that removing the child's adenoids at the time of the first insertion of ventilation tubes significantly reduced the likelihood of additional ear operations in children two years of age and older. Other doctors think that adenoidectomy at the time of tube placement should be performed only on children with a large number of risk factors for recurrent otitis media. Most agree that further study of this question is needed.

Alternative medicine

According to Dr. Kenneth Pelletier, former director of the program in complementary and alternative medicine at Stanford University, there is some evidence that homeopathic treatment is effective in reducing the pain of otitis media in children and lowering the risk of recurrence.

Resources

books

"Acute Otitis Media." Section 7, Chapter 84 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Lanternier, Matthew L., MD. "Otolaryngology: Ear Pathology," Chapter 20 in The University of Iowa Family Practice Handbook, 4th edition, edited by Mark Graber, MD, and Matthew L. Lanternier, MD. St. Louis, MO: Mosby, 2001.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II: CAM Therapies for Specific Conditions: Otitis Media. New York: Simon & Schuster, 2002.

periodicals

Ah-Tye, C., J. L. Paradise, and D. K. Colborn. "Otorrhea in Young Children After Tympanostomy-Tube Placement for Persistent Middle-Ear Effusion: Prevalence, Incidence, and Duration." Pediatrics 107 (June 2001): 1251–1258.

Coyte, P. C., R. Croxford, W. McIsaac, et al. "The Role of Adjuvant Adenoidectomy and Tonsillectomy in the Outcome of the Insertion of Tympanostomy Tubes." New England Journal of Medicine 344 (April 19, 2001): 1188–1195.

Desai, S. N., J. D. Kellner, and D. Drummond. "Population-Based, Age-Specific Myringotomy with Tympanostomy Tube Insertion Rates in Calgary, Canada." Pediatric Infectious Disease Journal 21 (April 2002): 348–350.

Gates, George A., MD. "Otitis Media—The Pharyngeal Connection." Journal of the American Medical Association 282 (September 8, 1999): 987–999.

Jassir, D., C. A. Buchman, and O. Gomez-Marin. "Safety and Efficacy of Topical Mitomycin C in Myringotomy Patency." Otolaryngology—Head and Neck Surgery 124 (April 2001): 368–373.

Lin, Yuan-Chi, MD. "Acupuncture Anesthesia for a Patient with Complex Congenital Anomalies." Medical Acupuncture 13 (Fall/Winter 2002) [cited February 22, 2003]. <http://www.medicalacupuncture.org/aama_marf/journal/vol13_2/poster3.html>.

Perkins, J. A. "Medical and Surgical Management of Otitis Media in Children." Otolaryngology Clinics of North America 35 (August 2002): 811-825.

Siegel, G. J., and R. K. Chandra. "Laser Office Ventilation of Ears with Insertion of Tubes." Otolaryngology—Head and Neck Surgery 127 (July 2002): 60–66.

organizations

American Academy of Medical Acupuncture (AAMA). 4929 Wilshire Boulevard, Suite 428, Los Angeles, CA 90010. (323) 937-5514. <http://www.medicalacupuncture.org>.

American Academy of Otolaryngology, Head and Neck Surgery, Inc. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. <http://www.entnet.org>.

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. <http://www.aap.org>.

Mary Zoll, PhD
Rebecca Frey, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Myringotomies are performed by family practitioners, pediatricians, and otolaryngologists, who are surgeons who specialize in treating disorders of the ears, nose, and throat.

A conventional myringotomy is usually done in an ambulatory surgical unit under general anesthesia, although some physicians do it in the office with sedation and local anesthesia, especially in older children and adults. In either case, it is considered same-day surgery. Laserassisted myringotomies are usually performed in doctors' offices or outpatient surgery clinics.

QUESTIONS TO ASK THE DOCTOR

• What alternatives to myringotomy might work for my child?
• How can I lower my child's risk of recurrent ear infections?
• Do you perform laser-assisted myringotomies?
• What is your opinion of removing my child's adenoids to lower the risk of future hospitalizations?

Myringotomy and Ear Tubes

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Myringotomy is a surgical procedure in which a small incision is made in the eardrum (the tympanic membrane), usually in both ears. The English word is derived from myringa, modern Latin for drum membrane, and tome, Greek for cutting. It is also called myringocentesis, tympanotomy, tympanostomy, or paracentesis of the tympanic membrane. Fluid in the middle ear can be drawn out through the incision.

