Myringoplasty with tympanostomy tube placement may be performed for patients with a variety of middle ear conditions. Often, eustachian tube dysfunction causes otitis media, tympanic membrane perforation, or conductive hearing loss. In the present case, myringoplasty was performed using the CO2 laser, providing reorganization of collagen fibers and improved compliance of the tympanic membrane. Given the ongoing eustachian tube dysfunction, a pressure equalization tube was placed to prevent recurrent retraction and atelectasis of the eardrum.
Patients with middle ear disease may present in a variety of ways. At the root of many middle ear disorders is the eustachian tube. When functioning properly, the eustachian tube allows for pressure equalization between the middle ear and the surrounding atmosphere.1 However, dysfunction of the eustachian tube can lead to the development of negative pressure in the middle ear, leading to effusion and tympanic membrane retraction. Patients may present to primary care providers or specialists with complaints of hearing loss, fullness/pressure in the ear, otorrhea, or pain. Over time, retraction of the tympanic membrane can lead to structural changes, resulting in hearing loss even in the absence of effusion.2 Treatments for this condition are aimed at establishing an equal pressure gradient across the tympanic membrane. This can be accomplished with procedures such as myringotomy, tympanostomy tube placement, and eustachian balloon tuboplasty. Myringoplasty can help restore a more normal structural anatomy to the eardrum, promoting greater sound transduction to the middle and inner ear.
Focused History of the Patient
In this case, the patient presented with a history of recurrent otitis media with effusion. This resulted in discomfort and conductive hearing loss. She had several sets of tympanostomy tubes placed in the clinic with drainage of the effusion and resolution of hearing loss. Over time, however, these tubes remained in place for only 2–3 months. Chronic eustachian tube dysfunction led to tympanic membrane retraction and atelectasis.
The patient’s external ear was normal in appearance, as was the external auditory canal. The tympanic membrane was globally retracted and atelectatic with adherence to the promontory. There was no evidence of a deep retraction pocket or keratinaceous debris to suggest cholesteatoma. Tuning fork testing with a 512-Hz fork was notable for a negative Rinne test on the affected ear as well as Weber lateralization to the affected ear. The nasal exam was normal without evidence of turbinate hypertrophy or chronic rhinitis/sinusitis.
The patient’s audiometric testing demonstrated a mild conductive hearing loss in the affected ear in addition to a type C tympanogram (negative pressure).
With chronic negative pressure in the middle ear, there is a risk of the development of retraction pockets and cholesteatoma. This could lead to additional associated complications such as severe or permanent hearing loss, meningitis, or labyrinthine fistulas.
Options for Treatment
There are several treatment options for eustachian tube dysfunction and middle ear effusion. Because the patient had received many sets of tympanostomy tubes in the clinic with the relief of effusion, this remained an option. However, atelectasis of the tympanic membrane and adherence to the promontory made doing so more difficult. Balloon eustachian tuboplasty is a relatively new treatment modality for eustachian tube dysfunction. Despite the fact that this patient had negative middle ear pressure, nasal endoscopy did not confirm the presence of dilatory eustachian tube dysfunction, and she was able to insufflate her middle ear space with a Valsalva maneuver.
Rationale for Treatment
For patients who have undergone multiple treatments or have had long-standing negative pressure of the middle ear, the collagen fibers of the tympanic membrane can become disorganized.
The objectives of treatment, in this case, were to release the fluid in the middle ear, improve the tensile strength of the tympanic membrane, and reduce future episodes of retraction and effusion.
There are no specific contraindications for this procedure from a patient-selection standpoint.
General anesthesia is used. An endotracheal tube or laryngeal mask airway can be used given the short duration of the procedure. One advantage of using endotracheal intubation is that administration of nitrous oxide can promote middle ear inflation, aiding in the release of an atelectatic tympanic membrane from the promontory.
The patient should be placed supine on the operating table and secured with straps. The bed can either be rotated or just brought away from the anesthesia machine in its standard orientation. The head is turned away from the surgeon, and the arm on the operative side is tucked. Although less important in a short case, the blood pressure cuff should ideally be placed on the contralateral arm.
Prepping the Patient
No specific prep (e.g. Betadine) or draping was required in this case.
Laser safety is paramount in all cases. The OmniGuide (Lexington, MA, USA) carbon dioxide laser is used, and all participants in the operating room should be provided with appropriate eye protection. This is not required for the primary surgeon using the microscope.
The laser should be tested on a moistened tongue depressor. It should be placed in “stand-by” mode unless in active use by the surgeon, who should instruct the circulating nurse or laser operator by confirming “laser-on” and “laser-standby.”
The settings for this laser are 2 Watts for a 100-millisecond pulse duration, single pulse. It is important to position the laser at a distance that allows for accurate localization of the target, but that is also far enough back that it does not penetrate the membrane. The key is to start back further and work inwards. Each area of the tympanic membrane that appears flaccid or hyperinflated can be treated with the laser to achieve the desired effect.
The myringotomy is made with a radial incision along the tympanic membrane. Standard teaching instructs surgeons to place the incision in the anterior-inferior quadrant. If this area is not well-visualized due to patient anatomy (e.g. anterior canal hump), it can be placed in the posterior-inferior quadrant. The superior aspect should be avoided due to the risk of injuring underlying anatomical structures (e.g. ossicular chain).
The tympanostomy tube can be trimmed to size and should be placed with the flanges in the middle ear. Once placed, the tube itself should be directed laterally to ensure patency, allow for monitoring, and facilitate the administration of topical medications if they are required.
