Myringotomy &

Tympanotomy Tube Insertion

Dewi Pratiwi

12TH ANNUAL OTOLOGY SCIENTIFIC MEETING

DEFINITION
Myringotomy Tympanostomy tube

Incision in the TM in order to drain effusion May be combined with insertion

of the ME or to provide aeration in case of a tympanostomy tube or
of malfunctioning ET grommet which keeps the
opening patent
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 Bluestone's guidelines for grommet insertion

1. COME not responding to antibiotic medication & has persisted for > 3 months when bilateral or 6 months
when unilateral

RAOM especially when antibiotic prophylaxis fails

2.
•The minimum episode frequency should be 3/4 during previous 6 months / 4 or more attacks during previous year

Recurrent episodes of OME in which duration of each episode does not meet the criteria given for
3. COM but the cumulative duration is considered to be excessive (6 episodes in the previous year)

4. Suppurative complication is present / suspected. It can be identified if myringotomy is performed

ETD even if the patient doesnt have middle ear effusion

5.
• Symptoms are usually fluctuating (dysequilibrium, tinnitus, vertigo, autophony and severe retraction pocket)

6. Otitis barotrauma in order to prevent recurrent episodes

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 Instruments & Equipment
1. Operating microscope or 0-
degree endoscope
2. Ear speculums
3. Alligator forceps 2
4. Myringotomy knife
5. Curved pick (rosen needle) &
right-angled hook for
completion of tube insertion
and orientation
6. 3F, 5F, and 7F micro suctions
to clear middle ear content
and tube orifice
7. Selected tympanostomy
tube(s) 4

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 Operative Risks
• Avoid contact of the canal skin with instruments.
Minor bleeding controlled with topical use of cotton soaked with
1:1000 epinephrine

• Ear canal should be filled with thrombin-soaked

Major bleeding Gelfoam and the head should be slightly raised

• Otorrhea should be treated with antibiotic drops

Infection

• An atrophic tympanic membrane is at risk for

Tympanic membrane perforation perforation

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 Operative Risks
• Rarely, the tube may fall into
the middle ear space
Middle ear • The tube should be removed
tympanostomy through the myringotomy site.
tube If the tube is not retrievable, a
new tube should be placed

Avoiding the • Prevent harm to the ossicular

chain and chorda tympani Endoscopic view of right tympanic
posterosuperior nerve membrane. X, posterior superior quadrant
quadrant and area of the ossicular chain to be
avoided at the time of myringotomy and
tube placement

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TYPE OF TYMPANOSTOMY TUBES

Divided into 2 major categories

1. Short term tubes

(Grommets)
- retained for 6-12 months
- Grommets feature both an
inner and an outer
flange
- the stiffer & larger the (inner)
flange, the longer
the tube stays in

2. Long term tubes (T tubes)

- retained > 12 months
- the longer the length of the
lumen, the longer
the tube will be
retained
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 LOCAL OR GENERAL ANESTHESIA

• General anaesthesia is used for children

• Local anaesthesia may be employed with adults (in selected cases)

Topical anaesthetic 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

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 SURGICAL STEPS: MYRINGOTOMY
1. Performed in the office or operating room
2. Patient is positioned with head turned so that affected head is up
3. Using the operating microscope and appropriately sized ear
speculum or 0-degree endoscope (4.0 mm or 2.7 mm), the ear
canal and tympanic membrane are visualized.
4. Removal of cerumen and squamous epithelium at the time of the
procedure will facilitate access and postoperative care
5. A speculum of a size appropriate for visualizing the TM is placed
into the EAC
6. 70% alcohol solution is used to sterilize the EAC to limit the
culturing of ear canal contaminants
7. With a myringotomy knife small radial incision (2 mm) is made,
avoid postero-superior quadrant, avoid contact with the malleus
handle & not extend to the annulus
8. Culture & sensitivity may be taken at this time from fluid
9. Middle ear fluids is evacuated using suction tip (middle ear fluid is
thickwith saline irrigation) Left Ear
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 a b

After performing the myringotomy, the VT is grasped with very fine crocodile forceps as shown (a)
(The 'wrong' grasp (b) makes the next manoeuvre more difficult.)

