History of Stapes Surgery

1. The Pre-History: Valsalva and Early Anatomists

• Cummings Otolaryngology, p. 2781; ACTA Ital review 2024

2. First Surgical Attempts and Their Abandonment (1876-1900)

• By 1919, Sir Charles Ballance's Surgery of the Temporal Bone made no mention of any operation to improve hearing.
• In 1930, Kerrison's Diseases of the Ear devoted less than a page to the topic, concluding that these operations "mentioned for their place in otologic history are quite obsolete today."
• Shambaugh Surgery of the Ear, p. 796

3. The Fenestration Era (1911-1952)

• Shambaugh Surgery of the Ear, pp. 796-797

4. Stapes Mobilization: A Return to the Oval Window (1953)

5. The Stapedectomy Revolution: John Shea (1956)

• Schuknecht (1960) developed a steel-wire loop prosthesis, improving reliability.
• Plester proposed partial footplate removal, further refining technique.
• Zöllner and Wullstein (1955-1960s) contributed concepts of tympanoplasty and ossicular reconstruction, including connecting the incus to the oval window in stapedectomy cases.
• The vein graft was soon supplemented and sometimes replaced with perichondrium or fat tissue seals.
• Cummings Otolaryngology, p. 2781; Shambaugh Surgery of the Ear, p. 797

6. Stapedotomy: The Small-Fenestra Technique (1970s-1980s)

• Preserves the footplate as a protective barrier to the inner ear
• Reduces risk of perilymphatic fistula
• Lowers the rate of sensorineural hearing loss (SNHL) and post-operative vertigo
• More stable long-term hearing outcomes

7. The Laser Era (1980s-Present)

• Precisely create the small fenestra in the footplate
• Divide the stapedial tendon and crura without mechanical trauma
• Reduce bleeding and the vibration transmitted to the inner ear during footplate penetration

8. Endoscopic Stapes Surgery (2000s-Present)

• ACTA Ital 2024 review

Summary Timeline

• Shambaugh Surgery of the Ear, pp. 795-797
• Cummings Otolaryngology Head and Neck Surgery, p. 2781

Intractable Epistaxis

Vascular Anatomy - The Foundation

• Sphenopalatine artery (SPA) - the dominant supply, a terminal branch of the internal maxillary artery entering through the sphenopalatine foramen. Responsible for the vast majority of posterior epistaxis.
• Internal maxillary artery - the parent of the SPA, accessible in the pterygopalatine fossa.
• Anterior and posterior ethmoidal arteries - branches of the ophthalmic artery (internal carotid system), supplying the superior nasal cavity and septum. Important in trauma and skull base surgery.
• Kiesselbach's (Little's) plexus - anastomotic network on the anteroinferior septum where multiple vessels converge; the source of most anterior epistaxis.
• External carotid artery - ligation proximal to lingual artery is a last resort.

What Defines "Intractable"

1. Anterior nasal packing fails to control bleeding
2. Posterior bleeding cannot be directly visualized or cauterized
3. Bleeding recurs after packing removal
4. Hemorrhage is life-threatening (requires blood transfusion)

Step-by-Step Escalating Management

Step 1 - Initial First-Line Measures (Not Intractable Yet)

• Firm compression of the lower third of the nose for at least 5 minutes
• Topical vasoconstrictors: 0.05% oxymetazoline spray or epinephrine 1:1,000 soaked cotton
• Anterior rhinoscopy to identify the bleeding point
• Silver nitrate cautery (chemical) at Kiesselbach's plexus - cauterize circumferentially first, then the active site
• Electrocautery for more severe active bleeding at 15W under endoscopic guidance

• Oxidized regenerated cellulose (Surgicel)
• Gelatin sponge (Gelfoam)
• Thrombin with gelatin matrix (Floseal) - particularly effective for both anterior and posterior bleeding

Step 2 - Anterior Nasal Packing

• Absorbable packing (Nasopore, MeroGel, hyaluronic acid): better tolerated, dissolve within ~1 week, but may not provide sufficient pressure for arterial bleeding
• Non-absorbable packing (Vaseline-impregnated ribbon gauze, Merocel sponge): more pressure, but removed at 48-72 hours - carries risk of rebleeding on removal
• Pack must be directed along the nasal floor, not superiorly toward the skull base
• Cummings Otolaryngology, p. 940