Ear tubes, or tympanostomy tubes, are small tubes open at both ends that are inserted into the incisions in the eardrums during myringotomy. They come in various shapes and sizes and are made of plastic, metal, or both. They are left in place until they fall out by themselves or until they are removed by a doctor.

Purpose

Myringotomy with the insertion of ear tubes is an optional treatment for inflammation of the middle ear with fluid collection (effusion) that lasts longer than three months (chronic otitis media with effusion) and does not respond to drug treatment. This condition is also called glue ear. Myringotomy is the recommended treatment if the condition lasts four to six months. Effusion refers to the collection of fluid that escapes from blood vessels or the lymphatic system. In this case, the effusion collects in the middle ear.

Initially, acute inflammation of the middle ear with effusion is treated with one or two courses of antibiotics. Antihistamines and decongestants have been used, but they have not been proven effective unless there is also hay fever or some other allergic inflammation that contributes to the problem. Myringotomy with or without the insertion of ear tubes is not recommended for initial treatment of otherwise healthy children with middle ear inflammation with effusion.

KEY TERMS

Acute otitis media— Inflammation of the middle ear with signs of infection lasting less than three months.

Adenoids— Clusters of lymphoid tissue located in the upper throat above the roof of the mouth. Some doctors think that removal of the adenoids may lower the rate of recurrent otitis media in high-risk children.

Barotrauma— Ear pain caused by unequal air pressure on the inside and outside of the ear drum. Barotrauma, which is also called pressure-related ear pain or barotitis media, is the most common reason for myringotomies in adults.

Chronic otitis media— Inflammation of the middle ear with signs of infection lasting three months or longer.

Effusion— The escape of fluid from blood vessels or the lymphatic system and its collection in a cavity, in this case, the middle ear.

Eustachian tube— A canal that extends from the middle ear to the pharynx.

Insufflation— Blowing air into the ear as a test for the presence of fluid in the middle ear.

Middle ear— The cavity or space between the eardrum and the inner ear. It includes the eardrum, the three little bones (hammer, anvil, and stirrup) that transmit sound to the inner ear, and the Eustachian tube, which connects the inner ear to the nasopharynx (the back of the nose).

Otolaryngologist— A surgeon who specializes in treating disorders of the ears, nose, and throat.

Tympanic membrane— The eardrum. A thin disc of tissue that separates the outer ear from the middle ear.

Tympanostomy tube— Ear tube. A small tube made of metal or plastic that is inserted during myringotomy to ventilate the middle ear.

In about 10% of children, the effusion lasts for three months or longer, when the disease is considered chronic. In children with chronic disease, systemic steroids may help, but the evidence is not clear, and there are risks.

When medical treatment doesn’t stop the effusion after three months in a child who is one to three years old, is otherwise healthy, and has hearing loss in both ears, myringotomy with insertion of ear tubes becomes an option. If the effusion lasts for four to six months, myringotomy with insertion of ear tubes is recommended.

The purpose of myringotomy is to relieve symptoms, to restore hearing, to take a sample of the fluid to examine in the laboratory in order to identify any microorganisms present, or to insert ear tubes.

Ear tubes can be inserted into the incision during myringotomy and left there. The eardrum heals around them, securing them in place. They usually fall out on their own in six to 12 months or are removed by a doctor.

While the tubes are in place, they keep the incision from closing, keeping a channel open between the middle ear and the outer ear. This allows fresh air to reach the middle ear, allowing fluid to drain out, and preventing pressure from building up in the middle ear. The patient’s hearing returns to normal immediately and the risk of recurrence diminishes.

Demographics

In the United States, myringotomy and tube placement have become a mainstay of treatment for recurrent otitis media in children. More than 500,000 procedures are performed annually, making myringotomy the most common pediatric, ambulatory operation performed in the U.S.

Myringotomy in adults is a less common procedure than in children, primarily because adults benefit from certain changes in the anatomy of the middle ear that occur after childhood. In particular, the adult ear is less likely to accumulate fluid because the Eustachian tube, which connects the middle ear to the throat area, lies at about a 45-degree angle from the horizontal. This relatively steep angle means that the force of gravity helps to keep fluids from the throat containing disease organisms out of the middle ear. In children, however, the Eustachian tube is only about 10 degrees above the horizontal, which makes it relatively easy for disease organisms to migrate from the nose and throat into the inner ear. Myringotomies in adults are usually performed as a result of barotrauma, which is also known as pressure-related ear pain or barotitis media. Barotrauma refers to earache caused by unequal air pressure on the inside and outside of the eardrum. Adults with very narrow Eustachian tubes may experience barotrauma in relation to scuba diving, using elevators, or frequent flying. A myringotomy with tube insertion may be performed if the condition is not helped by decongestants or antibiotics.

