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