Step 3 - Posterior Packing

• Belloc's (traditional) posterior pack: gauze pack positioned transorally via tapes passed from posterior choana to anterior nares. Secured anteriorly over padding to protect the columella from pressure necrosis. Requires opiate analgesia and antibiotics. Left in place minimum 48 hours.
• Foley catheter technique: size 12-14 Foley passed along the nasal floor, balloon inflated with 15 ml of water in the nasopharynx, pulled forward to occlude the posterior choana, then anterior packing added. Easier to insert but equally uncomfortable.
• Epistaxis balloon catheters (e.g., Rapid Rhino dual balloon): distal balloon inflated in nasopharynx, proximal sausage-shaped balloon inflated within the nasal fossa.

• Scott-Brown's Vol 1, p. 1224-1225

Surgical Management - When Packing Fails

Hierarchy of Ligation

1. Endoscopic Sphenopalatine Artery Ligation (ESPAL) - Procedure of Choice

• Performed under general or local anaesthetic
• An incision is made approximately 8 mm anterior to and under cover of the posterior end of the middle turbinate
• Incision carried down to bone; mucosal flap elevated posteriorly
• The fibro-neurovascular sleeve emerging from the sphenopalatine foramen is identified - the crista ethmoidalis (a bony projection of the palatine bone) is the key landmark signalling the foramen's location
• The main vessel is ligated with haemostatic clips and divided, or coagulated with bipolar diathermy
• The ipsilateral facial artery branches may also be addressed

• Scott-Brown's Otorhinolaryngology Vol 1, p. 1226

2. Internal Maxillary Artery Ligation (IMAL)

• Traditional approach: transantral via sublabial Caldwell-Luc antrostomy - posterior maxillary sinus wall elevated, pterygopalatine fossa entered, branches of the internal maxillary artery (proximal, descending palatine, sphenopalatine) identified and clipped
• Endoscopic approach: middle meatal antrostomy with posterior antrostomy to access the ptergyopalatine fossa

• Cummings Otolaryngology, p. 941

3. Anterior Ethmoidal Artery Ligation

• Skull base trauma (naso-orbito-ethmoidal fractures)
• Iatrogenic injury during endoscopic sinus or skull base surgery
• Confirmed ethmoidal origin of bleeding
• Upper/superior nasal cavity bleeding not controlled by SPA ligation

• Lynch incision: straight medial canthal incision - excellent access but leaves a visible scar
• Transcaruncular/precaruncular approach: scarless, incision at or anterior to lacrimal caruncle, dissect to lamina papyracea, elevate periorbita posteriorly to reveal ethmoidal foramina

• Cummings Otolaryngology, pp. 941-942

4. External Carotid Artery Ligation

• Cummings Otolaryngology, p. 941

5. Septal Surgery

• Scott-Brown's Otorhinolaryngology Vol 1, p. 1227

Embolization (Interventional Radiology)

1. Exclude AVMs, aneurysms, and fistulae before embolization
2. Identify the bleeding vessel
3. Pass a fine catheter into the internal maxillary artery (most common target) and embolize with polyvinyl alcohol particles, tungsten, or steel microcoils
4. The ipsilateral facial artery is also embolized to prevent re-circulation via anastomoses

• Avoids general anaesthesia
• Suitable for poor surgical candidates
• Effective for tumour-related bleeding (nasopharyngeal carcinoma, sinonasal tumours)
• Useful for vascular tumours (juvenile angiofibroma) - preoperative embolization reduces intraoperative blood loss
• Preferred for craniofacial trauma with distorted anatomy
• Essential for carotid blowout (iatrogenic or traumatic) after local endoscopic control

• Blindness (inadvertent ophthalmic artery embolization)
• Cerebrovascular accident / stroke (1.1-1.5%)
• Skin necrosis, facial paresthesia
• Groin haematoma at puncture site
• Acute kidney injury from iodinated contrast

