Myringotomy under topical anesthesia with phenol

Myringotomy is a common outpatient surgical procedure. It can be performed under general inhaled anesthesia, but it is usually carried out under local anesthesia by lidocaine infiltration or instillation of different anesthetic agents. We present our experience with myringotomy and tympanic tube placement using topical anesthesia with 88% phenol as an outpatient procedure. We report 55 patients in which we performed 81 treatments. In this series, only two ears (2.47%) did not tolerate the surgical procedure, tube insertion under general anesthesia being necessary in one case. Topical anesthesia with phenol facilitates the outpatient treatment of adult otitis media with effusion.     

Systemische Kortikoidgaben und additive lokale Applikation von Mitomycin oder Dexamethason

BACKGROUND: The purpose of this study was to determine whether systemic glucocorticoid application, in combination with topical mitomycin or dexamethasone, prolongs the patency of a tympanic membrane perforation. METHOD: Bilateral myringotomies were performed on 24 rats. The 48 ears were separated into eight groups. Treatment with combined systemic and topical dexamethasone or mitomycin differed between these groups. After the first 2 weeks, the animals were checked weekly for a total of 12 weeks. RESULTS: A combination of systemic and topical dexamethasone delayed tympanic membrane closure after myringotomy. Perforation size increased in all tympanic membranes treated with mitomycin plus systemic dexamethasone. CONCLUSION: Topical mitomycin plus systemic glucocorticoid may lead to a massive malfunction of tympanic membrane healing.     

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE: To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting. STUDY DESIGN: Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. METHODS: Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. RESULTS: All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements. CONCLUSIONS: The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.     

CO2 laser myringotomy in children with otitis media with effusion

BACKGROUND: The study aimed to evaluate the clinical application of CO2 laser myringotomy in children with otitis media with effusion (OME) under topical anaesthesia in an office setting. METHODS: Laser myringotomy was performed with the CO2 laser Otoscan (OtoLAM) in 54 children (73 ears) with OME. The procedure on the tympanic membrane was performed under topical anaesthesia using Bonain's solution or 10 per cent Xylocaine (lidocaine) solution for 30 minutes before surgery. A circular perforation was created with a power of 15 W, single pulse duration of 200 msec and a scanned area of 1.9 mm in diameter. RESULTS: The mean healing time was 2.51 weeks (range 1-5 weeks). Effusion content was not a predictive prognostic factor for perforation healing time. Perforation location over anterior inferior or posterior inferior quadrants was not a predictive factor for perforation healing time. Xylocaine was the more effective anaesthestic. The OME resolution rate was 73 per cent. CONCLUSION: Laser myringotomy provides intermediate duration middle-ear ventilation. It could be beneficial in selected children with OME.     

Ventilation time of the middle ear in otitis media with effusion (OME) after CO2 laser myringotomy

OBJECTIVE: The aim of this study was to investigate the transtympanic ventilation time, the healing course of the tympanic membrane, the early and late complications, and the recurrence rate of otitis media with effusion (OME) within 6 months after CO2 laser myringotomy with the CO2 laser otoscope Otoscan. STUDY DESIGN: Prospective clinical study. MATERIALS AND METHODS: In this study, laser myringotomy was performed with the CO2 laser otoscope Otoscan in a patient population comprising 81 children (159 ears) with a history of otitis media with effusion (OME) associated with adenoidal and sometimes tonsillar hyperplasia. The procedure on the tympanic membrane was accordingly combined with an adenoidectomy, a CO2 laser tonsillotomy, or a tonsillectomy and therefore performed under insufflation anesthesia. In all ears, approximately 2 mm circular perforations were created in the lower anterior quadrants with a power of 12 to 15 W, a pulse duration of 180 msec, and a scanned area of 2.2 mm in diameter. RESULTS: None of the children showed postoperative impairment of cochleovestibular function such as sensorineural hearing loss or nystagmus. Otomicroscopic and videoendoscopic monitoring documented the closure time and healing pattern of tympanic membrane perforations. The mean closure time was found to be 16.35 days (minimum, 8 days; maximum, 34 days). As a rule, an onion-skin-like membrane of keratinized material was seen in the former myringotomy perforations at the time of closure. At the follow-up 6 months later, the condition of the tympanic membrane of 129 ears (81.1%) could be checked by otomicroscopy and videoendoscopy and the hearing ability by audiometry and tympanometry. The CO2 laser myringotomy sites appeared normal and irritation-free. Two of the tympanic membranes examined (1.6%) showed atrophic scar formation, and 1 (0.8%) had a perforation with a diameter of 0.3 mm. The perforation was seen closed in a control otoscopy 15 months postoperatively. OME recurred in 26.3% of the ears seen intraoperatively with mucous secretion (n = 38) and in 13.5% of the ears with serous secretion (n = 37; P <.05). CONCLUSION: The most important principle in treating OME is ventilation of the tympanic cavity. CO2 laser myringotomy achieves this through a self-healing perforation in which its diameter roughly determines the duration of transtympanic ventilation. Laser myringotomy competes with ventilation tube insertion in the treatment of OME. It may be a useful alternative in the surgical management of secretory otitis media.     

