Myringotomy: Meaning, Procedure, Tube, Incision and Recovery

Myringotomy is a surgical procedure performed on the tympanic membrane (eardrum) to drain out the fluid from the middle ear. The fluid is drained by making a small hole in the eardrum.

Anatomy and Physiology of Tympanic Membrane (Eardrum)

The tympanic membrane (eardrum) is a thin, semi-transparent, and oval membrane that separates the middle ear from the outer ear. There are three layers of the tympanic membrane, i.e., the outer layer, the middle layer, and the inner layer. The outer layer is formed of the thin epidermis, while the inner layer is made of cuboidal epithelium. The middle layer comprises fibrous connective tissue comprising nerves and blood vessels.

The sound wave or vibrations from the outer ear reach the tympanic membrane, making it vibrate. These vibrations travel to the three ear bones. Finally, the vibration signals from the bones travel into the internal ear, enabling the person to hear.

Generally, myringotomy is done to drain out the ear fluid from the middle ear. However, myringotomy also helps treat other conditions such as:

1. Frequent ear infections (acute otitis media)
2. Ear bleeding due to trauma, severe infection or a ruptured eardrum
3. Balance problems
4. Hearing loss or muffled hearing
5. Speech delays (in children)
6. Ear barotrauma (a painful feeling in your ears due to air pressure changes)

Myringotomy is performed in adults and children who have an accumulation of fluid in the middle ear. It may be due to several conditions, such as:

1. Frequent or severe ear infections
2. Traumatic ear bleeding
3. Pain in the ear due to changes in air pressure
4. Ruptured eardrum

Myringotomy is a common type of ear surgery which is usually performed on an outpatient basis. The procedure usually takes 15 to 20 minutes to complete depending on the patient's age, medical condition of the patient and the complexity of the case. The procedure is done under general anaesthesia to keep the patient comfortable. However, in some cases, local anaesthetics can also be used. ENT specialist along with specialised medical staff performs this procedure. The following steps are involved in the procedure:

1. The surgeon will administer general anaesthesia to the patient.
2. The vital signs of the patient will be continuously monitored throughout the process.
3. The surgeon will use a  small microscope to view the eardrum clearly.
4. Then a very tiny hole will be made into the eardrum (tympanum) using a scalpel and drain the fluid from the middle ear. In some cases, the doctor may use the laser beam to make an opening in the eardrum.
5. In some cases, the surgeon may also perform a tympanostomy by placing a pressure-equalizing tube (PE tube) at the incision site. This tube will be placed without the help of any stitches. 
6. This will allow the fluid to drain from the middle ear. Hence, preventing the future chances of infections in the ear. In most cases, this tube remains there for some time.
7. The incision will heal on its own thus the incision is not stitched.
8. The surgeon will then pack the ear with gauze.
9. The patient will then be moved to the hospital ward so that he/she can recover.

Before the myringotomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Myringotomy

Before undergoing the myringotomy procedure, the ENT specialist will:

1. Visually examine the ear by using an instrument known as an otoscope.
2. Explain the procedural approach in detail and mentions its potential risks. 
3. Provide precautionary measures that a patient needs to take before the surgery.
4. Prescribe some medicines that the patient needs to take on the day of the surgery. The patient should take these medicines with a sip of water.
5. May run some blood tests to check for any presence of infections or any allergies. 
6. May also perform a hearing test to confirm the status of the hearing and to know the severity of the hearing problem. For this, they may do a tympanogram. The test determines how efficiently the eardrum changes with the change in pressure. 
7. May advise the patient not to drink anything after midnight, a day before surgery.
8. The patient should inform the ENT specialist if he/she has a cold or throat problem within seven days before surgery. 
9. The surgeon will postpone the surgery if the patient has a fever or cough as it can cause complications during surgery.

On the day of Myringotomy

1. The patient should reach the hospital before the scheduled time.
2. The patient must leave all the valuables, wearables, and piercings at home before leaving for the hospital.
3. The patient will be asked to sign the consent form before the surgery.
4. The staff will take the patient to the pre-operative area. There, the patient will be given a surgical gown to change into.
5. The staff will also wrap a hospital information band on the patient's wrist. This band will have information about the patient's characteristics and the procedure he/she will undergo.
6. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
7. The vitals of the patient will also be monitored.
8. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone myringotomy can expect the following after the surgery:

The recovery process at the hospital

1. Post-surgery, the patient will be moved to the hospital ward so that he/she can recover.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. The patient might feel an ear clog. However, this type of feeling is normal after myringotomy.
4. In case the procedure is performed in the afternoon, and if the patient requires medical observation, they will be advised to remain in the hospital for one night.
5. The doctor may prescribe an antibiotic ear drop to prevent the risk of infection. The drop has to get into the ear canal, so it may be necessary to temporarily remove the gel foam or cotton (which was used for packing). 
6. The doctor will also give some instructions for home care.

Recovery process/expectation after hospital discharge

1. Instructions provided by the doctor must follow at home.
2. The patient would need to change the cotton placed in the ear canal regularly.
3. The patient should not clean his/her ear after surgery or place anything other than ear drops, cotton or ear plugs unless instructed otherwise by the doctor.
4. The patient should take the medications and the ear drops as directed by the doctor.
5. After the surgery, it may take a few days to a week for the hearing to come back to normal.
6. Ear plugs should be used while swimming or bathing.
7. There is no need to care for the incision because the procedure is performed on the eardrum, and the stitches used there will heal and dissolve automatically. 
8. If there is a pus-like discharge from the ear, consult the doctor. 

First follow-up appointment

1. A follow-up appointment with the surgeon will be scheduled within 2 to 4 weeks of the completion of the surgery. During the follow-ups, the doctor will ensure the right placement and the proper functionality of the tube placed and the recovery of the ear. 
2. The doctor may perform audiometry tests also during the subsequent follow-ups.
3. The doctor may also provide some antibiotics and painkillers at the follow-up visit. 
4. The ENT specialist might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
5. The ENT specialist will advise the patient for further timely follow-ups as well.

Myringotomy is a simple and safe procedure with several benefits that helps improve the quality of life of an individual. Below mentioned are some of the benefits of myringotomy.

1. Improve the balance of the body
2. Ease pain in the ear and relieves pressure
3. It reduces the chances of ear infection
4. It restores the hearing of the person by draining the fluid build-up from the ear
5. Improves the speech in children
6. Increases the confidence in the children
7. Improves the quality of sleep 

Like any surgical procedure, myringotomy also has some risks and complications. These include:

1. A permanent hole in your eardrum that doesn’t heal.
2. Hardening of your eardrum can cause hearing problems.
3. Surgical injury to your ear canal.
4. Scarring of your eardrum.
5. Excess bleeding.
6. Infection.
7. Chronic drainage.
8. Allergic reaction to anaesthesia.

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she experiences:

1. Acute ear infection
2. The problem with body balance
3. Delayed speech in children
4. Loss of hearing
5. Severe infection in the ear
6. Ruptured eardrum
7. Redness and swelling
8. Excessive bleeding and heavy discharge from the ear
9. Fever
10. Nausea and vomiting
11. Cough, shortness of breath

Delaying a myringotomy procedure can increase the severity of the pain and discomfort in the ear, leading to reduced quality of life. Below mentioned are some of the common risks of delayed myringotomy:

1. The fluid build-up for a long time may result in causing the infection.
2. It may also cause permanent hearing loss.
3. Progressive and permanent damage to the eardrum.
4. It causes a delay in speech among children. 
5. It may result in a decrease in the confidence of the children. 

The cost of myringotomy ranges from ₹7,000 to ₹35,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.