• Cummings Otolaryngology, p. 942; Scott-Brown's Vol 1, p. 1227

Special Considerations

Hereditary Haemorrhagic Telangiectasia (HHT / Osler's Disease)

• Topical oestrogen, bevacizumab (anti-VEGF) nasal spray
• Laser photocoagulation of telangiectasias
• Septal dermoplasty (Young's procedure - surgical closure of the nasal cavity)
• Systemic anti-angiogenic therapy (bevacizumab IV)

Anticoagulated Patients

Tumour-Related Epistaxis

Summary Algorithm

Epistaxis
    ↓
Compression + topical vasoconstrictor (≥5 min)
    ↓ fails
Endoscopy + direct cautery / topical haemostatic agent
    ↓ fails
Anterior nasal packing (48-72 h)
    ↓ fails
Posterior packing (48 h) + admit + monitoring
    ↓ fails
↙                        ↘
ESPAL (1st choice)      Embolization (poor surgical
                         candidate, tumour, trauma,
                         carotid blowout)
    ↓ fails
IMAL / Ethmoidal artery ligation (by source)
    ↓ absolute last resort
External carotid artery ligation

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 1, pp. 1224-1228
• Cummings Otolaryngology Head and Neck Surgery, pp. 940-942
• Bailey and Love's Short Practice of Surgery 28th Ed., p. 789

Anterior Ethmoidal Artery: Anatomy in the Nose and Ligation

Origin and Overview

Course - Three Compartments

1. Orbital Segment

• After branching from the ophthalmic artery in the medial orbit, the AEA passes between the superior oblique and medial rectus muscles
• It exits the orbit through the anterior ethmoidal foramen in the frontoethmoidal suture line
• This orbital segment is readily visible on pre-operative coronal CT imaging

2. Ethmoidal (Skull Base) Segment - Surgically Critical

• The artery enters the ethmoid cavity and travels obliquely in a posterior-to-anterior direction
• It runs either:
  • Within the bone of the skull base (most common - ~75% of cases)
  • Within a mucosal mesentery hanging below the skull base (in ~20-25% of cases)
• The artery can always be found between the 2nd and 3rd lamella endoscopically - a key surgical landmark
• It then traverses intracranially through the lateral lamella of the lamina cribrosa into the olfactory fossa
• Inside the cranial cavity, it gives off anterior meningeal branches

3. Nasal Cavity Segment

• Re-enters the nasal cavity through the cribroethmoidal foramen
• Divides into anterior and posterior nasal arteries
• Each nasal artery gives lateral branches to the superior lateral nasal wall and medial branches to the nasal septum

Vascular supply of the lateral nasal wall. - Scott-Brown's Otorhinolaryngology Vol 1, p. 1016

Key Anatomical Distances (The 24-12-6 Rule)

Important caveat: While these distances are relatively consistent, the number of foramina is variable - multiple accessory ethmoidal arteries exist, and the posterior ethmoidal artery may even be absent. Surgeons must be aware of this variability and should not assume a single foramen for each vessel.

• Cummings Otolaryngology, p. 942

Middle Ethmoidal Artery

• Unilateral
• Positioned within the skull base
• Cummings Otolaryngology, p. 934

Surgically Important Variations: The "Low-Lying" or Dehiscent AEA

1. Presence of a supraorbital ethmoid air cell (Onodi-type variant)
2. High Keros classification (Keros type 3 = deep olfactory fossa, long lateral lamella, inherently lower skull base)
3. Increased distance between the anterior wall of the frontal sinus and the skull base

• Cummings Otolaryngology, p. 941

What Happens When the AEA is Injured

Indications for AEA Ligation

1. Skull base trauma (naso-orbito-ethmoidal fractures) causing superior/ethmoidal epistaxis
2. Iatrogenic injury during FESS or skull base surgery
3. Confirmed ethmoidal origin of bleeding not controlled by SPA ligation
4. Anterior skull base tumor resection (prophylactic ligation of both AEA and PEA to reduce intraoperative blood loss - e.g., anterior skull base meningiomas, olfactory groove tumors)
5. Adjuvant to SPA ligation when superior nasal bleeding persists

The AEA contributes minimally to nasal blood supply compared to the SPA. Ligation of ethmoidal arteries as a primary treatment for epistaxis reflects the technical ease of the open procedure rather than a logical vascular rationale. It is best used as an adjuvant to SPA ligation or when ethmoidal origin is confirmed.