Effects of topical anesthetics on tympanic membrane structure

Summary Topical application of a local anesthetic agent can induce adequate insensibility to pain, and therefore can avoid the use of general anesthesia or invasive infiltration techniques for myringotomy or the insertion of a tympanostomy tube. A comparative study was conducted on a guinea pig animal model to determine the effects of three agents on the structure of the tympanic membrane: 5% tetracaine base dissolved in dimethylsulfoxide (DMSO), pure DMSO, and Bonain's solution. Survival times ranged from 1 day to 3 months. Following removal from the animals, membranes were embedded in Spurr and cut in semithin sections. Signs of mild or severe external otitis were frequent; to avoid non-specific results, infected specimens were not evaluated. Bonain's solution caused loss of the epidermis and mucosal epithelium within 1 day of treatment. The connective tissue layers of the drum were severely hyperplastic after a survival time of 1 month. Tetracaine base in DMSO caused a loss of epithelium and mucosal cells in 3 days. Regeneration started within 7 days and a restitution to integrity was seen after 3 months in drums treated with tetracaine base or DMSO alone.     

Effects of topical anesthetics on tympanic membrane structure

Topical application of a local anesthetic agent can induce adequate insensibility to pain, and therefore can avoid the use of general anesthesia or invasive infiltration techniques for myringotomy or the insertion of a tympanostomy tube. A comparative study was conducted on a guinea pig animal model to determine the effects of three agents on the structure of the tympanic membrane: 5% tetracaine base dissolved in dimethylsulfoxide (DMSO), pure DMSO, and Bonain's solution. Survival times ranged from 1 day to 3 months. Following removal from the animals, membranes were embedded in Spurr and cut in semithin sections. Signs of mild or severe external otitis were frequent; to avoid non-specific results, infected specimens were not evaluated. Bonain's solution caused loss of the epidermis and mucosal epithelium within 1 day of treatment. The connective tissue layers of the drum were severely hyperplastic after a survival time of 1 month. Tetracaine base in DMSO caused a loss of epithelium and mucosal cells in 3 days. Regeneration started within 7 days and a restitution to integrity was seen after 3 months in drums treated with tetracaine base or DMSO alone.     

Effectiveness of laser-assisted myringotomy for otitis media in children

OBJECTIVE: To evaluate the effectiveness of OtoScan CO2 laser-assisted myringotomy (OtoLAM ESC/Sharplan) for acute otitis media and chronic otitis media with effusion (COME) in children. STUDY DESIGN: Retrospective review of 47 children with refractory acute otitis media (RAOM) or COME more than 3 months in duration in a pediatric otolaryngology practice. METHODS: Laser-assisted myringotomy was performed on 47 patients (79 ears) using the OtoLAM device. There were 28 children (ages 0.50-3 years) with RAOM and 19 children (ages 0.58-15 years) with COME. RESULTS: A total of 57.4% of procedures were considered treatment failures. Failures occurred in 53.6% of patients with RAOM on average +/-SD 3.89 +/- 2.16 weeks after the procedure and in 63.2% of patients with COME on average +/-SD 7.25 +/- 5.57 weeks after the procedure. Age, sex, microorganism isolated, myringotomy size, wattage, and laterality did not predict outcome. Ventilation tube insertion was performed in 27 (57.4%) patients. Two patients have persistent tympanic membrane perforations at 2 years. CONCLUSIONS: Laser-assisted myringotomy in children with RAOM and COME was associated with a high incidence of recurrence or persistence of disease and with perforation of the tympanic membrane. Recommendations for use of the OtoLAM should include discussion of high failure rates and the strong likelihood of subsequent ventilation tube insertion. The OtoLAM remains an option for office-based ventilation of the middle ear for families and patients where general anesthesia is a concern.     

