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Myringotomy

Myringotomy

Myringotomy is the surgical incision of the tympanic membrane to aspirate fluid from the middle ear. It is performed to drain suppurative or non-suppurative effusions from the middle ear cavity. A ventilation tube, also known as a grommet or pressure-equalizing tympanostomy tube, may also be placed to provide drainage or ventilation in cases of eustachian tube dysfunction. Various materials are used for ventilation tubes, with Teflon or medical-grade silicone being most common due to their biocompatibility. Titanium, gold, or silver oxide-coated tubes are also utilized to inhibit biofilm formation.

Serous Otitis mediaIndications for Myringotomy
  1. Acute suppurative otitis media
    • Severe earache with bulging drum about to perforate.
    • Persistent tympanic membrane retraction causing conductive hearing loss
    • Complications of acute otitis media, such as facial nerve paralysis, labyrinthitis, or meningitis with a bulging tympanic membrane
  2. Recurrent acute otitis media
  3. Otitis media with effusion
  4. Aero-otitis media (to drain fluid and “unlock” the eustachian tube)
  5. Patulous eustachian tube
  6. Atelectatic ear (grommet is often inserted for long-term aeration)
  7. Hemotympanum

Anesthesia for Myringotomy

General anesthesia is routinely used in children and geriatric patients. Otherwise, myringotomy can be performed under local anesthesia or without anesthesia.

Surgical Technique

  1. Clean the external auditory canal of wax and debris.
  2. Always operate under an operating microscope.
  3. The preferred site for ventilation tube insertion is the anteroinferior quadrant (right ear at 5 o’clock, left ear at 7 o’clock) through a circumferential or radial incision. Insertion of the ventilation tube in the posterosuperior quadrant is not recommended due to the risk of ossicular chain damage. For longer retention of ventilation tube, the anterosuperior quadrant is preferred. The type of incision (radial or circumferential) does not affect extrusion rates.

    Dull tympanic membrane Dr Rahul Bagla ENT Textbook

    Image showing all quadrants on the right side tympanic membrane Dr Rahul Bagla ENT Textbook

  4. The incision should penetrate the entire thickness of the tympanic membrane, avoiding injury to the ossicular chain, posterior meatal wall, jugular bulb, or any abnormal vascular structures (e.g., high jugular bulb, aberrant carotid artery, or glomus tympanicum).
  5. Aspiration of middle ear fluid through the incision site before placing the grommet should be avoided, as it may promote biofilm infection and tympanosclerosis (secondary to trauma and bleeding of the tympanic membrane).

Postoperative Care

  1. Topical ear drops at the time of grommet placement reduce the risk of blockage by blood or mucus and the chances of local infection during the early postoperative period.
  2. Avoid swimming and water entry into the ear canal as long as the grommet is in place.
  3. In cases of acute suppurative otitis media, perform daily cleaning of ear discharge from the canal. In serous otitis media, leave a cotton wool wick for 24-48 hours.

Complications

  1. The most common operative complication is displacement of the ventilation tube into the middle ear. Attempts should be made to retrieve the tube, but failure to remove it rarely causes problems due to the inert nature of the grommet.
  2. Infection around the grommet can lead to middle ear infection.
  3. Otorrhea may follow an acute upper respiratory tract infection.
  4. Granulation tissue may develop secondary to infection.
  5. Residual tympanic membrane perforation
  6. Pars tensa atrophy and retraction
  7. Blockage due to blood or secretions
  8. Tympanosclerosis is the most common structural complication

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Learning resources.

  • Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
  • Glasscock-Shambaugh, Textbook of  Surgery of the Ear.
  • Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
  • Rob and smith, Textbook of Operative surgery.
  • P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
  • Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
  • Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck surgery.
  • Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
  • W. Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
  • Salah Mansour, Textbook of Comprehensive and Clinical Anatomy of the Middle Ear.

Author:

Dr Rahul Bagla ENT Textbook

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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