Myringotomy And Ear Tube Insertion: Issues To Consider
Most children have middle-ear infections (otitis media) at some time in their young lives. These infections usually go away, often after treatment with antibiotics.
Some cases, however, are more complicated. Fluid builds up in the middle ear and stays there for months on end. Perhaps the child's hearing gets noticeably worse. Or maybe the ear infection resolves but comes back — over and over.
For these children and those with other ear problems, doctors sometimes recommend a surgical procedure called a myringotomy with tube insertion. During myringotomy, the doctor makes a hole in the eardrum. He or she then drains out fluid from the middle ear. An ear tube (also called a tympanostomy tube) is inserted in the hole to help drain built-up fluid and improve hearing.
As with all surgical procedures, however, myringotomy with tube insertion carries a risk of complications. Doctors must carefully weigh the circumstances of a particular case before deciding whether to recommend surgery. Parents also must balance the potential benefits and risks when making a decision for their child.
If you are a parent facing this decision, here are some basic questions that you may want to explore:
Normally, the middle ear is filled with air that gets there through the eustachian tube (a passageway from the middle ear to the back of the nose). The small amount of fluid produced by the lining of the middle ear drains through the eustachian tube to the throat. An allergy or respiratory infection, such as a cold, sometimes causes too much fluid to be produced and/or makes the lining of the eustachian tube swell. As drainage through the swollen tube becomes more difficult, fluid builds up behind the eardrum, causing hearing loss and creating a fertile climate for infection. If the fluid becomes infected, pressure can build up in the middle ear, causing pain. The excess fluid can interfere with the vibrations of the eardrum and middle ear bones, which are essential for hearing.
Myringotomy with tube insertion usually improves hearing, relieves discomfort and keeps fluid from building up. It also can dramatically reduce the number of ear infections a child has.
A surgeon cuts a small opening in the eardrum and, using suction, removes fluid that has accumulated behind the eardrum. Usually, a small plastic or metal tube (a tympanostomy tube, or pressure-equalization tube) is then inserted through the opening.
Most doctors perform this procedure in the outpatient surgical department of a hospital, where the patient usually is given general anesthesia. With some adults, myringotomy with tube insertion can be done in the doctor's office using a local anesthetic. Regardless of where the procedure is performed, the patient goes home the same day.
A child who undergoes myringotomy can return to normal activities by the next day. Fluid may drain for a day or two after the procedure. Drainage after this time usually means that the ear is infected. Eventually (between six and 18 months) the tympanostomy tubes are pushed out into the ear canal as the eardrum heals.
To prevent infections, some doctors recommend that the child keep water out of his or her ears. This can be done with earplugs or with careful bathing technique. Underwater swimming, diving and jumping into the water may increase the chance of infection if earplugs are not worn. The child should also wear earplugs when taking a shower or bath or when washing hair.
Most middle-ear infections resolve either on their own or with antibiotic treatment. For this reason, doctors typically have established guidelines to follow when considering myringotomy and tube insertion.
The U.S. Agency for Healthcare Research and Quality, the American Association of Family Physicians and the American Academy of Pediatrics all recommend similar guidelines for deciding when surgery and tube insertion is appropriate.
All three organizations recommend that myringotomy be performed when:
- Ear fluid has been present for four to six months in both ears.
- Tests show a significant loss of hearing (20 decibels or more) in both ears.
The guidelines say myringotomy also is an option for children who have had fluid in both ears for three months and have hearing loss in both ears. (Hearing tests are recommended for any child who has had fluid in both ears for at least three months.)
The main benefits are that myringotomy with tube insertion restores hearing and reduces the frequency of ear infections. Some parents say their children are less irritable, sleep better and communicate better after myringotomy, but there are no studies that document these benefits.
As with all surgeries, myringotomy carries a risk of complications. Besides the need to keep water out of the ears after surgery, the most common drawbacks include the following:
- Tympanosclerosis — Studies indicate that tympanosclerosis (scarring of the eardrum) occurs about half of the time after myringotomy. This scarring rarely affects long-term hearing.
- Otorrhea — Otorrhea is a persistent discharge from the ears. The estimated risk in patients who have undergone myringotomy with tube insertion is about 13 percent. Otorrhea clears with antibiotic therapy.
- Need for a repeat procedure — As many as 30 percent of children who have ear tubes inserted need to have the procedure repeated within five years. Most kids outgrow the need for tubes by the ages of 3 to 5.
- Eardrum perforation — Permanent perforation of the eardrum also can occur in about 1 percent of the children. Surgical repair of the perforation can be done after the child has developed adequate eustachian tube function.
Other potential complications, for which the rate is not known, include the risks associated with general anesthesia. In rare cases, the ear tubes do not fall out of the ears naturally over time; instead, the tubes either remain in the eardrums or push inward into the middle ear and must be surgically removed.
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