What Are the Indications for Myringotomy and Ear Tubes?

Children with frequent ear infections (three ear infections in a six-month period or four ear infections within one year) should receive myringotomy and ear tubes to prevent chronic hearing loss and/or a cholesteatoma as a result of the accumulation of fluid in the middle ear with subsequent infection. The criteria can be shortened if the child has demonstrated diminished hearing.

What Will Your Anesthetic Plan Be for This Child?

Myringotomy and ear tube placement is a relatively minor and short procedure. Nearly all anesthetics consist of mask anesthesia with sevoflurane, without intravenous catheter placement, unless there are additional patient factors that warrant a more invasive strategy. Some children will awaken with severe ear pain that typically lasts an hour or two. Pain management varies between centers, and ranges from oral to intramuscular use of opioids and/or nonsteroidal antiinflammatory agents.

A study by Stricker et al. suggested that a combination of intramuscular fentanyl (1.5 mcg/kg) and ketorolac (1.0 mcg/kg) was associated with optimal outcomes with respect to analgesia and postoperative nausea and vomiting.

What Are the Implications of This Patient’s Respiratory Symptoms?

Viral upper respiratory tract infections (URIs) are frequent in children, especially during the winter months. Typical symptoms include rhinorrhea, congestion, cough, fever, and malaise. Subclinical manifestations may include upper and lower airway edema, increased respiratory tract secretions, pneumonia, and bronchial irritability.

What Are the Increased Anesthetic Risks in Children with a URI?

Intraoperative airway complications during general anesthesia appear to be more common in children with a URI. These include coughing, laryngospasm, bronchospasm, and hypoxemia. Infants under 12 months of age tend to have more intraoperative complications than older children, and use of an endotracheal tube as compared with a facemask or laryngeal mask airway (LMA) increases the risk of these complications, but even LMA placement may be associated with complications in children with a URI. Passive exposure to cigarette smoke and a history of atopy are additional risk factors.

Transient postoperative hypoxemia, postintubation croup, and postoperative pneumonia are probably more likely to occur in children with a URI. Long-term complications and true outcomes are difficult to define and quantify and may not differ between normal children and those with a current or recent URI.

In infants and children with a URI, apneic oxygenation is less effective; thus oxyhemoglobin desaturation may occur when, during rapid sequence induction, the child is not receiving positive-pressure ventilation.