A cotton ball can be placed in the external meatus if there is drainage, otherwise no dressing is required.
While patients may feel relatively normal or improved immediately after surgery, they should not drive or make any important decisions for 24 hours after surgery. If there is significant effusion, a prescription for otic drops should be provided (ofloxacin or ciprofloxacin/dexamethasone). Patients should be instructed to administer 3–5 drops once daily for 5 days. Patients may shower immediately after surgery but should avoid getting water directly in the ear or submerging in soapy water.
While myringotomy is one of the most commonly performed otolaryngological procedures, this case is unique for its use of the CO2 laser and myringoplasty. The operative time for the case is typically 10–15 minutes, and the patient goes home on the same day. Patients may experience some transient otorrhea; however, the pain is minimal and is controlled with over-the-counter analgesics. If an effusion is present, the patient can be treated with ofloxacin (0.3% otic solution) drops for 3–5 days, 1 to 2 times daily. Tubes typically extrude between 6–9 months, and recurrence of symptoms with ongoing eustachian tube dysfunction is common. Nevertheless, the performance of myringoplasty can reduce the incidence of recurrent retractions. The patient should have a follow-up hearing test 4–6 weeks after the surgery and should be monitored every 3–6 months thereafter.
- Standard otolaryngology ear tray (alligator, Rosen needle, straight pick, 3- and 5-suction)
- OmniGuide CO2 Laser with Oto-M fiber
- Tympanostomy tube (brand and type at the discretion of the operating surgeon)
C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.
Statement of Consent
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published on-line.
- Magnuson B, Falk B. Physiology of the Eustachian tube and middle ear pressure regulation. Physiology of the ear. 1988:81-100.
- O’Reilly RC, Levi J. Anatomy and Physiology of the Eustachian Tube. In: Cummings Otolaryngology: Head and Neck Surgery. 6th ed. New York, NY: Elsevier; 2015:2027-37.
Alright, so this woman has eustachian tube dysfunction and has a globally retracted eardrum, and she's had 8 sets of tubes in the past. So what we're going to do is- I'll take a 6 speculum- is we're going to do a laser myringoplasty, which tightens the eardrum and allows the collagen that's all stretched out in the middle layer of the pars tensa to snap back to its native configuration. So - I'll take a curette. So we'll just get a good view of the eardrum.
So in clinic, when I saw her, her eardrum was retracted back onto the promontory, the entire eardrum. And when she Valsalva'd, it completely reinflated, so it was floppy and hyperinflated. And that gave her hearing loss because the eardrum isn't conducting sound properly. So what the laser will do is it'll tighten the eardrum back to its- native configuration.
Can we have an alligator?
What we can see- is this part of the eardrum is very floppy. And the fact that its anterior eardrum is retracted is a sign of eustachian tube dysfunction because that tells me that the- there's not getting air into the front- the anterior portion of the middle ear space.
So we'll go ahead and set the laser up. So the CO2 laser is particularly useful for this because- one of the molecules that the CO2 laser interacts with, other than water, is collagen, and it's called, it's chromophore. So it's a molecule that- a chromophore is molecule that a laser interacts with and is absorbed maximally.
Right. So that's the OmniGuide OTO-M fiber. So, CO2 laser's different than visible light.
It's a very long wavelength and it can't be transmitted through a fiber like visible light, like KTP. So this is actually a hollow waveguide, it's not really a fiber. The internal- the- the internal portion of the fiber- or of the guide, is a mirror. And so as the laser bounces along, the way it's designed is the laser doesn't lose its energy as it gets to the tip. Because it- the way the multilayers of the fiber are designed that all light bounces off of it with virtually no loss of intensity. So what's going into the fibers- or the waveguide, is essentially what's coming out.
So- you extend it- out to there, and tighten it down.
Right, so it's- we set it at 2 watts for 100 ms pulse duration, so very low power. For a 100 ms pulse duration. Single pulse.
And so what we see- is the- eardrum right there, is- when the laser light goes off- see, that's a- it's hyperinflated.
Alright. So, first I'm going to test the laser. So can I have a- stick? Alright. So, does everyone have goggles? Alright, so… Alright, so, I'll say laser on, and then we'll turn it on, and then- alright, so- Good. Alright, standby.
Okay, so I'll turn her head away just a little bit, get- a good view of that- hyperinflated area.
Alright. I'll take the laser. So, you want a diffuse- firing, you don't want it real close because that'll burn a hole. So I start back very far. Okay, so laser on.
So I start by- and I can see, there's the- argon blowing. So you see, as I zap it, it's blanching, it's not burning. You see how it's tightening. So that whole area now is completely flat, like it should be. Standby.
So I'm going to get the back part of the eardrum, which was a little less retracted, but still, nonetheless, it was retracted. Alright. Laser on.
Good. Alright, standby.
So that's pretty much it. So now we have a- an adequately tightened- eardrum. And that little bit of char there, that did not perforate it, but that's about where I'm going to put my tube. So now I'm going to put a T-tube in. We're done with the laser, so I'll take that.
So I'm just going to trim this.
I'll take an alligator and a scissors. These T-tubes come out very long, longer than they need to be. So I'll trim off- a bit of each flange. Fold it back. So like that. Now hold it like that. And I'll take a myringotomy. I'll take a myringotomy blade.
Alright, I'll take a small suction. I don't think there's an effusion. Can you put a- like a 20 suction on?
And it's pretty dry in there. Now there's a nicely aerated middle ear space.
Alright, so now… There we go. And I'll take full suction.
And so now, having this tube in there will help keep it aerated and keep the eardrum from retracting again.
Alright. That's it!