Bilateral Myringotomy Tubes (BMT)

Patient Considerations

• Disease Specific Considerations

  • Assess patient for URI – often difficult to avoid runny noses as patients have seasonal allergies

• Associated Comorbidities/Syndromes

  • Trisomy 21

    • Associated with narrow ear canals leading to longer procedures

      • Consider LMA placement

    • Atlantoaxial instability is possible in these patients

      • Minimize neck movement

Case Planning

• Specific or Unique Room Set-Up Requirements

  • Airway

    • Plan for mask induction and maintenance – assist ventilation during the procedure

    • Machine set-up with laryngoscope, appropriate sized ETT, oral airways and machine drawer checked for presence of LMAs

    • Always tape the eyes

  • Drugs/Infusions

    • Usually no IV unless patient is older or has other co-morbidities, i.e. Down’s Syndrome or congenital cardiac disease

    • For Down’s syndrome patient

      • Keep Sevoflurane at 6% or lower – these patients are very prone to bradycardia!

      • have atropine (0.02mg/kg) drawn up and ready for IM injection

    • Analgesia – intranasal fentanyl 2mcg/kg divided between nares with atomizer WHEN ANESTHETIC DEPTH IS APPROPRIATE – risk of causing laryngospasm

      • OR

    • IM Morphine 0.1mg/kg max dose 2mg

    • May supplement both of the above with IM Ketorolac 0.5mg/kg

  • Monitors

    • Standard – O2 Sat, EKG, NIBP, skin temperature

  • Blood Availability

    • Not required

  • PICU Bed Availability

    • Not required

Anesthetic Considerations

• Induction – gentle mask induction with Sevoflurane/ N2O/O2

• Positioning

  • Supine, does not require turning the bed

  • The microscope will be used

  • Requires turning the patient’s head to allow surgeon to access the ear canal

  • Imperative that the head be held still especially when the tympanotomy is being performed

• Maintenance

  • Maintenance of Anesthesia

    • Place oral pharyngeal airway as soon as appropriate

    • Sevo with O2, surgeon may request nitrous if the TM is flat

      • Particularly on repeat cases where the TM is flat

  • Hemodynamic/Physiologic goals

    • No unique goals

  • Surgical Considerations

    • Imperative that the head be held still especially when the tympanotomy is being performed

      • Turn the head to allow surgeon optimal view through the microscope

      • Do not turn the patient’s head in preparation for second ear until any needed ear drops and the cotton ball have been placed

        • Dr. Borders does not use cotton balls

• Emergence/Disposition

Awake:

• Patient has proceeded through stage 2

  • Awake and purposeful with no airway obstruction

Deep:

• This means a MAC greater than 1.6 with appropriate evaluation of anesthetic depth to include checking eye signs, respiratory rate and depth and VS

• Place the patient in left lateral decubitus – recovery position on stretcher with oral airway in place

• Post-Op Pain Management

  • Usually not a problem in PACU, may be given oral acetaminophen

• Case-Specific Complications

  • None

• Surgeon Specific Considerations (If applicable)

  • None