• Scott-Brown's Otorhinolaryngology Vol 1, p. 1225

Surgical Approaches to AEA Ligation

1. Endoscopic Transnasal Approach

1. Perform a complete anterior ethmoidectomy and define the ethmoid skull base
2. The AEA is identified at the junction of the 2nd and 3rd lamellae, running as a fibrovascular pedicle from the lateral wall (orbit side) to the skull base
3. If the artery is within a bony canal, the canal is gently drilled with a diamond burr to expose the vessel; alternatively, a curette manipulates bone fragments off the vessel
4. Bipolar electrocautery on low setting is applied - equally effective as clips
5. Haemostatic clips may be applied if the vessel is well isolated
6. The artery is NOT transected after cauterization - transection risks retraction of the proximal stump into the orbit with consequent retrobulbar hematoma
7. Frontal sinus and orbital landmarks confirm position (frontal sinus anterosuperiorly, orbit laterally)

Endoscopic view - AEA being drilled for bipolar cautery. Frontal sinus anterosuperior, orbit lateral, septum medial. - Cummings Otolaryngology, p. 941

2. Open Transorbital Approach - Lynch Incision

• A medial canthal (Lynch) incision - straight vertical incision at the medial canthus, carried down to the bone of the anterior lacrimal crest
• Periosteal elevators elevate the bulbar fascia and periorbita, retracting it laterally
• The anterior ethmoidal artery is seen as a fibro-neurovascular mesentery (a "pedicle") running from the bulbar fascia into the anterior ethmoidal foramen
• The vessel is clipped and divided
• Dissection continues 12 mm posteriorly to identify the posterior ethmoidal artery (between PEA and optic canal is only 6 mm - extreme care required not to confuse PEA with the optic nerve)
• Closed with fast-absorbing gut sutures, treated with erythromycin ophthalmic ointment

3. Precaruncular / Transcaruncular Approach (Scarless)

• Incision at the lacrimal caruncle (transcaruncular) or anterior to it (precaruncular)
• Dissection through superior and inferior conjunctival folds
• Horner muscle identified and left undissected (to avoid epiphora)
• Periorbita posterior to its insertion is incised vertically to expose the lamina papyracea
• Blunt posterior elevation reveals the ethmoidal neurovascular foramina sequentially
• Vessels ligated and divided
• Closed with fast-absorbing gut sutures

• Cummings Otolaryngology, pp. 941-942

Summary Comparison of Approaches

Critical Safety Points

1. Never transect endoscopically without haemostatic control on both ends - the proximal orbital stump retracts and causes retrobulbar hematoma
2. The 6 mm rule - only 6 mm separates the posterior ethmoidal foramen from the optic canal; do not clip what you cannot clearly identify
3. Multiple foramina - additional accessory ethmoidal arteries exist and the posterior ethmoidal artery may be absent
4. Both sides have overlapping supply - bilateral AEA supply means ligation may need to be bilateral in selected cases

• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 1, pp. 1015-1016, 1225-1226
• Cummings Otolaryngology Head and Neck Surgery, pp. 934, 941-942

Middle Meatal Antrostomy (MMA)

Relevant Anatomy

The Osteomeatal Complex (OMC)

• Uncinate process - sickle-shaped bone running anterosuperior to posteroinferior; the first structure encountered in the middle meatus on lateralizing the middle turbinate; forms the medial wall of the ethmoidal infundibulum
• Ethmoidal infundibulum - a funnel-shaped 3D space between the uncinate process medially and the lamina papyracea laterally, into which the anterior sinuses drain
• Hiatus semilunaris - a 2D slit (cleft) between the free (posterior) edge of the uncinate process and the ethmoid bulla; connects the middle meatus to the infundibulum; the entry point for surgical probes accessing the infundibulum
• Ethmoid bulla - the largest anterior ethmoidal air cell, posterior to the uncinate
• Maxillary sinus natural ostium - opens into the inferior aspect of the ethmoidal infundibulum at a 45-degree angle
• Anterior ethmoidal cells and ostia of maxillary and frontal sinuses

