Myringotomy

The term ‘myringotomy’ is a surgery where a tiny incision is made on the eardrum to drain out any fluid or pus that may have accumulated in the middle ear. Before going further, it would be helpful to understand the anatomy of the ear and why myringotomy surgery is needed.

Ear Anatomy

The Eustachian tube is a tube that connects the middle ear (that is the area behind the eardrum) to the nasopharynx. The main functions of the Eustachian tube are ventilation and regulation of air pressure in the middle ear, prevention of fluids entering from the nose and throat into the middle ear and drain off any fluid that might have entered the middle ear.

Anatomy of the Ear

Ear Anatomy

 

The Eustachian tube is generally closed and opens only when we yawn, swallow or talk. In children it also opens with crying. When the tube is open, any fluid in the middle ear drains out. Bacteria or viruses can affect the Eustachian tube causing it to swell thereby preventing it from opening. This can cause fluid to accumulate in the middle ear, especially fluid secreted by the middle ear itself due to a cold. With prolonged blockage of the Eustachian tube, the fluid in the middle ear can become infected causing acute otitis media.

Symptoms of otitis media include fullness in ear, difficulty hearing, ear pain, headache, fever, uneasiness and/or difficulty sleeping. Otitis media occurs mostly in children. If left untreated, otitis media can lead to hearing loss and speech problems. A myringotomy addresses the problem and can prevent hearing and speech disabilities.

Preparation for the Surgery

Usually there is no need for the patient to stay overnight at a hospital or medical center for the procedure to be carried out. An anesthesiologist after checking previous medical history of the patient, monitors him throughout the surgery. In case the operating doctor advices to have prelaboratory studies, then it should be done well in advance.

Since, this kind of surgery is carried out mostly on children, it becomes very necessary to prepare the child mentally as well before the operation. So, if the child is old enough to understand things, it is always better to brief him/her about the entire episode of the operation. This will relieve the child of the anxiety as he/she will be assured that the ear ache will be gone after this.

Nothing is to be consumed at least 6 to 12 hours before the surgery as even a tiny amount of food in the stomach may cause anesthetic complications.

In case, the patient is sick with fever or any other discomfort in the body, the day before or on the day of surgery, the doctor in charge should be consulted. The doctor will be able to advice as to whether to carry on with the surgery or not.

The Procedure

The procedure of myringotomy is an elective procedure that is done only after medications fail to improve the condition.

The patient is first given premedication in order to relax before being taken to the operating room. However, premedication is mostly given to children as they are very anxious and fearful of the surgery.

The procedure begins with administering topical anesthesia, though small children usually need general anesthesia. The anesthesia takes effect within 10-15minutes. Other factors like the cardiac rhythm (EKG) and pulse oximeter are monitored throughout the surgery by the surgical team.

Anesthesia is followed by an incision made on the tympanic membrane or the eardrum as it is commonly called. The fluid from the middle ear is then drained through this incision. A tympanostomy tube made of either synthetic plastic, like silicone or teflone, or metal is inserted through the incision. Ear drops are then instilled followed by plugging the ear canal with a cotton plug. The tube is generally left in place until it falls off on its own, usually within 2-24 months; mostly when the patient does not require it anymore. In case it fails to fall off even after 2 to 3 years, then it needs to be removed surgically. During this time a follow-up is necessary at least every 6 months.

In more recent times, another less invasive procedure is performed called the LAM surgery or Laser Assisted Myringotomy. In this procedure, instead of making an incision, a laser is used to make an aperture. This surgery is a much more convenient method as it can be carried out in an office setting or even on an outpatient basis using only topical anesthesia. This process uses a carbon dioxide laser to make a hole on the tympanic membrane, which is of the exact size that is required. This is then left open for a few weeks. Since at this time the middle ear is well ventilated, it provides quick relief from the pain in otitis media thereby aiding the infection to heal rapidly. If the infection requires more time for healing, the tubes can be easily inserted into the bloodless holes. Research has shown that usage of this treatment reduces the recurrence of pain in the mid ear in most cases.

Risks and complications

Though myringotomy is a very common surgery, certain difficulties may be faced as after effects of it. These could be as listed below:
• Inability to heal the eardrum.
• Ear infection.
• Thickening of the eardrum.
• Tiny pores being formed after the tubes fall off.
• Inability to hear.
• Need for a more grave surgery of the adenoid, tonsil etc.
• Scarring of the eardrum.
• Chronic ear drainage.
• Possible allergic reaction to the tympanostomy tube itself.
However, these side effects are not found in Laser Assisted Myringotomy.

Post Surgery

As soon as the surgery is over, the patient is taken to the recovery room. It takes almost an hour for the patient to completely come out of the anesthetic state. On getting back to normalcy, he/she is discharged home on the same day after giving some advices.

Some patients may become hungry immediately after surgery, but it is advised not to eat instantly as it might induce vomiting due to the reaction with the anesthesia. However, it is completely normal for the patient to vomit once or twice post surgery. In case the patient continues to vomit for quite some time, then the doctor may prescribe some medication to stop it.

Follow-up Care

After about 10-14 days of the surgery a follow up ear check up is recommended in order to check the position and functioning of the ear tubes.

Cortisporin ear drop is usually given to use immediately after the surgery for 3 or 4 days. If the ears continue to drain after that, the ear drops can be continued as per the prescription of the doctor. In case the use of this medication causes severe ear aches or skin rash, it is advisable to discontinue it. It could be substituted with sulfacetamide/prednisolone drops, which is usually used if water accidentally enters the ear, to prevent water contamination. However, it should be kept in mind that before taking this medicine it should be warmed by holding it in the hand for about 5 minutes. It can then be pumped into the ear by pushing the ‘tragus,’ that is, the cartilage tissue located in front of the ear canal.

During the healing period the patient may feel uneasy due to the bloody discharge or discharge of a clear yellowish liquid from the ear, which is quite normal after the surgery. In such cases, cotton may be placed in the ear canal and changed from time to time in order to keep the area dry. If, however, during the immediate post operative period, a continuous drainage of foul smelling fluid is witnessed, the doctor should be consulted.

The doctor usually orders for an audiogram, after the ear has completely healed.

A minor debate as to the protection of the ear, post surgery, against water is prevalent. While conventionally it is believed that the ear should be well protected against water from entering the ear canal, some otolaryngologists believe there is no such need. Conventional medical advice says that since now there is a passage in the middle ear because of the tubes, water might enter there as well, which in turn will cause infection or ear drainage. As opposed to the chlorinated water of the swimming pools, pond or lake water has greater risks of infection. Doctor’s advice is to be taken in such cases.

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