Most myringotomies in children are performed in children between one to two years of age. One Canadian study found that the number of myringotomies performed was 12.8 per thousand for children 11 months old or younger; 54.2 per thousand for children between 12 and 23 months old; and 11.1 per thousand for children between three and 15 years old. Sex and race do not appear to affect the number of myringotomies in any age group, although boys are reported to have a slightly higher rate of ear infections than girls.

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 2007, however, this approach is still being studied.

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

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Myringotomies are performed by family practitioners, pediatricians, and otolaryngologists, who are surgeons who specialize in treating disorders of the ears, nose, and throat.

A conventional myringotomy is usually done in an ambulatory surgical unit under general anesthesia, although some physicians do it in the office with sedation and local anesthesia, especially in older children and adults. In either case, it is considered same-day surgery. Laser-assisted myringotomies are usually performed in doctors’ offices or outpatient surgery clinics.

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.

Morbidity and mortality rates

Morbidity following myringotomy usually takes the form of either otorrhea, which is a persistent discharge from the ear, or changes in the size or texture of the eardrum. The risk of otorrhea is about 13%. If the procedure is repeated, the eardrum may shrink, retract, or become flaccid. The eardrum may also develop an area of hardened tissue. This condition is known as tympanosclerosis. The risk of hardening is 51%; its effects on hearing aren’t known, but they appear to be insignificant.

QUESTIONS TO ASK THE DOCTOR

• What alternatives to myringotomy might work for my child?
• How can I lower my child’s risk of recurrent ear infections?
• Do you perform laser-assisted myringotomies?
• What is your opinion of removing my child’s adenoids to lower the risk of future hospitalizations?

A report published in 2002 indicates that morbidity following myringotomy in the United States is highest among children from families of low socioeconomic status. The study found that children from poor urban families had more episodes of otorrhea following tube insertion then children from suburban families. In addition, the episodes of otorrhea in the urban children lasted longer.

Mortality rates are extremely low; case studies of fatalities following myringotomy are rare in the medical literature, and most involve adults.

Alternatives

Preventive measures

There are several lifestyle issues related to high rates of middle ear infection. One of the most serious is parental smoking. One study of the effects of passive smoking on children’s health estimated that as many as 165,000 of the myringotomies performed each year on American children are related to the use of tobacco in the household.

Studies have shown that children in daycare have a higher risk of chronic ear infection, and therefore a higher risk of needing myringotomy..

A third factor that affects a child’s risk of recurrent middle ear infection is breastfeeding. Toddlers who were breastfed as infants for at least four months have a lower risk of ear infection than those who were bottlefed.

Other surgical approaches

Because the adenoids may harbor infection, when myringotomy and tube placement fails, adenoidectomy may be performed in order to resolve chronic otitis media.

Alternative medicine

According to Dr. Kenneth Pelletier, former director of the program in complementary and alternative medicine at Stanford University, there is some evidence that homeopathic treatment is effective in reducing the pain of otitis media in children and lowering the risk of recurrence.

Resources

BOOKS

Behrman RE, et al. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders, 2004.

Cummings, CW, et al. Otolayrngology: Head and Neck Surgery. 4th ed. St. Louis: Mosby, 2005.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II: CAM Therapies for Specific Conditions: Otitis Media. New York: Simon & Schuster, 2002.

PERIODICALS

Desai, S. N., J. D. Kellner, and D. Drummond. “Population-Based, Age-Specific Myringotomy with Tympanostomy Tube Insertion Rates in Calgary, Canada.” Pediatric Infectious Disease Journal 21 (April 2002): 348–350.

Lin, Yuan-Chi, MD. “Acupuncture Anesthesia for a Patient with Complex Congenital Anomalies.” Medical Acupuncture 13 (Fall/Winter 2002) [cited February 22, 2003]. http://www.medicalacupuncture.org/aama_marf/journal/voll3_2/poster3.html.

Perkins, J. A. “Medical and Surgical Management of Otitis Media in Children.” Otolaryngology Clinics of North America 35 (August 2002): 811–825.