• Cummings Otolaryngology, p. 865

The Natural Maxillary Ostium

• Located in the floor of the infundibulum, lateral to the lower third of the uncinate process
• Opens at a 45-degree angle (inferolateral) - this is why angled endoscopes (30° or 45°) are mandatory for visualization
• Elliptical in shape (vs. accessory ostia which are more circular)
• Cannot be visualized without first removing the uncinate process
• Mucociliary clearance within the entire maxillary sinus is directed toward the natural ostium - this is a physiological principle with profound surgical implications

Accessory Ostia

• More circular than the natural ostium
• Commonly found in the posterior fontanelle (the membranous area of the lateral nasal wall posterior to the uncinate)
• Do not provide functional drainage - because mucociliary flow always goes toward the natural ostium
• Must be identified and incorporated into any antrostomy to prevent recirculation

Indications

• Chronic rhinosinusitis (CRS) with or without nasal polyps, refractory to medical therapy
• Acute recurrent sinusitis with OMC obstruction
• Maxillary sinus pathology requiring access (fungal ball, retention cyst, antrochoanal polyp, odontogenic sinusitis)
• Mucociliary dysfunction
• Postoperative drainage in revision surgery

Preoperative Planning

• Cummings Otolaryngology, p. 878

Operative Setup

• Patient supine, head slightly elevated (reverse Trendelenburg) to reduce venous engorgement
• Topical vasoconstriction: oxymetazoline or epinephrine 1:1000 on pledgets
• Local anaesthetic infiltration (under endoscopic vision):
  • Axilla of the middle turbinate (~1-1.5 mL 1% lidocaine with 1:100,000 epinephrine - until blanching)
  • Anterior to the inferior uncinate process
  • Optional: greater palatine block (transnasal or transoral) for posterior structures
• Eyes included in the surgical field and lubricated - must be visible at all times
• Image-guided navigation optional, but useful in revision cases or complex anatomy
• Endoscopes: 0°, 30°, 45°, 70° available

Step-by-Step Surgical Technique

Step 1 - Diagnostic Endoscopy and Middle Turbinate Medialization

• Begin with a 0° endoscope
• Identify the middle turbinate - the most important landmark
• Gently medialize the middle turbinate with a Freer elevator to expose the middle meatus
• Optional: a formal basal lamella relaxing incision at the junction of the oblique and vertical middle turbinate attachments to improve access

Step 2 - Uncinectomy (Prerequisite for MMA)

1. Identify the uncinate's posterior free margin (sickle-shaped; has a rolled/everted edge when polyps are present)
2. Slide a ball-tipped probe into the infundibulum behind the posterior free edge to medialize the uncinate off the lamina papyracea (critical when the uncinate is atelectatic over the orbit - as in silent sinus syndrome)
3. A pediatric backbiter punch is placed through the hiatus semilunaris and cuts the uncinate in an axial plane at the junction of the inferior one-third and superior two-thirds - this low incision location:
   • Avoids inadvertent orbital penetration
   • Corresponds to the natural maxillary ostium location
4. Extend the incision anteriorly until the anterior maxillary line (junction with lacrimal bone) is reached - penetrating this bone damages the nasolacrimal duct
5. Remove the middle third of the uncinate with cutting instruments or microdebrider
6. The superior third may be preserved initially to protect the frontal recess from scarring
7. Rotate the inferior third medially with a probe and remove with a downbiter + microdebrider

• Vertical incision on the anterior uncinate surface continued inferiorly and posteriorly along its crescent-shaped margin

Key safety point: Always verify the uncinate is being resected and not the lamina papyracea, which lies immediately lateral to it.

