Anesthesia for Myringotomy

Chronic middle ear infections rank in the top three pediatric chronic medical disorders. The first line of treatment for this condition is a regimen of antibiotics. When this treatment fails to resolve the symptoms, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to rid of the fluid buildup in the child's ear and to keep the pressure in the ear the same as it is in the air. This will reduce the chances of any new infections and can potentially correct any hearing loss caused by the fluid buildup.

But many parents have reservations about allowing their child to undergo this procedure. Their concerns include postoperative vomiting (POV), intravenous (IV) placement, postoperative pain, and time spent in the hospital. The presence or absence of an IV catheter can affect all of these variables. An IV allows perioperative fluid and drug administration, but can result in discomfort, subcutaneous infiltration, and possible parental dissatisfaction if numerous venipunctures were required. The absence of an IV often results in earlier discharge because oral fluids and medication can be given at home.

Postoperative vomiting is a common problem after surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. The target age of children who develop POV is 2-12 years. POV is common after strabismus, adeno-tonsillectomy, orchidopexy, gastrointestinal, and otologic surgeries. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays ambulation and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

There are several ways to decrease POV. These include gastric suctioning to relieve distension, avoidance of selected anesthetic agents such as nitrous oxide and opioids, and withholding oral fluids postoperatively. Aggressive IV hydration and adequate pain control may also decrease POV.

A team of researchers from Detroit set out to assess whether the presence of IV access or lack thereof, affects the incidence of POV, postoperative pain and length of hospital stay. Parental satisfaction was also identified as a measure of perioperative outcome. The authors of "Anesthesia without Intravenous Access for Myringotomy Improves Parent Satisfaction" are Michael S. Haupert DO, Clarina Pascual MD, Abboy Mohan MD, Beata Bartecka-Skrzypek MD, and Maria M. Zestos, MD, all from the Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI. Their findings are to be presented at the 18th Annual Meeting of the American Society of Pediatric Otolaryngology http://www.aspo.us/, being May 4-5, 2003, Nashville, TN.

Methodology: One hundred children were enrolled in this randomized prospective study. Only healthy children or those with mild systemic disease were enrolled. All patients were age 2-12, undergoing BMT at Children's Hospital of Michigan. Any child with an allergy to fentanyl, a history of severe postoperative nausea and vomiting, severe systemic disease, obesity, history of motion sickness, or who needed IV medication was excluded.

All children received general anesthesia with sevoflurane, nitrous oxide, and oxygen by mask as routinely done for BMT. All children received 1mcg/kg IM fentanyl for pain. Random number tables were used to randomize patients into two groups. Group 0 had no IV; group 1 had an IV and received a bolus of Ringer's lactate, 20ml/kg IV during the anesthetic.

An objective pain scale was used to assess postoperative pain and the need for additional pain medications. A pain score of five or greater was considered significant requiring analgesic administration. Postoperative pain was treated with codeine 0.5 mg/kg po (group 0) or 0.25 mg/kg IV (group 1), and acetaminophen 15mg/kg po. Blood pressure, heart rate, respiratory rate, oxygen saturation, and pain scores were recorded every five minutes in the recovery room. Additional pain medication, time in operating room, time in recovery room, time in the wake-up room, time to first oral intake, time until ready for discharge, and actual discharge time were recorded. Parents were contacted by telephone 24 hours after the procedure, to assess the child and parental satisfaction with presence or absence of an IV as well as documentation of any additional vomiting or oral pain medication

Results: One hundred eligible patients were included in this study. There was no significant difference in age, weight, and incidence of POV between the two groups. Children with IV access spent more time in the operating room (21±8 vs 17±7 min.) and in phase 2 recovery (75±67 vs 51±24 min). Children in group 1 spent a significantly greater amount of time in the hospital (119±67 vs 88±30 min). The incidence of the objective pain score being >5 was significantly greater in group 1 (31 percent vs two percent). Lastly, parental satisfaction was significantly greater for children without IV access (95 percent vs 28 percent).

Conclusions: BMT is the most common surgical procedure performed in the United States on children. Anesthetic complications are one factor affecting the outcome of BMT. A recent study confirmed that anesthesia can be administered for BMT with a very low rate of perioperative complications. POV is one of the most common adverse perioperative complications that patients experience. Although, perioperative hydration has been shown to decrease POV, the incidence was essentially the same in both groups of this study

The establishment of IV access in healthy children undergoing BMT provided no added benefit. On the contrary, children without IV access had lower postoperative pain scores, reduced opioid requirements, spent less time in the OR, in phase 2 recovery, and in the hospital. IV access did not decrease POV. Parental satisfaction, a clinically relevant outcome, was significantly greater for parents of children who did not receive an IV.