Siegel, G. J., and R. K. Chandra. “Laser Office Ventilation of Ears with Insertion of Tubes.” Otolaryngology—Head and Neck Surgery 127 (July 2002): 60–66.

ORGANIZATIONS

American Academy of Medical Acupuncture (AAMA). 4929 Wilshire Boulevard, Suite 428, Los Angeles, CA 90010. (323) 937-5514. http://www.medicalacupuncture.org.

American Academy of Otolaryngology, Head and Neck Surgery, Inc. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org.

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. http://www.aap.org.

Mary Zoll, PhD

Rebecca Frey, PhD

Myringotomy and ear tubes

Definition

Myringotomy is a surgical procedure in which a small incision is made in the eardrum (the tympanic membrane), usually in both ears. The word comes from myringa, modern Latin for drum membrane, and tomē, Greek for cutting. It is also called myringocentesis, tympanotomy, tympanostomy, or paracentesis of the tympanic membrane. The doctor can withdraw fluid from the middle ear through the incision.

Ear tubes, or tympanostomy tubes, are small tubes open at both ends that are inserted into the incisions in the eardrums during a myringotomy. The tubes come in various shapes and sizes and are made of plastic, metal, or both. They are left in place until they fall out by themselves or until they are removed by a doctor. Ear tubes are also sometimes called ventilation tubes.

Purpose

Myringotomy with the insertion of ear tubes is an optional treatment for inflammation of the middle ear with fluid collection (effusion), also called glue ear, that lasts more than three months (chronic otitis media with effusion) and does not respond to drug treatment. Myringotomy is the recommended treatment if the condition lasts four to six months. Effusion is the collection of fluid that escapes from blood vessels or the lymphatic system. In this case, the effusion collects in the child's middle ear.

Initially, acute inflammation of the middle ear with effusion is treated with one or two courses of antibiotic drugs. Antihistamines and decongestants have also been used to treat otitis media, but they have not been proven effective unless the child also has hay fever or some other allergic inflammation that contributes to the ear problem. Myringotomy with or without the insertion of ear tubes is not recommended as the initial treatment for otherwise healthy children with middle ear inflammation with effusion.

In about 10 percent of children, the ear effusion lasts for three months or longer; at that point the condition is considered chronic. Systemic steroids may help children with chronic ear infections, but the evidence that these drugs are beneficial is not clear, and there are risks associated with steroid use.

Myringotomy with insertion of ear tubes becomes an option when medical treatment does not stop the effusion after three months in a child who is one to three years old, is otherwise healthy, and has hearing loss in both ears. If the effusion lasts for four to six months, myringotomy with insertion of ear tubes may be recommended. Although doctors in the past sometimes removed the child's tonsils or adenoids to treat recurrent otitis media with effusion, this practice is not recommended as of the early 2000s.

Myringotomy may be performed to relieve the pain and other symptoms of otitis media; to restore the child's hearing; to take a sample of the fluid to examine in the laboratory in order to identify any microorganisms present; or to insert ventilation tubes.

Ear tubes can be inserted into the incision during a myringotomy and left there. The eardrum heals around them, securing them in place. They usually fall out on their own in six to 12 months or are removed by a doctor.

While in place, the tubes keep the incision from closing, forming an open channel between the middle ear and the outer ear. This channel allows fresh air to reach the middle ear, allows fluid to drain out, and prevents pressure from building up in the middle ear. The patient's hearing returns to normal immediately and the risk of recurrence diminishes.

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.

Description

The procedure is usually performed in an ambulatory surgical unit under general anesthesia, although some physicians do it in the office with sedation and local anesthesia, especially in older children. Most primary care physicians prefer to refer children who need a myringotomy and tube placement to an otolaryngologist. 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.

Carbon dioxide lasers may also be used to perform the myringotomy. 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 made with a scalpel. On the other hand, laser-assisted myringotomies have a higher rate of recurrence of infection.

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 the early 2000s, however, this technique is still in its experimental stages.

Some researchers have designed ear tubes that are easier to insert or to remove or that stay in place longer.

Precautions

As of 2004 clinical practice guidelines emphasized the importance of watchful waiting and medical treatment before performing a myringotomy and the importance of distinguishing between children at risk for speech or hearing problems from otitis media from others with chronic ear infections.

Preparation

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

Aftercare

The use of antimicrobial drops after a myringotomy 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.