• Cummings Otolaryngology, p. 882; K.J. Lee's Essential Otolaryngology, p. 617

Step 3 - Identification of the Natural Maxillary Ostium

1. Switch to a 30° or 45° angled endoscope angled inferolaterally - this brings the maxillary ostium into optimal view
2. The natural ostium is found in the floor of the infundibulum, lateral to the lower uncinate third
3. It is elliptical - if only a circular opening is seen, suspect an accessory ostium in the posterior fontanelle
4. If mucosal edema obscures the ostium:
   • Follow the "mucus trail" with a small curved suction
   • Use a double-ball (maxillary sinus seeker) probe directed inferolaterally - never laterally alone (orbital injury risk), never forced
   • The inferior turbinate is a useful inferior landmark

Pitfall: Probing directly lateral risks orbital penetration. The probe must be directed inferolateral at 45°.

• K.J. Lee's Essential Otolaryngology, p. 617

Step 4 - Antrostomy Creation

1. Gently dilate the natural ostium posteriorly with the seeker ball probe
   • Avoid the sharp anterior aspect - this minimizes risk of circumferential scarring and stenosis
   • Do not strip mucosa off the maxillary roof or medial wall - risks submucosal hematoma, delayed healing, and scarring
2. Extend the ostium posteriorly with back-biting forceps or through-cutting instruments
3. A straight punch can transect mucosa between medial and superior sinus walls (minimizes shearing/mucosal stripping)
4. Extend inferiorly with a down-biting instrument, taking care not to injure the inferior turbinate
5. Expand superiorly as needed with side-biting antrum punches
6. The final result is a pear-shaped antrostomy verified with a 30° endoscope

Do NOT bite anteriorly into the natural ostium - this risks damage to the nasolacrimal duct.

• Cummings Otolaryngology, pp. 883-884; K.J. Lee's Essential Otolaryngology, p. 617

Step 5 - Incorporation of Accessory Ostia

Sizing the Antrostomy

Inferior meatal antrostomy is rarely indicated and risks creating a separate drainage opening that bypasses mucociliary transport - it may cause recirculation and is reserved for mucociliary dysfunction conditions.

• K.J. Lee's Essential Otolaryngology, p. 618

Instruments Used

Common Causes of Failure

• Missed MMA - natural ostium not identified, only posterior fontanelle opened
• Maxillary ostium stenosis - circumferential scarring from mucosal stripping
• Recirculation - accessory ostium not connected to natural ostium
• Lateralized middle turbinate - adhesion to lateral wall post-operatively blocking access
• Residual ethmoidal cells - incomplete ethmoidectomy maintaining OMC obstruction
• Middle meatal adhesions
• Cummings Otolaryngology, p. 880

Key Complications

Summary of Key Principles

1. The natural ostium must always be identified - opening only the posterior fontanelle does not provide functional drainage
2. Mucociliary transport always heads toward the natural ostium - physiology cannot be redirected surgically
3. Dilate posteriorly, never anteriorly - anterior biting risks nasolacrimal duct injury
4. 30° or 45° endoscope is mandatory for ostium visualization - it opens at 45° into the infundibulum floor and cannot be seen on 0°
5. Always incorporate accessory ostia - to prevent recirculation
6. Preserve mucosa - stripping causes scarring and stenosis, not faster healing
7. Tailor the size to disease extent and mucociliary function

• Cummings Otolaryngology Head and Neck Surgery, pp. 865, 878, 882-884
• K.J. Lee's Essential Otolaryngology, pp. 617-618

Tympanostomy Tubes (Ventilation Tubes / Grommets)

Tympanostomy tube in situ through the tympanic membrane. - Cummings Otolaryngology, p. 3774

Rationale and Mechanism

• Provide a surrogate pathway bypassing the under-functioning Eustachian tube
• Equalize middle ear pressure with atmospheric pressure
• Provide a drainage route for middle ear effusion (MEE) and purulent material
• Reverse OME and restore hearing
• Allow subsequent AOM episodes to present as otorrhoea rather than pain - treatable with topical antibiotics directly through the tube, avoiding systemic antibiotics
• Cummings Otolaryngology, p. 3773

