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What is myringotomy?

Myringotomy is a surgical procedure involving a small incision of the eardrum membrane. It is performed in cases of otitis with accumulation of mucus, phlegm or purulent material in the middle ear (effusion) that does not respond to medical therapy. The benefits are truly remarkable, both in terms of reducing pain and preventing recurrences.

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When is a myringotomy useful?

Myringotomy is indicated in the treatment of serous, purulent, recurrent otitis or otitis resistant to medical therapy. Anaesthesia is usually general in children and local in adults. Myringotomy through the placement of a small tube allows the drainage of the effusion in the middle ear and is necessary, especially for children, when otitis recurs (more than 3-4 times a year) and medical therapy is ineffective.

Recurrent otitis with the presence of fluid in the middle ear leads to a decrease in hearing, so if left untreated, especially in younger children, it can lead, in addition to pain, to delayed learning of language, and to difficulties integrating at school and with friends.

Myringotomy is also indicated in all those cases in which the Eustachian tube fails to properly ventilate the middle ear due to frequent colds or frequent barotrauma (trauma to the middle ear with pain felt when changing pressure when going underwater or travelling by plane).

Otitis media with effusion (OME)

Otitis media exudative, one of the most common diseases in paediatrics, is caused by the constant presence of catarrh in the middle ear over a long period of time (usually at least three months). It may be asymptomatic or present with pain, fever, headache and asthenia.

There are various causes: it can be the consequence of acute otitis media, obstruction of the Eustachian tube, inflammatory processes of the nose or throat, allergies, adenoid hypertrophy. Other causes include the particular anatomical conformation of the Eustachian tube in the first few years of life, prolonged sucking, such as using a soother or feeding bottle for a long time, as well as passive smoking and artificial breastfeeding. 

It is important for the disease to be detected early because hearing loss in children can go undetected resulting in speech delay and chronic inflammatory processes. 

Recurrent otitis media

Generally, otitis media is defined as recurrent when three episodes of catarrhal otitis occur in six months. The symptoms are throbbing otalgia (ear pain), hearing loss and even high fever. The most frequent cause of recurrent otitis media is the common cold. Excessive accumulation of exudate in the middle ear can also lead to perforation of the tympanic membrane.

The use of mucoregulators and frequent nasal washes (e.g. with saline solution, sulphurous water, hyaluronic acid) lead to better aeration of the middle ear, which favours the drainage of secretions through the Eustachian tube.

In children, therapy is also based on the elimination of risk factors, such as the use of dummies, exposure to passive smoking, treatment of nasal infections and the possible removal of adenoids. 

Ear pressure

The pressure in the middle ear is regulated through the opening and closing (3-4 times per minute) of the Eustachian tube, a narrow duct that connects the eardrum case of the middle ear to the nasopharynx. If the patency of the Eustachian tube is compromised, a negative relative pressure develops in the middle ear, which can lead to an accumulation of fluid that may be sterile or contain viruses or bacteria. This effusion causes hearing loss.

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Examinations to be performed before a myringotomy

Before performing a myringotomy, it is essential to carry out specific examinations that allow the ENT specialist to define the diagnosis and subsequent treatment with certainty.  These examinations include:

  • Rhinofibroscopy or rhino-pharyngoscopy: Using a rhinofibroscope, a flexible tube with a camera, which is introduced by the doctor into the nose, the turbinates, soft palate and vocal cords can then be seen.
  • Tympanogram: A painless examination that assesses the state of the middle ear, useful for identifying exudates or changes. A rubber-tipped cone emits a sound pressure that sets the eardrum and ossicles in motion. It is not suitable for those with tympanic perforations or ongoing acute otitis. 
  • Audiometry: Assesses a patient's hearing ability. An audiometric technician determines the threshold of minimal hearing and detects abnormalities. It takes place in an isolated booth and includes tonal, speech and high frequency audiometry. The results help the ENT specialist identify any deafness or hearing loss.
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How is myringotomy performed?

Myringotomy is performed by the ENT doctor after sedation of the patient (usually under general anaesthesia for children) to ensure immobility during the procedure. Using an operating microscope, the doctor inspects the outer ear and ear canal, cleaning them of any obstructions that prevent a clear view of the eardrum. Then, he or she incises the eardrum 2-3 mm with a small scalpel and sucks out any mucus or phlegm present.

A small drainage and ventilation (TV) tube made of synthetic material (Teflon or Silastic) is then inserted into the eardrum to allow fluids to drain out even after the operation. No stitches or swabs are required, and the tube will remain in place for about three months, and then be expelled spontaneously or removed by the doctor.

How long does the myringotomy operation take?

Myringotomy is normally a fairly quick operation; it takes about 5 minutes and the patient can be discharged after a few hours. General and local antibiotics are generally prescribed for 5-7 days.

How are transtympanic tubes removed?

Transtympanic ventilation tubes, inserted after a myringotomy, are intended to aerate the middle ear, eliminating secretions and promoting healing. These tubes remain in place until they are spontaneously expelled when the tympanic membrane closes again. Usually, they do not cause discomfort, but it is important to prevent water from entering the ear, so it is recommended not to swim in the pool or sea and to use special plugs when showering or bathing.

If the tube is ejected and the tympanic membrane does not close spontaneously, surgery may be necessary to close the perforation. It is essential to undergo regular specialist check-ups: the first check-up is 10-15 days after surgery, followed by visits every 30-40 days to monitor the recovery of hearing ability, middle ear function and the condition of the tube.

Recovery period post myringotomy

After a myringotomy, recovery usually does not involve any particular problems. In general, it is normal for a serous-hematous or purulent secretion to come out of the ear. Although this can sometimes cause worry, it is perfectly normal behaviour and is indeed a sign that the middle ear is emptying. In the event of a haematic discharge, excessive post-operative pain or dizziness, the doctor should be consulted.

What are the post-operative risks and complications?

The risks associated with myringotomy are very rare: it is a minimally invasive procedure and complications are rare. However, it can happen that water enters the operated ear: this, if it occurs in the days after the operation, can be the cause of infections with the appearance of otorrhea, i.e. discharge of mucus or pus from the ear, which can be easily treated with both local and general antibiotics.

Post-operative recommendations

After myringotomy it is important to avoid contact of the operated ear with water, particularly in the days following the operation, but more generally also afterwards, until the tube of drainage is completely expelled.

In the first week post-surgery, however, it is important to take a few extra precautions, such as: not using earphones, cotton buds or introducing foreign bodies into the ear.

What are the advantages of myringotomy?

The advantages of myringotomy are many, here are the main ones 

  • reduction in the number of otitis, their intensity and related pain;
  • improved hearing ability, due to the absence of catarrh in the eardrum;
  • increased ventilation of the tympanic cavity and middle ear;
  • removal of phlegm from the middle ear, which can cause infections;
  • prevention of mucus accumulation in the ear.

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