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Thread: Myringotomy and Insertion of PE Tube pictures - Ear Atlas

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    Default Myringotomy and Insertion of PE Tube pictures - Ear Atlas

    Myringotomy and PE Tubes
    A myringotomy is a surgical opening of the eardrum in an effort to remove fluid or decrease the number of infections of the middle ear. Usually, a small plastic tube--or pressure equalizing tube (PE tube)--is inserted through the opening in order to allow air to get to the middle ear for a prolonged period. It also allows for continued drainage of middle ear fluid. This tube does not impair hearing nor can your child feel it. The tube usually remains in place for an average of 12 months and falls out on its own.

    Water
    Water should not be allowed to enter the ear, since this may cause an infection. Underwater swimming, as well as jumping and diving into the water, is not encouraged. Otherwise swimming is allowed, as long as earplugs are used. If your child does not feel comfortable with earplugs, he or she will be allowed to swim in clean chlorinated pools, or the ocean, without them. Swimming in lake water, which is usually more likely to be contaminated, is discouraged without earplugs. Either earplugs or cotton with Vaseline on it must be used when taking a bath or washing the hair. Also, if your child does get water in his or her ear, he or she might develop drainage from the ear canal and could need treatment with eardrops. Please call your child's doctor if this happens.

    Drainage
    Ear drainage may occur immediately after the procedure or at any time while the tubes are in place. If drainage lasts for more than two days or smells foul, further treatment may be necessary. Your child's doctor or nurse should be contacted for instructions.

    Ear Popping
    Ear popping, cracking, or pain when burping, yawning, or chewing might occur following insertion of the tubes. This will disappear as the ear heals.
    Follow-Up Appointments
    During the follow-up appointment, the position of the tubes will be checked and your child’s hearing may be evaluated. Your child’s ears should be checked every six months by his or her pediatrician or otolaryngologist to determine the position of the tubes and remove them from the ear canal if they have come out of the drum.

    Relevant Anatomy
    The ear is composed of external, middle (tympanic) (malleus, incus, and stapes), and inner (labyrinth) (semicircular canals, vestibule, cochlea) portions. The auricle and external acoustic meatus (or external auditory canal) compose the external ear. The external ear functions to collect and amplify sound, which then gets transmitted to the middle ear. The tympanic cavity (middle ear) extends from the tympanic membrane to the oval window and contains the bony conduction elements of the malleus, incus, and stapes. The primary functionality of the middle ear is that of bony conduction of sound via transference of sound waves in the air collected by the auricle to the fluid of the inner ear. The inner ear, also called the labyrinthine cavity, is essentially formed of the membranous labyrinth encased in the bony osseus labyrinth. The labyrinthine cavity functions to conduct sound to the central nervous system as well as to assist in balance.
    Myringotomy Insertion Tube pictures Atlas attachment.php?s=a216b397706d19a4470d0e4494da8cb5&attachmentid=1861&d=1441390468

    Indications
    The most common indication for ear tube insertion remains persistent (> 3 mo) otitis media with effusion (OME), or serous otitis media (SOM), that does not resolve after 3 months of clinical observation or does not improve with antibiotic therapy. Ear tube insertion promotes drainage of middle ear fluid, which can cause speech and language delay if left untreated for a prolonged period. Middle ear fluid also predisposes to recurrent infections.

    Another indication for ear tube insertion is acute otitis media (AOM) that is refractory to antibiotic therapy. In persons who do not tolerate antibiotic therapy well, ear tube insertion allows egress of middle ear fluid (purulent, serous, mucoid) and permits easy delivery of topical antibiotic drops to the middle ear space.

    Additional indications for prompt ear tube insertion include complications of AOM, such as meningitis, facial nerve palsy, and otomastoiditis. In patients with these complications, ear tubes can help halt tympanic membrane injury (eg, from retraction pockets, which distort the eardrum, and the subtle process of adhesive otitis media, which limits ossicular vibrations and can lead to permanent hearing loss). Prompt insertion of tympanostomy tubes ventilates the middle ear space and prevents further retraction of an eardrum under the negative pressure.

    Expected Outcomes
    Overall, 80% of children requiring ear tubes need 1 set of ear tubes. In children with ear tubes, episodes of otitis media are less frequent and are more readily treated with antibiotic ear drops.

    Paradise's long-term study of a small cohort of children with OME did not show an overall improvement with respect to developmental outcomes in children who received tubes more promptly at age 3 years, regardless of baseline hearing. However, this study did not examine individual improvements or improvements within more handicapped populations.