Indications

1. Otitis Media with Effusion (OME / "Glue Ear")

• Bilateral OME persisting ≥ 3 months with documented hearing loss ≥ 25 dB HL in both ears
• OME with type B (flat) tympanogram persisting ≥ 3 months in an at-risk child
• OME associated with vestibular/balance problems, behavioural problems, reduced quality of life, poor school performance
• OME in at-risk children (even if unilateral or without confirmed hearing loss): cleft palate, Down syndrome, autism, pervasive developmental disorder, craniofacial syndromes, pre-existing sensorineural hearing loss, visual impairment, speech-language delay

2. Recurrent Acute Otitis Media (rAOM)

• Defined as ≥3 AOM episodes in 6 months, or ≥4 in 12 months
• AAO-HNS guidelines recommend against tubes in rAOM when no MEE is present at time of assessment
• Recommended as an option for rAOM with MEE in one or both ears at assessment
• Modestly reduces AOM recurrences (~1 episode prevented by 6 months); effect diminishes at 12 months
• Benefit is greatest in children with MEE persisting between AOM episodes

3. Other Indications

• Eustachian tube dysfunction in adults causing chronic OME, barotrauma, or serous otitis
• Severe complications of AOM - mastoiditis, meningitis, intracranial abscess, facial nerve paralysis (as part of acute myringotomy + drainage)
• Persistent AOM despite ≥2 courses of different empiric antibiotics
• Adults with OME > 3 months with persistent aural fullness or hearing loss
• Cleft palate - high rate of Eustachian tube dysfunction; early tube insertion commonly performed
• Barotrauma - failed Valsalva in divers, aviation personnel
• Cholesteatoma retraction pockets - tubes can arrest progression by restoring middle ear pressure (though the causal relationship with cholesteatoma formation is debated)
• Cummings Otolaryngology, pp. 3773-3774; AAO-HNS 2013 guidelines

Types of Tympanostomy Tubes

Short-term (Grommet) Tubes

• Small inner diameter, no lateral flange or small medial flange
• Self-extrude within 6-18 months as the TM migrates laterally
• Used for most routine cases in children
• Examples: Shepard (93% extruded by 2 years), Armstrong (~1 year clinical life; 50% extruded by 12 months, 75% by 18 months), Reuter-Bobbin (66% extruded by 2 years)

Long-term Tubes

• Larger medial flange (T-shape) or flanges on both ends that resist extrusion
• Remain in situ for years - require surgical removal when no longer needed
• Goode T-tube: only 31% extruded by 2 years
• Reserved for:
  • Older children with atrophic TM
  • Cleft palate (grommets extruded too quickly)
  • Multiple previous sets of short-term tubes
  • Conditions requiring prolonged ventilation (e.g. primary ciliary dyskinesia)
  • Adults with irreversible Eustachian tube dysfunction

Material and Coating

• Fluoroplastic (Teflon) or silicone - silicone tubes were associated with longest time to first infection in a 400-patient RCT
• Long Armstrong tubes least prone to extrude among the short-term designs
• Antimicrobial coatings (silver oxide, etc.) proposed to reduce biofilm - data mixed

• Cummings Otolaryngology, p. 3774

Surgical Technique

Anaesthesia

• Children: general anaesthesia (inhalational), brief mask anaesthetic - no intubation required in most
• Selected children and adults: local anaesthesia (topical EMLA or lidocaine iontophoresis) in an office or clinic setting

Equipment

• Binocular operating microscope (mandatory)
• Ear speculum
• Myringotomy knife (curved radial blade) or tympanotomy lancet
• Fine suction (Frazier or Baron tip)
• Alligator forceps
• Tympanostomy tube of choice