Avoidance of postoperative blockage of ventilation tubes

While most of the complications of ventilation tubes are widely described in the literature, little is mentioned about postoperative blockage of these tubes. Generally, this blockage is caused by viscid secretion or a blood clot. This study was conducted to assess the effect of using a vasoconstrictor solution to cover the tympanic membrane after ventilation tube insertion to ensure hemostasis in the immediate postoperative period and to decongest the mucosa of the middle ear and the eustachian tube. Xylometazoline hydrochloride (Otrivin^r? Nasal Drops 0.1% or Pediatric Nasal Drops 0.05%) was introduced into 60 ears in 32 patients undergoing myringotomy and ventilation tube insertion. The control group, consisting of 76 ears in 40 patients, underwent only myringotomy and ventilation tube insertion. In a follow-up period of 3 months, postoperative tube obstruction occurred 10.5% of the patients in the control group. No case of blocked tube occurred in the patients who received xylometazoline.     

Dauer der Paukenbelüftung nach Lasermyringotomie mit dem CO2-Laserotoskop Otoscan®

Background: The most important principle in treating secretory otitis media (SOM) is ventilation of the tympanic cavity. CO₂ laser myringotomy achieves this via a self-healing perforation whose diameter essentially determines the duration of transtympanic ventilation. Patients, methods: In this study, laser myringotomy was performed with the CO₂ laser otoscope Otoscan? in a homogeneous patient collective comprising 81 children (159 ears) suffering from SOM. The tympanic intervention was combined with an adenoidectomy or a CO₂ laser tonsillotomy and therefore performed under general insufflation anesthesia. In all ears, approximately 2 mm circular perforations were created in the lower anterior quadrants with a power of 12–15 W and a pulse duration of 180 ms. Results: None of the children showed postoperative impairment of inner ear function. Otomicroscopic and videoendoscopic monitoring documented the healing process. The mean closure time was found to be 16.35 days (8–34 days). As a rule, an onion-skin-like membrane of keratinized material was seen in the former myringotomy perforations at the time of closure. At the follow-up 6 months later the laser myringotomy sites appeared normal and irritation-free. Two of the tympanic membranes (1.6%) examined showed atrophic scar formation, one (0.8%) a perforation with a diameter of 0.5 mm. In 19 ears (14.7%) there was a recurrence of SOM within the observation period. Conclusions: Laser myringotomy competes with ventilation tube insertion in the treatment of SOM. It may be an useful alternative in the surgical management of secretory otitis media.     

The feasibility of office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion: the duPont Hospital experience.

OBJECTIVE: To determine the feasibility of inserting tympanostomy tubes in children using office-based laser-assisted tympanic membrane fenestration. METHODS AND MATERIALS: Study consisted of a retrospective review of the charts of all children who underwent office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion from July 1, 1998 to August 31, 2000. Tetracaine eardrops were used for topical anesthesia. Fenestration was achieved with the OtoLAM flashscanner laser (ESC Sharplan, Yokneam, Israel). RESULTS: Of the 127 patients (185 ears) who underwent laser-assisted tympanic membrane fenestration, 61 ears underwent tympanostomy tube insertion. Ten ears were treated for otitis media with effusion, 43 for recurrent acute otitis media, and eight for acute otitis media not responding to antibiotics. Fifteen ears had purulent effusion, five had a serous effusion, and 23 had mucoid middle ear fluid. Eighteen ears had no middle ear fluid. At the first follow-up visit, all tested ears had hearing of 20 dB or better. Two children had tubes that were blocked. Blockage occurred in ears that required more than one laser firing to penetrate the tympanic membrane. Otorrhea was present in 13 ears (21%). Otorrhea occurred exclusively in ears with purulent or mucoid middle ear fluid. CONCLUSIONS: Office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion is a safe and effective alternative to tube placement in the operating room. The outcome compares favorably with previously published data.     