An additional element of postoperative care is the recommendation by 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.

Risks

The risks of a myringotomy and ear tube placement include the following:

• cutting the outer ear
• formation of granular nodes due to inflammation at the site of the myringotomy
• formation of a cholesteatoma, which is a mass of skin cells and cholesterol in the middle ear that can grow and damage the surrounding bone
• permanent perforation of the eardrum
• hearing loss in late adolescence or early adulthood
• a 13 percent risk of persistent discharge from the ear (otorrhea)

If the procedure is repeated, structural changes in the eardrum can occur, such as loss of tone (flaccidity), shrinkage or retraction, or hardening of a spot on the eardrum (tympanosclerosis). The risk of hardening is 51 percent; its effects on hearing were not known as of 2004, but they are probably insignificant.

It is also possible that the incision will not heal properly, leaving a permanent hole in the eardrum, which can cause some hearing loss and increases the risk of infection.

It is also possible that the ear tube will 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 this possibility 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 percent of children undergoing myringotomy with insertion of ear tubes need to undergo another procedure within five years.

The other risks include the usual risks associated with sedatives or general anesthesia.

Parental concerns

Parental concerns with regard to a myringotomy and tube insertion are usually related to the risks associated with the procedure itself, such as the child's reaction to the anesthetic, the possibility that the procedure will have to be repeated at a later date, and the risk of eventual mild hearing loss. These potential complications against the risks of language delay , possible learning problems, or hearing loss resulting from chronic otitis media.

KEY TERMS

Acute otitis media —Inflammation of the middle ear with signs of infection lasting less than three months.

Chronic otitis media —Inflammation of the middle ear with signs of infection lasting three months or longer.

Effusion —The escape of fluid from blood vessels or the lymphatic system and its collection in a cavity.

Middle ear —The cavity or space between the eardrum and the inner ear. It includes the eardrum, the three little bones (hammer, anvil, and stirrup) that transmit sound to the inner ear, and the eustachian tube, which connects the inner ear to the nasopharynx (the back of the nose).

Tympanic membrane —The eardrum, a thin disc of tissue that separates the outer ear from the middle ear. It can rupture if pressure in the ear is not equalized during airplane ascents and descents.

Tympanostomy tube —An ear tube. A tympanostomy tube is small tube made of metal or plastic that is inserted during myringotomy to ventilate the middle ear.

See also Ear exam with an otoscope; Hearing impairment; Otitis media.

Resources

BOOKS

"Acute Otitis Media." Section 7, Chapter 84 in The Merck Manual of Diagnosis and Therapy. Edited by Mark H. Beers, and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

Lanternier, Matthew L. "Otolaryngology: Ear Pathology." Chapter 20 in The University of Iowa Family Practice Handbook, 4th ed. Edited Mark Graber and Matthew L. Lanternier. St. Louis, MO: Mosby, 2001.

PERIODICALS

Cotter, C. S., and J. R. Kosko. "Effectiveness of Laser-Assisted Myringotomy for Otitis Media in Children." Laryngoscope 114 (March 2004): 486–9.

de Beer, B. A., et al. "Hearing Loss in Young Adults who Had Ventilation Tube Insertion in Childhood." Annals of Otology, Rhinology, and Laryngology 113 (June 2004): 438–44.

d'Eredita, R. "Contact Diode Laser Myringotomy and Mitomycin C in Children." Otolaryngology and Head and Neck Surgery 130 (June 2004): 742–6.

Koopman, J. P., et al. "Laser Myringotomy versus Ventilation Tubes in Children with Otitis Media with Effusion: A Randomized Trial." Laryngoscope 114 (May 2004): 844–9.

Rosenfeld, R. M., et al. "Clinical Practice Guideline: Otitis Media with Effusion." Otolaryngology and Head and Neck Surgery 130, Supplement 5 (May 2004): S95–S118.

ORGANIZATIONS

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org>.

American Academy of Otolaryngology, Head and Neck Surgery Inc. One Prince St., Alexandria, VA 22314–3357. Web site: <www.entnet.org>

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. Web site: <www.aap.org>.

WEB SITES

Jones, Michael, Leslie Wilson, and David Malis. "Otitis Media." eMedicine, September 21, 2004. Available online at <www.emedicine.com/ped/topic1689.htm> (accessed November 30, 2004).