Steps

1. Remove cerumen and debris from the external canal under direct microscopic vision
2. Inspect the entire tympanic membrane - identify the pars flaccida, pars tensa, handle of malleus, and light reflex; rule out pre-existing pathology
3. Myringotomy incision: made in the anteroinferior quadrant of the pars tensa
   • A radial incision directed toward the umbo
   • Size: large enough for tube insertion with alligator forceps, but small enough to prevent premature extrusion
   • The anteroinferior location avoids the ossicles (postero-superiorly), the facial nerve (posteriorly), and prevents tube migration onto the umbo
4. Aspirate the MEE through the myringotomy with a fine Frazier suction
   • If MEE is too thick to aspirate:
     • Make a counterincision in the inferior TM, or
     • Irrigate with sterile saline through the myringotomy to thin the fluid
5. Insert the tube through the myringotomy incision using alligator forceps
   • Advance the medial flange through the TM
   • Ensure the tube sits flush and stable, with the lumen patent

Postoperative Care and Follow-Up

• First follow-up: 2-3 months post-insertion (otoscopy + hearing assessment)
• Subsequent reviews: every 6-12 months (or sooner if problems arise)
• At each visit: assess tube status (in situ, blocked, extruded), TM integrity, and hearing
• Water precautions: swimming and bathing water entry is a common parental concern. Evidence on mandatory use of ear plugs is mixed - many guidelines do not mandate plugs for surface swimming but do advise avoiding diving/submersion
• Topical antibiotic drops (e.g. ciprofloxacin/dexamethasone) at the time of insertion reduce early post-operative otorrhoea (NNTB 13 for single intraoperative dose)
• Middle ear saline washouts at surgery reduce early otorrhoea (NNTB 7)
• Cummings Otolaryngology, p. 3774

Complications and Sequelae

1. Acute Tympanostomy Tube Otorrhoea

• Most common complication: 25-75% of children develop ≥1 episode
• Results from AOM with middle ear fluid draining through the tube
• Risk factors: young age, rAOM as indication, recent recurrent URTIs, older siblings
• Management: topical antibiotic-corticosteroid drops (e.g. ciprofloxacin/dexamethasone) as first-line - these reach the middle ear directly through the tube
• If unresolved at 2 weeks: culture from tube lumen to guide therapy
• If yeast is predominant: topical clotrimazole
• Persistent or frequently recurring otorrhoea: remove the tube (foreign body reaction, biofilm)

2. Tube Blockage

• Incidence: ~6.9% (range 0-37%)
• Caused by dried blood/mucus, granulation tissue, or polyps
• Risk factors: serous effusion at surgery, delayed follow-up
• Management: suction, pick/Rosen needle, or ototopical drops for 10-14 days
• If cannot be unplugged: tube removal and reinsertion

3. Early (Premature) Extrusion

• ~3.9% of ears
• Causes: active middle ear infection pushing tube out; improper insertion into thickened TM; TM atrophy
• Requires tube reinsertion if indication persists

4. Tympanosclerosis

• ~32% after tube extrusion (range 7-64%)
• Calcification/hyalinisation of TM at insertion site - usually minimal functional significance
• No significant difference between short-term and long-term tubes

5. Focal Atrophy

• ~25% after extrusion (range 1.6-75%)
• Thin, healed TM patch at the tube site; usually functionally insignificant

6. Persistent Perforation

• Short-term tubes: 2.2% (range 0-12.3%)
• Long-term tubes: 16.6% (range 0-47%) - a major reason to avoid long-term tubes unless necessary
• Usually small; associated with only mild conductive hearing loss
• Management: myringoplasty (fat plug, paper patch, or formal fascia/perichondrium graft)
  • Prerequisite: Eustachian tube function should have recovered; contralateral TM intact and infection-free for 1 year

7. Retraction Pockets

• ~3.1% after extrusion
• More relevant as a pre-existing complication of OME itself than of tubes per se

8. Cholesteatoma

• Reported incidence 0-6.5% - controversial; likely represents underlying middle ear pathology rather than a tube-specific complication
• Possible mechanism: ingrowth or transplantation of keratinised epithelium through the tube site
• Cummings Otolaryngology, pp. 3774-3775

Adjuvant Adenoidectomy

• Cummings Otolaryngology, p. 3773

Eustachian Tube Balloon Dilatation

• Cummings Otolaryngology, p. 3774

Summary Table

• Cummings Otolaryngology Head and Neck Surgery, pp. 3773-3775
• AAO-HNS Clinical Practice Guideline: Tympanostomy Tubes in Children, 2013