Laser myringotomy in different age groups

OBJECTIVE: To study the qualities of laser myringotomy (LM) as a treatment for middle ear ventilation problems. DESIGN: Prospective study and follow-up of consecutive cases of adults, children, and infants. Patients were observed for up to 2 years. SETTING: Children underwent LM, with or without adenoidectomy, under general anesthesia in the operating room. Adults and infants underwent LM under topical anesthesia, as an outpatient procedure. PATIENTS: All consecutive patients with either secretory otitis media (SOM) (adults and children) or acute otitis media (AOM) (infants) who agreed to participate were included without selection. INTERVENTION: Myringotomy was performed using new laser equipment, enabling a 0.1-second ablation with changeable diameter. OUTCOME MEASURES: Close follow-up, with microscopic examination of all ears. Findings were noted on the medical charts. RESULTS: Among all age groups, 136 ears were followed up. Perforation lasted a mean 22 days in adults, 17 days in children, and 11 days in infants. Patient age was found to be a significant determining factor for duration of perforation (P =.002). Laser myringotomy in the anterior and inferior areas lasted longer than posterior LM (P<.001). In patients with SOM, during the time the LM was patent, all ears were ventilated. In children, 38% of SOM cases resolved after a single LM treatment. All infants with AOM recovered promptly without antibiotic treatment. CONCLUSIONS: Laser myringotomy is a convenient, quick procedure that can be performed in the medical office with the use of topical anesthesia and is suitable for patients with AOM or for those who need short-term ventilation for SOM. It was found to be a safe alternative to ventilation tubes in these patients. In AOM, it was used instead of antibiotics and gave prompt relief from symptoms and cure of the AOM.     

Late effects of topical anesthetics on the healing of guinea pig tympanic membranes after myringotomy

BACKGROUND: The optimal local anesthetic for myringotomies or the insertion of tympanostomy tubes in adults should be easy and rapid to use, be painless during application, provide good anesthesia, be reversible, be inexpensive, and not cause any long-term damage to the tympanic membrane (TM). OBJECTIVE: To evaluate the histologic effects of topical anesthetic agents on the healing of the TM after myringotomy. METHODS: Sixty male albino guinea pigs were randomly assigned to 1 of 5 groups. Of the 5 groups, 2 were used as controls: one group underwent a myringotomy and the other group did not. The remaining 3 groups had both TMs treated with a topical anesthetic (phenol, tetracaine base, and eutectic mixture of lidocaine and prilocaine in a cream) prior to myringotomy. All TMs were inspected periodically and then harvested at 3 months or 6 months postoperatively for histologic examination. RESULTS: The TMs of the group treated with tetracaine appeared the most normal at 6 months (P=.001). However, histologic evaluation failed to demonstrate any significant differences in the thickness of the TM or the lamina propria (P=.45), the amount (P=.80) and orientation (P=.07) of collagen, or the number of infiltrating lymphocytes (P=.70). CONCLUSION: Based on the histologic findings, all 3 topical anesthetic agents appear to cause equivalent changes to the TM when used for a myringotomy.     

Office myringotomy and ventilation tube insertion using 10% Xylocaine aerosol

Acquiring adequate, safe and painless local anesthesia of the tympanic membrane for the purpose of myringotomy with or without insertion of a middle ear ventilating tube has been a challenge for the otologist. A simple technique using 10% Xylocaine aerosol has been successfully employed in 74 adults to perform this procedure in the office. No complications or side-effects were encountered. This method not only avoids the pain associated with local infiltration of anesthetics, but has made iontophoresis unnecessary.     

Myringotomy and tube for relief of patulous eustachian tube symptoms

Reports on the effectiveness of myringotomy and tube for treatment of symptoms of the patulous eustachian tube are discouraging, even though there are no large series substantiating its ineffectiveness. To further investigate this problem, we have reviewed the charts of all patients at the Otologic Medical Group (OMG) from 1974 to 1981 with the diagnosis of patulous eustachian tube who underwent myringotomy and tube for their symptoms. We identified 60 ears of 46 patients with complaints consistent with patulous eustachian tube symptoms. The treatment either eliminated or substantially reduced symptoms in 32 ears (53%). For the other 28 ears, myringotomy and tube were of no benefit. Nine of 13 (70%) ears with a definitive diagnosis based on movement of the tympanic membrane with respiration or tympanometry showed relief of symptoms with myringotomy and tube. Myringotomy and tube will remain part of the treatment regimen because it is relatively simple to perform, reversible, and effective in the majority of patients.     

