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Myringotomy

by Karen Schroeder, MS, RD, MEd

Anatomy and Physiology
The ear consists of three main parts: the outer, middle, and inner ear. The outer ear includes the pinna and the ear canal. The pinna is the visible part that we recognize as the ear. It collects sound waves and sends them down the ear canal.

The ear canal carries sound waves to the eardrum, which is a paper-thin layer of tissue separating the outer and middle ear. Sound waves cause the eardrum to vibrate, which in turn vibrates three tiny bones inside the middle ear. The bones pass these vibrations along to the inner ear.

The inner ear translates vibrations into electrical signals. These signals are sent along the auditory nerve to the brain, where they are interpreted as sound. This complex process occurs instantly so that we hear the sounds around us as they happen.

For the eardrum to vibrate properly, the middle ear must contain only air. This air must be at the same level of pressure as air outside the ear. Air enters the middle ear through the Eustachian tube, which runs between the ear and upper throat just behind the nose. When you yawn and hear a pop, your Eustachian tube has just carried an air bubble to your middle ear to equalize the pressure.

Reasons for Procedure
An infection, allergy, mass, or enlarged adenoids can block the Eustachian tube, allowing fluid to collect in the middle ear. Fluid prevents the eardrum from vibrating properly, which may cause hearing loss by blocking the normal transmission of sound through the middle ear. In some instances, the fluid may become infected with bacteria, resulting in a painful condition called otitis media.

A myringotomy is a surgical procedure to remove fluid in the middle ear and reestablish equal air pressure on either side of the eardrum. In many cases, a tube is placed in the ear to drain fluid that collects after surgery. This procedure is also called a tympanostomy or tympanotomy.

Reasons for performing a myringotomy include: draining middle ear fluid that lasts 3-6 months and does not respond to other treatments, restoring hearing loss caused by fluid build-up, preventing delays in speech development due to hearing loss in children, treating ear infections that are not cleared up with antibiotics, testing fluid from the middle ear for bacteria.

Fluid build-up and middle ear infections are common in young children. Symptoms to look for in infants and toddlers include: pulling or scratching at the ear, hearing problems, crying or irritability, fever, vomiting, ear drainage.

Symptoms of fluid build-up and ear infection in older children, adolescents, and adults include: ear pain, feeling of fullness or pressure in the ear, eardrum perforation and drainage, loss of hearing over a three-month period, dizziness or loss of balance, nausea and vomiting, and/or fever.

Treatments
Before considering surgery, doctors try to remove the fluid by recommending lifestyle changes and prescribing medications. If allergies are causing the Eustachian tubes to swell, avoiding known allergens may help. Medications include: antihistamines and steroid nasal sprays to treat allergies, decongestants to treat colds, antibiotics if a bacterial infection is present.

Doctors will often try these medications repeatedly, and for several months, before deciding that a surgical treatment is necessary.

As children grow, their Eustachian tubes tend to drain better, which generally reduces the need for surgery in older children and adults.

When middle ear fluid persists despite non- invasive treatments, a myringotomy is the most common surgery performed. In this procedure, a surgeon makes a small incision in the eardrum to drain the fluid. He or she may also place a tube to prevent the eardrum from immediately closing up and allowing further fluid build-up.

Procedure
In the days leading up to your procedure: Arrange for a ride to and from the surgery. Do not take medications that may thin the blood, such as aspirin, ibuprofen or similar products, without first discussing it with your doctor. Do not eat or drink anything for at least eight hours prior to the surgery.

When you arrive for the procedure an IV line will be placed. In most cases, myringotomies are done under general anesthesia, which will put you to sleep for the duration of the procedure. Your surgeon will use a lighted instrument, called an otoscope, or a microscope, to carefully examine your eardrum and plan the procedure.

Your surgeon will make a small incision in the eardrum using a scalpel or laser. Fluid in the middle ear will be drained through the incision.

In many cases, your surgeon will place a ventilation tube through the incision. This small tube will drain any fluid that collects after surgery and allow air into the middle ear to help dry it out.

