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2.5: Myringotomy and Ventilation Tube Insertion

  • Page ID
    15437
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    OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

    MYRINGOTOMY WITH VENTILATION TUBE INSERTION

    Tashneem Harris & Thomas Linder


    Ventilation tubes (grommets) are generally inserted for refractory middle ear effusions with persistent conductive hearing loss, present for a minimum duration of 3 months and with hearing loss exceeding 25dB. They may also be inserted as an adjunct procedure in acute mastoiditis secondary to acute suppurative otitis media.

    Preoperative assessment

    • Pneumatic otoscopy to confirm the diagnosis
    • Pure tone audiometry within the preceding 3 months, or age appropriate hearing test, as well as tympanometry
    • A middle ear effusion may be caused by pathology (benign or malignant) in the nasopharynx which causes tubal dysfunction. Therefore, particularly in adult patients the nasopharynx should be examined, and the neck palpated for metastases from a nasopharyngeal malignancy
    • A CSF leak may present as a middle ear effusion. A high index of suspicion is therefore necessary in the presence of a clear serous or watery effusion or when the history is suggestive of a CSF leak.

    Surgical technique

    Temporary ventilation tube insertion

    • General anesthesia is used for children
    • Local anesthesia may be employed with adults. Topical anesthetic spray (e.g. xylocaine) can be applied to the tympanic membrane 10 minutes before the procedure. Alternatively, Emla cream® (lidocaine 2.5% and prilocaine 2.5%) can be applied to the tympanic membrane 30 minutes prior to the procedure, or the deep ear canal may be injected with local anesthesia with a dental needle

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    Figure 1: Ear speculum in place right ear with radial incision placed anteroinferiorly

    • An ear speculum is introduced into the ear canal and held in place with the left hand (Right-handed surgeon) (Figure 1)

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    Figure 2: Typical myringotomy knife

    • Using an operating microscope or endoscope, a radial incision is made in the anteroinferior quadrant around the region of the light reflex with a myringotomy knife (Figures 1 & 2). Incisions in the posterosuperior quadrant are avoided as they can injure the ossicular chain or the chorda tympani. The incision must be large enough to accommodate a ventilation tube.
    • The middle ear effusion may be aspirated with a microsuction tube before inserting the grommet

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    Figure 3: Examples of short stay tubes

    • A ventilation tube is picked up with crocodile forceps and introduced into the ear canal using the right hand (Figure 3)

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    Figure 4: Placement of tube on right tympanic membrane, followed by advancement of tube with a hook

    • The tube is placed on the tympanic membrane adjacent to the myringotomy opening (Figure 4)
    • Using a 1,5 mm, 45° hook the inner flange is rotated through the myringotomy incision so that the tube straddles the tympanic membrane (Figure 4)

    Long-term ventilation tube insertion

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    Figure 5: Example of a T-tube

    For long-term middle ear ventilation, a ventilating T-tube is used (Figure 5). It remains in place for up to 3 years. After extrusion or removal, it results in a chronic perforation of the tympanic membrane in about 16-19% of cases.2, 3

    • The flanges of the T-tube are grasped with crocodile forceps

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    Figure 6: The flanges are both trimmed

    • The flanges are then trimmed so that the ends are pointed; this facilitates insertion of the tube through the myringotomy opening (Figure 6)
    • A myringotomy is made in the anteroinferior quadrant of the tympanic membrane (Figure 1)
    • The T-Tube is grasped with a fine crocodile forceps and the pointed end of the flange is inserted through the myringotomy incision

    Special problem: Ventilation tube falls into middle ear

    • Although tubes are inert and are unlikely to cause damage when left in the middle ear, removal should be attempted because of the potential for foreign body reaction.4
    • If the grommet lies close to and can be seen through the myringotomy incision, then it may be possible to retrieve it using small crocodile forceps, and then reinserted correctly
    • If the tube however lies beyond the confines of the mesotympanum, cannot be seen and removal would be difficult, then one option is to leave it in situ and for the patient to return regularly for surveillance and otomicroscopy4
    • Surgical removal when one has a healed, intact tympanic membrane entails a wide myringotomy and removal of ventilation tube
    • Very rarely an exploratory tympanotomy may be required

    References

    1. Fisch U, May J. Tympanoplasty, Mastoidectomy and Stapes Surgery. New York: Thieme; 1994
    2. Van Heerbeek N, De Saar GM, Mulder JJ. Long term ventilation tubes: results of 726 insertions. Clin Otolaryngol Allied Sci. 2002;27(5): 378-83
    3. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001;124(4):374-80
    4. Rosenfeld RM, Bluestone CD. Evidence Based Otitis Media. 2nd Ed. Hamilton: BC Decker Inc; 2003

    Author

    Tashneem Harris MBChB, FCORL, MMED (Otol), Fisch Instrument Microsurgical Fellow
    ENT Specialist
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    harristasneem@yahoo.com

    Senior Author

    Thomas Linder, M.D. Professor, Chairman and Head of Department of Otorhinolaryngology, Head, Neck and Facial Plastic Surgery
    Lucerne Canton Hospital, Switzerland
    thomas.linder@ksl.ch

    Editor

    Johan Fagan MBChB, FCS(ORL), MMed
    Professor and Chairman
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    johannes.fagan@uct.ac.za