Vitamin e-coated tympanostomy tube insertion decreases the quantity of free radicals in tympanic membrane

OBJECTIVE: Tympanosclerosis is a common sequela of ventilation tube treatment of otitis media with effusion causing hearing disability. It is associated with an increased production of free radicals (also known as reactive oxygen species) after myringotomy. Vitamin E is a scavenger of different free radicals by working as an antioxidant. The aim of the present study was to evaluate the effect of vitamin E-coated tympanostomy tube insertion at quantity of free radicals in rat tympanic membrane. METHODS: This prospective, controlled animal study consisted of male Sprague-Dawley rats divided into two groups of 10 animals each. Ordinary silcone tubes were applied to the right ears of the first group and vitamin E-coated silcone tubes were applied to the right ears of the second group. The left ears were used as controls. Then, the animals were killed and chemiluminescence measurements were made for tympanic membranes. RESULTS: Reactive oxygen species levels (ROS) were significantly increased in right ears of the first group when compared with the control ears (P < .0001), and the levels were statistically significant decreased in right ears of the second group as compared with the operated ears of the first group (P < .0001). The free radical levels of right and left ears in the second group were similar. CONCLUSIONS: Our results indicate that vitamin E-coated tube insertion decreases the quantity of reactive oxygen species in tympanic membrane after myringotomy and tympanostomy tube insertion.     

Topical mitomycin C application before myringotomy and ventilation tube insertion: Does it affect the final outcome?

Previous animal studies have shown that the topical application of mitomycin C is safe and effective in prolonging the patency of myringotomy openings in ears that have not received a ventilation tube. We conducted a randomized, controlled study in humans to determine if this treatment would make a difference in outcomes when a ventilation tube is inserted. To that end, we prospectively studied a group of patients with resistant otitis media with effusion who underwent bilateral myringotomy and ventilation tube insertion. Our original study population was made up of 55 children aged 2 to 12 years; 15 of these patients were lost to follow-up, leaving us with 40 patients and 80 ears. Each patient served as his or her own control, as mitomycin C was applied to the tympanic membrane on one side just prior to myringotomy creation and normal saline was applied to the other side. Our main outcomes measures were the duration of tube placement (i.e., the length of time before extrusion of the tube) and the incidence of other early and late postoperative complications. We found no statistically significant difference between the mitomycin C-treated ears and the control ears in any of these parameters. We conclude that the use of mitomycin C prior to myringotomy and ventilation tube insertion is not worthwhile.     

Laser myringotomy

The aim of the study was assessment of the qualities of laser-assisted myringotomy (LAM) as a treatment for acute and secretory otitis media. Laser-assisted myringotomy was performed on 65 children (113 ears) mean age 6.2 years diagnosed with secretory otitis media (80%), recurrent secretory otitis media (11%) and acute otitis media (9%). Myringotomy was performed under general anesthesia using the OtoLAM device (ESC/Sharplan, Israel). In 64 ears pressure equalisation tubes were inserted after fenestration of the tympanic membrane with laser. Adenoidectomy alone or with tonsillectomy was performed at the same time in 51 cases. Laser tympanostomies remained patent for 7-32 days. All tympanostomies healed with no noticeable scarring. LAM appears to be a safe, and easy to performed, alternative technique in the treatment of otitis media.     

Topical anesthesia of the tympanic membrane using DMSO and local anesthetics

A solution of 10% cocaine hydrochloride plus 10% water in 80% dimethyl sulfoxide (DMSO) or 5% tetracaine base in pure DMSO was topically applied to the eardrum in 112 and 52 cases respectively. Both preparations induced well-tolerated analgesia suitable for myringotomy with or without insertion of a grommet in the office environment. DMSO-tetracaine induced analgesia within ten, DMSO-cocaine within 30 minutes. This method has distinct advantages as compared to iontophoretically induced analgesia or topical agents with a destructive mode of action.