    In contrast, Maw et al showed a small benefit in language development in children with bilateral OME and hearing loss.

    Preprocedural Planning
    Institutional protocols should be followed regarding verification of the procedure and the patient. An appropriate workup should be carried out, as follows.

    Audiography
    An audiogram is often obtained before the procedure to assess the degree and severity of hearing loss. If a patient reports normal hearing and has a normal audiogram before the procedure, a repeat audiogram after ear tube insertion is not imperative.

    Pneumatic otoscopy and tympanometry
    Pneumatic otoscopy is the primary diagnostic method for otitis media with effusion (OME) and helps distinguish this condition from acute otitis media (AOM). Tympanometry (tympanography) can be done to confirm the diagnosis of OME. In addition to pneumatic otoscopy and tympanometry, skilled examination of the tympanic membrane under a microscope remains the best clinical way to diagnose other types of otitis media.

    Imaging and laboratory studies
    Imaging and laboratory studies are generally helpful for complications of AOM but are not indicated in most chronic cases of OME.

    When computed tomography (CT) of the temporal bone and head is done in the setting of mastoiditis, the images reveal whether the fluid is in the middle ear space and, more important, whether bone destruction within the mastoid region of the temporal bone is present; such destruction leads to expansion of infection into the cranial vault, the meninges, the temporal lobe region of the brain, or the periauricular regions of the pinna and neck or scalp.

    Patient Preparation
    Ear tube insertion is performed with general anesthesia in children and local anesthesia in adults. General anesthesia is induced via mask ventilation. The patient is supine, with the head positioned square to bed and then rotated laterally, with the nose about 30-45º away from vertical.
    Myringotomy Insertion Tube pictures Atlas attachment.php?s=a216b397706d19a4470d0e4494da8cb5&attachmentid=1862&d=1441390519

    Monitoring and Follow-up
    Patients who undergo ear tube placement should be followed every 6–12 months until the tubes have extruded and episodes of otitis media have resolved. Tubes that that do not extrude within 2-3 years should be removed with the patient under general anesthesia.

    Short -Term Tube Placement
    An operating microscope with a 250-mm lens is brought into the field and focused on the external auditory meatus. An oval 4-mm speculum (eg, Gruber type, of a size appropriate for visualizing the tympanic membrane) is placed into the external auditory canal, and the cerumen is removed so that the entire tympanic membrane can be visualized. The anterior half of the eardrum is then visualized, with the tympanic annulus anterior and the umbo posterior.

    A horizontal incision is placed over the region of the middle ear, most commonly in the anteroinferior quadrant. It should be deep enough to incise the eardrum but not so deep that it injures the middle structures. The incision may have to be slightly smaller than the diameter of the tube’s inner flange. The knife incising all layers of the eardrum should be placed in the center of the field of vision to leave sufficient room for visualizing the insertion of the tube.

    If an effusion is present, a 3, 5 or 7 French Baron suction cannula, with or without saline irrigation via an angiographic catheter, is employed. Large (7 French) suction cannulas are essential for removing the thick inspissated fluid that is frequently present in chronic otitis media with effusion (OME).

    An Armstrong beveled grommet tube is introduced by holding the posterior surface of the inner flange with small alligator forceps. The tube is then passed through the speculum to the anterior-inferior canal; the anterior surface of the flange is inserted into the drum. If necessary, insertion is completed with a curved or straight pick. Most tubes can be inserted directly with small alligator forceps.

    Residual effusion or blood is aspirated. Oxymetazoline, normal saline, or otic antibiotic drops are instilled to reduce bleeding and loosen any thickened secretions that were not removed by suction. Often, the external meatus is covered with a cotton ball plug at the end of the procedure

    Long-Term Tube Placement
    T-tubes, being generally longer-lasting than other types, are commonly chosen for long-term placement. Long-term tube placement proceeds in the same manner as short-term tube placement, up through the myringotomy and the placement of the cannula (if necessary).

    The leading flange of the T-tube is held close to the tip with an alligator forceps, then inserted into the myringotomy until the base of the T-tube stem reaches the hole (see the video below). Paparella No. 2 tubes are also helpful.

    References:
    Myringotomy and PE Tubes - University of Chicago Medicine Comer Children's Hospital
    http://emedicine.medscape.com/articl...57-overview#a3











    Last edited by Medical Photos; 09-04-2015 at 06:15 PM.

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