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PLACING A GROMMET TYPE TUBE

1. The grommet is introduced into the

ear with a microforceps

2. The leading edge of the inner flange

is slipped beneath the edge of the
myringotomy

3. The rest of the inner flange is

pushed through the incision with a
small hook

4. Antibiotic-steroid drops are applied

when middle ear effusion, infection,
or bleeding is present to treat the
disease process and prevent tube
obstruction
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 Left Myringotomy T-Tube Insertion
using a 2.7mm endoscope

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

The flanges are then trimmed so that the ends are pointed; this facilitates insertion of the tube
through the myringotomy opening

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Operative Challenges in Myringotomy & Tube Placement

 Atelectatic tympanic membrane

 Injection of 0.1 to 0.2 cc of air with a 27-

gauge needle can help aerate the middle
ear and create an area for tube placement

 Stenotic meatus

 Serial dilations of the stenotic meatus with

increasing speculum size can be helpful. In
cases where a small-diameter speculum is
used, the tube can be placed into the medial
ear canal independent of the ear speculum
and then maneuvered to the myringotomy
site. Atelectatic Ear
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 POSTOPERATIVE PERIOD

1. No ear drops are needed if there is no middle ear effusion, purulent

secretions, or bleeding
2. Steroid-fluoroquinolone drops or fluoroquinolone drops alone for 3 days
in patients with serous effusion or bleeding
3. Steroid-fluoroquinolone drops or fluoroquinolone drops alone for up to 10
days in cases with mucoid or purulent effusion
4. Follow up in 1 to 2 weeks if mucoid or purulent effusion is encountered;
otherwise, follow-up can be scheduled up to weeks postoperatively
5. Postoperative audiogram and tympanogram
6. Routine follow-up every 3 to 6 months after initial postoperative visit
7. Water precautions

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 COMPLICATION
• Patients with
 Treated with obstructive sleep
• Treated with • Treated with drops antibiotic-steroid apnea on
antibiotic drops with or hydrogen drops continuous positive
or without steroids peroxide • In persistent airway pressure
• Persistent otorrhea granulation (CPAP)
after culture-based should be • Lowering the
treatment  removed to resolve pressure setting
evaluated for the foreign-body may be helpful
cholesteatoma & reaction
other sources of
middle ear/mastoid Tube Premature
disease Granulation tube
obstruction
(7%) (4%) extrusion
Otorrhea
(4%)
(>20%)

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 COMPLICATION
• Observation, myringoplasty, or
tympanoplasty can be
recommended • Rarely the tube can fall into the
• A small perforation can be middle ear
observed because it is • Tube retrieval should be  Tube replacement or tube
functioning like a ventilation attempted through the removal with
tube  Irreversible
myringotomy site myringoplasty should be
• If retrieval is not possible or the considered
TM has healed, exploratory
tympanotomy with tube retrieval
Myringosclerosis,
should be considered in the
presence of an inflammatory Tympano-
reaction TM tube sclerosis,
TM atrophy
retention
TM perforation
Middle ear > 2-2.5
following years
extrusion
tube (0.5%)
(1-6%)

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 TIPS : PREREQUISITE KNOWLEDGE AND SKILL

1. Know anatomy of the external ear, tympanic membrane & middle ear

2. Practice removal cerumen impaction under microscope then under

endoscope
knowing how to positioning patient under microscope, visualize
ear canal and tympanic membrane

3. Practice grommet insertion in artificial ear model

In ENT, the concept of myringotomy and grommet insertion is
straightforward but junior trainees can find the initial attempts frustrating
Using artificial ear model allows training exercises in
6. grommet insertion and manual dexterity prior to attempting the procedure on
patients
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 ARTIFICIAL EAR MODEL

Constructing the artificial ear. a Plastic drill cover with oblique cut. b Cut end covered with a piece of vinyl glove and in-
serted into a empty Cophenylcaine ® bottle. c Artificial eardrum with a myringotomy knife and grommet inserted. The
angulation of the oblique cut and the depth of insertion of the plastic cylinder end into the bottle may be adjusted to provide
different levels of difficulty for training. d Artificial ear with the pin placed in Blutack at the bottom of the bottle. The
myringotomy may be enlarged to allow the trainee to attempt positioning the grommet on the pin as an additional exercise in
manual dexterity.
THANK YOU