Myringotomy & Tube Placement (Pediatric)
Patient phenotype
Toddlers and young children (1-5 yr), recurrent otitis media or chronic effusion. Usually otherwise healthy. Outpatient. Frequent runny nose/URI in this age group.
Procedure
Otologist makes small incision in tympanic membrane, suctions middle ear fluid, places ventilation tube. ~5-10 minutes total. Usually no IV — strictly mask anesthetic.
Anesthetic plan
Sevoflurane mask anesthesia, no IV. Patient arrives screaming or sleeping. Spontaneous ventilation throughout. Acetaminophen 15 mg/kg PR or PO at end. Recovery 30-60 min.
Setup
- ·Pediatric ASA monitors (forehead pulse ox often most reliable)
- ·Mapleson D circuit OR pediatric circle
- ·Sevoflurane vaporizer + N₂O
- ·Suction at head of bed
- ·PR acetaminophen drawn
- ·No IV needed (have setup ready in case)
- ·Lateral recovery position
Biggest concerns by phase
URI assessment — proceed or postpone?
URI within 2 weeks → 7x respiratory adverse events (laryngospasm, breath-holding, desat). Postpone if: fever > 38, mucopurulent rhinorrhea, productive cough, wheeze. Otherwise proceed cautiously with mask, spontaneous breathing.
Mask induction with crying, struggling toddler
Stage 2 (excitement) phase = laryngospasm risk. Approach: parent present if helpful, distraction (phone, toy), pleasant scent on mask, sevo started low (2%) gradually increased, gentle restraint. Once asleep, parent leaves.
Laryngospasm — recognize + treat fast
Common in this age + URI. Signs: paradoxical chest movement, no ETCO₂, ↑PIP, desat. Treatment: 100% O₂, jaw thrust, Larson's maneuver (firm pressure behind earlobe), CPAP, succinylcholine 0.1-0.5 mg/kg IV (or 2-4 mg/kg IM if no IV).
Bradycardia in peds — atropine ready
Vagal tone high in young children. Bradycardia from sevo + manipulation can drop dramatically. Atropine 0.02 mg/kg IV (min 0.1 mg) or 0.04 mg/kg IM. Pre-induction not standard but ready in syringe.
Emergence delirium — high in this population
Sevoflurane + young age + pain = emergence delirium 30-50%. Strategies: dexmedetomidine 0.3-0.5 mcg/kg before emergence, propofol 0.5-1 mg/kg before emergence, smooth quiet recovery environment, parent presence in PACU if available.
Quick discharge — confirm awake + drinking
Most patients home in 30-60 min. Discharge criteria: awake/easily roused, drinking clear fluids, no respiratory distress, pain controlled, parent comfortable. PR acetaminophen lasts 4-6h.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
3-year-old for PE tubes, mom in OR for induction. As you place mask, child screams + struggles. Three minutes in, you see paradoxical chest motion, ETCO₂ flat, SpO₂ 88 and falling. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes laryngospasm in stage 2 induction
- ▹Immediate: 100% O₂ + jaw thrust + Larson's maneuver
- ▹Tight mask seal + CPAP 15-20
- ▹If persists: sux 0.1-0.5 mg/kg IV if access; 2-4 mg/kg IM if not
- ▹Atropine ready for bradycardia
Sources
- Coté Pediatric Anesthesia
- AAP perioperative URI guidelines
Anatomy reference
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