Mary Zoll, PhD

Myringotomy and Ear Tubes

Definition

Myringotomy is a surgical procedure in which a small incision is made in the eardrum (the tympanic membrane), usually in both ears. The word comes from myringa, modern Latin for drum membrane, and tomē, Greek for cutting. It is also called myringocentesis, tympanotomy, tympanostomy, or paracentesis of the tympanic membrane. Fluid in the middle ear can be sucked out through the incision.

Ear tubes, or tympanostomy tubes, are small tubes, open at both ends, that are inserted into the incisions in the eardrums during myringotomy. They come in various shapes and sizes and are made of plastic, metal, or both. They are left in place until they fall out by themselves or until they are removed by a doctor.

Purpose

Myringotomy with the insertion of ear tubes is an optional treatment for inflammation of the middle ear with fluid collection (effusion), also called glue ear, that lasts more than three months (chronic otitis media with effusion) and does not respond to drug treatment. It is the recommended treatment if the condition lasts four to six months. Effusion is the collection of fluid that escapes from blood vessels or the lymphatic system. In this case, the fluid collects in the middle ear.

Initially, acute inflammation of the middle ear with effusion is treated with one or two courses of antibiotics. Antihistamines and decongestants have been used, but they have not been proven effective unless there is also hay fever or some other allergic inflammation that contributes to the problem. Myringotomy with or without the insertion of ear tubes is NOT recommended for initial treatment of otherwise healthy children with middle ear inflammation with effusion.

In about 10% of children, the effusion lasts for three months or longer, when the disease is considered chronic. In children with chronic disease, systemic steroids may help, but the evidence is not clear, and there are risks.

When medical treatment does not stop the effusion after three months in a child who is one to three years old, is otherwise healthy, and has hearing loss in both ears, myringotomy with insertion of ear tubes becomes an option. If the effusion lasts for four to six months, myringotomy with insertion of ear tubes is recommended.

The purpose of myringotomy is to relieve symptoms, to restore hearing, to take a sample of the fluid to examine in the laboratory in order to identify any microorganisms present, or to insert ear tubes.

Ear tubes can be inserted into the incision during myringotomy and left there. The eardrum heals around them, securing them in place. They usually fall out on their own in 6-12 months or are removed by a doctor.

While they are in place, they keep the incision from closing, keeping a channel open between the middle ear and the outer ear. This allows fresh air to reach the middle ear, allowing fluid to drain out, and preventing pressure from building up in the middle ear. The patient's hearing returns to normal immediately and the risk of recurrence diminishes.

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.

Description

The procedure is usually done in an ambulatory surgical unit under general anesthesia, although some physicians do it in the office with sedation and local anesthesia, especially in older children. 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.

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

Preparation

The child may not have food or water for four to six hours before anesthesia. Antibiotics are usually not needed.

Aftercare

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.

The risk of persistent discharge from the ear (otorrhea) is 13%.

If the procedure is repeated, structural changes in the eardrum can occur, such as loss of tone (flaccidity), shrinkage or retraction, or hardening of a spot on the eardrum (typmanosclerosis). The risk of hardening is 51%; its effects on hearing are not known, but they are probably insignificant.

It is possible that the incision will not heal properly, leaving a permanent hole in the eardrum, which can cause some hearing loss and increases the risk of infection.

It is also possible that the ear tube will 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.

An additional element of post-operative care is the recommendation by 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.

KEY TERMS

Acute otitis media— Inflammation of the middle ear with signs of infection lasting less than three months.

Chronic otitis media— Inflammation of the middle ear with signs of infection lasting three months or longer.

Effusion— The escape of fluid from blood vessels or the lymphatic system and its collection in a cavity, in this case, the middle ear.

Middle ear— The cavity or space between the eardrum and the inner ear. It includes the eardrum, the three little bones (hammer, anvil, and stirrup) that transmit sound to the inner ear, and the eustachian tube, which connects the inner ear to the nasopharynx (the back of the nose).

Tympanic membrane— The eardrum. A thin disc of tissue that separates the outer ear from the middle ear.

Tympanostomy tube— Ear tube. A small tube made of metal or plastic that is inserted during myringotomy to ventilate the middle ear.

Resources

BOOKS

Lim, David J., et al., editors. Recent Advances in Otitis Media: Proceedings of the Sixth International Symposium, June 4-8, 1995, Marriott Harbot Beach, Ft. Lauderdale, Florida. Hamilton, Ontario: B. C. Decker Inc., 1996.