If necessary, your surgeon will repeat the procedure on the opposite ear. The entire procedure takes 30-60 minutes. The ear tube usually falls out on its own within several months. The incision in the eardrum will heal itself, so no stitches are required.

Risks and Benefits
After a myringotomy, hearing loss, pain, and pressure caused by the fluid build-up will often be greatly improved. If tubes are placed, they will usually prevent fluid from accumulating again, reducing the risk of recurrent infections.

A myringotomy is considered a low risk procedure, but complications can occur. These include: persistent ear drainage, excessive bleeding, failure of the eardrum to heal properly, permanent hearing loss, injury to surrounding structures including ear canal, Eustachian tube, middle ear bones, and blood vessels, need for repeat surgery, formation of a benign growth, called a cholesteatoma, which may damage surrounding bone and require surgery.

In a myringotomy, or any procedure, you and your doctor must carefully weigh the risks and benefits to determine whether it's the most appropriate treatment choice for you.

After the Procedure
After surgery, you will go to the recovery room for monitoring. Children may be fussy after their procedure. They should be encouraged to eat and drink anything they can tolerate. In the event your child has pain, avoid aspirin; acetaminophen at an age-specific dose will often suffice. If additional pain relief is necessary, your doctor can recommend other options.

Following the procedure, it is normal for some clear or bloody liquid to leak from the ears. This should stop within 2-3 days. If you have ear tubes placed, you may feel popping, clicking, or slight pain when chewing or yawning. These symptoms will go away as the eardrum heals.

To care for your eardrums as they heal: use ear drops as directed for three days; do not get water in your ears until your doctor determines your eardrum has healed on a follow-up examination; if water inadvertently gets in your ear, tell your doctor. When bathing, wear a cap or insert cotton balls coated in Vaseline; if cotton is placed in your ears, change it regularly; ask your doctor about plugs or molds for swimming; do not put anything in your ears other than drops, cotton, or plugs.

You may resume your normal activities as soon as you feel able. Children may return to school the next day. Complete healing should occur within four weeks. Ear tubes usually fall out within 6-24 months; in some cases, additional surgery may be required to remove them.

Call your doctor if you experience: redness, swelling, or excessive bleeding from the ear, a change in color or consistency of the drainage from your ear, drainage that persists for more than three days, ear pain that is not relieved by a non-aspirin pain reliever, worsening hearing, signs of infection, such as fever and chills, headache or dizziness, and/or severe nausea or vomiting.

Sources:

  • Ear infections and earache. American Academy of Otolaryngology, Head and Neck Surgery. Available at: http://www.entnet.org/healthinfo/ears/earache.cfm. Accessed November 3, 2004.
  • Ear tube insertion. US National Library of Medicine. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003015.htm. Accessed October 27, 2004.
  • Hearing impairment. American Academy of Family Physicians. Available at: http://www.kidshealth.org/PageManager.jsp?dn=familydoctor&lic=44&article_set=22591. Accessed November 3, 2004.
  • How the ear works. American Academy of Otolaryngology, Head and Neck Surgery. Available at: http://www.entnet.org/healthinfo/ears/ear.cfm. Accessed November 3, 2004.
  • Myringotomy: A description of the operation and taking care of your child after a myringotomy. Eastern Virginia Medical School, Department of Otolaryngology. Available at: http://www.evmsent.org/ped_ops/myringotomy.html. Accessed October 27, 2004.
  • Myringotomy: ear tube placement for otitis media. College of Physicians and Surgeons, Columbia University at New York-Presbyterian Hospital. Available at: http://entcolumbia.org/eartube.htm. Accessed October 27, 2004.
  • Myringotomy with tube placement. UCSD Otolaryngology. Available at: http://www-surgery.ucsd.edu/ent/PatientInfo/instructions_pet.html. Accessed October 27, 2004.
  • Otitis media (ear infection). National Institute on Deafness and Other Communication Disorders. Available at: http://www.nidcd.nih.gov/health/hearing/otitism.asp. Accessed November 3, 2004.


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