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  1. Bilateral myringotomy tube placement is frequently a short case. Rapid turnover is usually expected.

  2. Children presenting for bilateral myringotomy tube (BMT) placement may have an active or recent URTI. The risks and benefits of proceeding should be evaluated and discussed with the caregivers and surgeon.

  3. Bilateral myringotomy tube placement is frequently done under inhalational anesthesia with mask ventilation. Peripheral IV access is not mandatory for otherwise healthy patients.

  4. Nitrous oxide may be used to distend the tympanic membrane.

  5. Children with trisomy 21 may have narrow ear canals, which increases the operative time. IV and laryngeal mask airway (LMA) placement may be appropriate.

  6. Pain control may be achieved with nasal and IM medications supplemented by acetaminophen and/or ibuprofen.


Ear, nose, and throat (ENT) surgery encompasses a wide variety of procedures, frequently short, taking as little as 5 minutes for uncomplicated myringotomy tubes. Given the brief nature of many pediatric ENT procedures, multiple surgeries are routinely scheduled in an operating room (OR), and a rapid turnover is often expected. ENT procedures carry a high incidence of airway complications, and a balance must be achieved between safety and efficiency. The anesthesia team must remain vigilant and be prepared to manage perioperative complications such as laryngospasm and bronchospasm. A factor that increases the risk of airway complications is that children presenting for ENT surgery are frequently experiencing or recovering from an upper respiratory tract infection (URTI). ENT procedures also vary in the amount of pain the patient may experience, from unstimulating brainstem auditory evoked response (BAER) evaluations to tonsillectomy and adenoidectomy surgeries. A wide variety of anesthesia techniques may be safely utilized for ENT procedures; however, there is no one “recipe” for each case and an anesthetic plan must be individualized to each patient and procedure.

As with any anesthetic, preoperative evaluation and physical examination should be performed, and any comorbid conditions should be medically optimized prior to proceeding with elective surgery. Preparation of the anesthesia workstation should include rescue medications and emergency airway management equipment.


A 14-month-old girl presents for BMTs, 6 days after being diagnosed with acute otitis media, and has been taking antibiotics as prescribed by her pediatrician. The patient had been referred to an ENT surgeon for BMT placement after being treated for multiple episodes of acute otitis media in the preceding months. Discussion with the patient’s family reveals that she was born at term and is otherwise healthy. The parents state that she has had multiple “ear infections” over the past several months, and it seems like she is “always fighting one.” Physical exam reveals a playful, well-developed 14-month-old child with dried mucus in her bilateral nares. Cardiac and pulmonary auscultation are unremarkable and her vital signs are age-appropriate.



Bilateral myringotomy ...

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