Myringotomy with tympanostomy tube placement is among the most frequently performed procedures in otology and represents a cornerstone of management for patients with chronic otitis media and eustachian tube dysfunction. Performing this procedure in the clinic offers significant advantages in patient convenience, efficiency, and cost, while maintaining high safety and efficacy. This chapter reviews the indications, technical considerations, and outcomes associated with office-based myringotomy and tympanostomy tube placement, with emphasis on best practices, common pitfalls, and patient selection.

Tympanostomy tubes (TTs) provide for ventilation to the middle ear. They are among the most common procedures performed in the outpatient setting in both children and adults. TTs are placed for a variety of clinical indications. The most common indications include Eustachian tube dysfunction, chronic otitis media, tympanic membrane (TM) retractions, and complications of acute and chronic otitis media, such as mastoiditis, that necessitate ventilation.

Phenol is gently applied to the tympanic memrane in only the location where the myringotomy will be made.

A linear myringotomy is made avoiding critical structures, such as the ossicular chain.

A tympanostomy tube is placed with a alligator avoiding touching the external auditory canal.

The typical evaluation of a patient for the need of a TT is a history and a full head and neck exam, including an otologic exam. History should include documentation of hearing loss, dizziness, tinnitus, otalgia, otorrhea, aural fullness, otologic trauma, prior ear infections, and surgery. The otologic exam should include evaluation of the TM, including documentation of fluid and/or TM retraction. The surgeon should ensure there are no vascular structures, such as a high-riding jugular bulb, that may preclude placement. In addition, in the case of a unilateral effusion, nasopharyngoscopy should be performed to rule out malignancy that may obstruct the Eustachian tube orifice. If there are any complicating features of the effusion, such as concern for a vascular anomaly, computed tomography may be performed to better evaluate the middle ear anatomy. Pure tone audiometry and tympanometry should be performed before any tube placement. Particular attention to be made to the presence of an air-bone gap, as well as flat or negative pressures on tympanometry.

Tympanostomy tubes are routinely placed in an awake adult in the outpatient setting. Pediatric patients commonly require sedation. There is a wide variety of tympanostomy tube options for patients. The most common designs include a short tube, generally referred to as a grommet tube, or T-tubes. Grommet tubes typically remain in the TM for 4–18 months, whereas T-tubes stay in good position in the TM for more than 15 months. In most cases, short-term tubes are the more appropriate option for in-office placement, resulting in less discomfort for patients during the tympanostomy. While it depends on the surgeon’s preference, three to four sets of grommet tubes are typically applied before considering a T-tube. Due to the discomfort caused by placing a T-tube in the office, most patients opt to have this long-term tube placed under general anesthesia in the operating room.

Indications for T-tubes include weakened or atelectatic TMs, early extrusion of grommet tubes in the past, and a long history of eustachian tube dysfunction (ETD). There is no differentiation between the rates of recurrent otitis media or serous otitis media regarding the type of tube placed. The primary difference is the duration before the tube extrudes or is manually removed by the surgeon.