Myringotomy and Tympanostomy Tube Placement
Recurrent acute otitis media / chronic otitis media with effusion / eustachian tube dysfunction
Same
Bilateral myringotomy and tympanostomy tube placement
[***, MD/DO]
[Resident/Fellow/PA name]
General inhalational (mask) / local
Patient presents with [recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months, with middle ear effusion present at time of assessment) / chronic bilateral OME ≥3 months with conductive hearing loss, speech delay, or at-risk condition (Down syndrome, cleft palate, ASD, craniofacial anomaly)]. [Bilateral] middle ear effusion confirmed on [pneumatic otoscopy / tympanometry]. Conservative management for [X months] failed. Risks including persistent perforation, tube extrusion, and otorrhea discussed. Consent obtained.
Bilateral tympanic membranes [dull / retracted / with effusion]. [Amber / grey] effusion present bilaterally. [Fluid expressed on myringotomy: serous / mucoid / purulent.] Landmarks [visible / obscured]. No cholesteatoma.
The patient was brought to the operating room. Inhalational general anesthesia administered via mask [without intubation]. The patient was positioned supine and the ear canal cleaned under the operating microscope.
RIGHT EAR: The ear canal was cleaned of cerumen. The tympanic membrane was visualized with the operating microscope. A radial myringotomy incision was made in the anteroinferior quadrant using a myringotomy knife. [Effusion aspirated with a Baron suction.] A [Reuter Bobbin / Armstrong / T-tube] tympanostomy tube was placed through the myringotomy using alligator forceps. Position confirmed in the myringotomy, tube [patent].
LEFT EAR: Same procedure performed in mirror fashion.
Both ears inspected. Tubes patent and in good position. [Antibiotic otic drops instilled bilaterally at end of procedure.] Patient awakened without difficulty.
None
Middle ear fluid [sent for culture / discarded]
Minimal
Bilateral tympanostomy tubes in place
Patient taken to PACU. Discharged same day.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Recurrent acute otitis media / chronic otitis media with effusion / eustachian tube dysfunction]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Bilateral myringotomy and tympanostomy tube placement
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General inhalational (mask)
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [recurrent AOM (*** episodes in *** months, with middle ear effusion confirmed at time of assessment) / chronic bilateral OME ≥*** months with conductive hearing loss / speech delay / at-risk condition]. Bilateral middle ear effusion confirmed on pneumatic otoscopy and tympanometry. Conservative management for *** months failed. Risks including persistent perforation, tube extrusion, and otorrhea were discussed. Informed consent obtained.
FINDINGS: Bilateral tympanic membranes dull and retracted. [Amber / mucoid] effusion present bilaterally. Landmarks visible. No cholesteatoma.
DESCRIPTION OF PROCEDURE:
The patient was taken to the OR; inhalational general anesthesia administered via mask without intubation. Positioned supine. RIGHT EAR: Ear canal cleaned under operating microscope. Tympanic membrane visualized. Radial myringotomy incision made in the anteroinferior quadrant. Effusion aspirated with Baron suction. A [Reuter Bobbin / Armstrong] tympanostomy tube placed through the myringotomy with alligator forceps, confirmed patent and in good position. LEFT EAR: Same procedure performed in mirror fashion. Both tubes confirmed patent. Antibiotic otic drops instilled bilaterally. Patient awakened without difficulty.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Middle ear fluid [sent for culture / discarded]
COMPLICATIONS: None
DRAINS: Bilateral tympanostomy tubes in place
DISPOSITION: Patient taken to PACU. Discharged same day.
Signed: .ME, .MYDEGREE
.TODAYVariants
T-tube placement
For chronic Eustachian tube dysfunction. T-tubes remain for several years. Document tube type and placement site.
In-office with automated delivery device (Tula System / Hummingbird TTS)
In-office procedure with topical anesthesia. FDA-cleared for patients ≥6 months old (not adult-only). Document which device was used, anesthesia adequacy, and tube placement.
Tube removal
Document tube location, removal technique (alligator forceps), and tympanic membrane status.
Charting Tips
- Document tube type (short-term grommet vs. long-term T-tube — affects expected dwell time and follow-up plan)
- State fluid character (serous, mucoid, purulent) — affects postoperative antibiotic decisions
- Document that tube is patent and in correct quadrant (anteroinferior is standard)
- Document otic drops if instilled at end of case
- Bilateral placement: use bilateral-procedure reporting for most payers (single line), but verify — some Medicaid/commercial payers require RT/LT modifiers on separate lines
- Per 2022 AAO-HNS CPG: document that MEE was confirmed at time of surgical assessment (required for recurrent AOM indication), and document OME duration (≥3 months for chronic OME indication)
Documentation & Reimbursement Considerations
- Primary service: Report Myringotomy and Tympanostomy Tube Placement as the primary service when it is the definitive operation performed.
- This is the primary service for most pediatric bilateral tube placements.
- Use for in-office adult procedures or awake procedures.
- Medicare and many commercial payers reimburse at 150% for the bilateral modifier. However, some state Medicaid and commercial payers require two separate lines with RT/LT modifiers — verify payer-specific requirements.
- Subsequent tube checks and audiograms are separately billable after the global period.
- The primary service requires general anesthesia as an integral part — do not use for in-office tube removal without GA; report an E/M instead.
- In-office tube placement with automated delivery devices: coding differs by device.