Is IV access necessary for myringotomy with tubes?

Ear, Nose & Throat Journal, Nov, 2007 by Arthur H. Allen

Abstract

A retrospective chart review was conductedata community-based hospital to determine whether intravenous access is necessary during the performance of myringotomy with tube insertion. The study included 50 pediatric patients divided equally into 2 groups: group 1, who did not have intravenous access established before the procedure, and group 2, who did have intravenous access established. To be enrolled, patients in both groups had to be [less than or equal to]12 years of age, have an American Society of Anesthesiologists physical status classification of P1 or P2, and had to have undergone no adjunctive procedure with the myringotomy. Induction time was significantly shorter in group 1 (average: 6.96 [ or -] 2.72 minutes) than in group 2 (average: 9.80 [ or -] 3.82 minutes; p = 0.004). Operating time and total operating room time were not significantly different between the two groups. Additionally, 24 of 25 patients in group 1 had their pain managed with acetaminophen or no medication at all, while 9 of 25 group 2 patients received acetaminophen and 13 received intravenous pain medication. Interestingly, no patients in group 1 required antiemetics, whereas 4 patients in group 2, who were given intravenous or intramuscular narcotics, received antiemetic medications. These findings indicate that myringotomy with tube insertion can be safely accomplished without establishing intravenous access. Induction times and time under general anesthesia were significantly increased when intravenous access was obtained. The findings also suggest that acetaminophen provides adequate postoperative pain control in this patient population and that the use of intravenous or intramuscular narcotics increases the risk of postoperative nausea.

Introduction

Otitis media (OM) in the pediatric population accounts for an estimated 24 million visits to physicians' offices per year, with a direct cost of $1.96 billion annually and an indirect cost of $1.02 billion annually, according to 1995 data. (1-3) This makes OM one of the most common diseases of children in the United States. For acute cases of OM, antibiotics have been the mainstay of therapy. In 2004, the American Academy of Pediatrics presented new guidelines for the treatment of acute otitis media (AOM). (3) These include recommendations that (1) an accurate diagnosis of AOM should be made, differentiating it from otitis media with effusion (OME); (2) ibuprofen or acetaminophen should be given for pain relief, especially during the first 24 hours; and (3) antibiotic side effects can be minimized by waiting 48 to 72 hours from the onset of symptoms before prescribing an antibiotic (usually amoxicillin). (3)

Myringotomy is generally not indicated in the treatment of a patient with AOM. The role of myringotomy with pressure equalization (PE) tube placement is reserved for a select number of patients, including (1) children in whom OME lasts 4 months or longer, with hearing loss or other signs and symptoms; (2) children with recurrent or persistent OME who are at risk for speech, language, or learning problems regardless of hearing status; and (3) children with structural damage to the middle ear or tympanic membrane secondary to OME. (4)

Myringotomy with PE tube insertion must be carried out under general anesthesia in the pediatric population. In these patients, it is generally agreed that inhalation anesthesia is preferred for this brief procedure. Two available inhaled anesthetics are halothane and sevoflurane. Sevoflurane has gained popularity because it has been shown to allow faster induction and emergence times, it has fewer induction complications (e.g., laryngospasm), and it is associated with less risk of impairing hemodynamic performance when compared with halothane. (5)

Postoperative pain associated with myringotomy with PE tube insertion is generally minimal. A number of medications have been studied and compared, including acetaminophen, acetaminophen with codeine, ketorolac, and butorphanol. These drugs can be administered by a variety of routes: Acetaminophen is given orally or rectally, acetaminophen with codeine is given orally, ketorolac is given intravenously (IV) or intramuscularly (IM), and butorphanol is given via an IV, IM, or intranasal route. Comparative studies have examined these medications and their routes of administration. (6-8) All these studies have been able to show one agent or route superior to another, but there is no clear consensus among them as to which is superior to all other medications and routes. Each facility must weigh such factors as the cost of various medications, the increase in cost and risk for the route by which they are delivered, and patient satisfaction with the medication and route of administration. The facility at which the present study was conducted routinely prefers acetaminophen (10 to 15 mg/kg) administered rectally after induction or orally in the recovery room. This is an effective, low-cost treatment for the pain of the procedure, and it has a convenient route of administration.