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In-Office Placement of Tubes in Pediatric Patients While Awake

In-Office Placement of Tubes in Pediatric Patients While Awake

The position of the AAO-HNS is that tympanostomy tubes are safe and effective for managing otitis media in children who meet current guidelines for tube insertion [Rosenfeld 2013]. Although insertion of tympanostomy tubes in children is generally accomplished in the operating room under general anesthesia, insertion in the clinic in appropriately selected patients using shared decision making between clinicians and families can be appropriate.

Adopted 7/9/19


  1. Bhananker SM, Azasvedo L, MacCormick J, Splinter W. Topical lidocaine and oral acetaminophen provide similar analgesia for myringotomy and tube placement in children. Can J Anesth 2008; 53:1111-6.
  2. Brodsky L, Brookhauser P, Chait D, Reilly J, Deutsch E, Cook S, Waner M, Shaha S, Nauenberg E. Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration. Laryngoscope. 1999 Dec;109(12):2009-14. PubMed PMID: 10591365.
  3. Cofer S, Meyer A, Yoon D, et al. Tympanostomy tube placement in children using a single-pass tool with moderate sedation. Otolaryngol Head Neck Surg 2017; 156:533-5.
  4. Cohen LL, Martin SR, Gamwell KL, McCarty C, Shih SW. Behavioral techniques to optimize success of in-office pediatric tympanostomy tube placement without sedation. Int J Pediatr Otorhinolaryngol 2015; 79:2170-3.
  5. Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, Stargatt R, Bellinger DC, Schuster T, Arnup SJ, Hardy P, Hunt RW, Takagi MJ, Giribaldi G, Hartmann PL, Salvo I, Morton NS, von Ungern Sternberg BS, Locatelli BG, Wilton N, Lynn A, Thomas JJ, Polaner D, Bagshaw O, Szmuk P, Absalom AR, Frawley G, Berde C, Ormond GD, Marmor J, McCann ME; GAS consortium. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet. 2016 Jan 16;387(10015):239-50. doi: 10.1016/S0140-6736(15)00608-X. Epub 2015 Nov 4. Erratum in: Lancet. 2016 Jan 16;387(10015):228. PubMed PMID: 26507180; PubMed Central PMCID: PMC5023520.
  6. FDA. FDA Drug Safety Communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Accessed 5/29/19 at:
  7. Friedman O, Deutsch ES, Reilly JS, Cook SP. The feasibility of office-based laser-assisted tympanic membrane fenestration with tympanostomy tube insertion: the duPont Hospital experience. Int J Pediatr Otorhinolaryngol 2002; 62:31-5.
  8. Hoffmann KK, Thompson GK, Burke BL, Derkay CS. Anesthetic complications of tympanostomy tube placement in children. Arch Otolaryngol Head Neck Surg 2002; 128:1040-3.
  9. Lee DH. How do you select an anesthesia method prior to tympanostomy tube insertion for a child? J Audiol Otol 2016; 20:127-30.
  10. Lee DH, Jung K, Kim H. Age as a Determinant to Select an Anesthesia Method for Tympanostomy Tube Insertion in a Pediatric Population. J Audiol Otol 2015:12:45-50.
  11. McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, Grobler A, Stargatt R, Hunt RW, Sheppard SJ, Marmor J, Giribaldi G, Bellinger DC, HartmannPL, Hardy P, Frawley G, Izzo F, von Ungern Sternberg BS, Lynn A, Wilton N,Mueller M, Polaner DM, Absalom AR, Szmuk P, Morton N, Berde C, Soriano S,Davidson AJ; GAS Consortium. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet.
  12. O’Leary JD, Janus M, Wijeysundera DN et al. Influence of Surgical Procedures and General Anesthesia on Child Development Before Primary School Entry Among Matched Sibling Pairs. JAMA Pediatr 2019 Jan 1;173:29-36.
  13. Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: tympanostomy tube insertion in children. Otolaryngol Head Neck Surg 2013; 148(1 Suppl):S1-S35.
  14. Rosenfeld RM, Sury K, Mascarinas C. Office insertion of tympanostomy tubes without anesthesia in young children. Otolaryngol Head Neck Surg 2015; 153:1067-70.
  15. Rosenfeld RM. Shared decision making and office insertion of tympanostomy tubes. Otolaryngol Head Neck Surg 2016; 154:807-9.
  16. Scholes MA, Jensen EL, Polaner DM, Gao D. Multiple surgeries in pediatric otolaryngology patients and associated anesthesia risks. Int J Pediatr Otorhinolaryngol 2018; 113:115-8.
  17. Consensus Statement Supplement 11/2015 on the Use of Anesthetic and Sedative Drugs in Infants and Toddlers. Accessed 5/29/19 at:
  18. Summerfield MJ, White PS. Ventilation tube insertion using topical anesthesia in children. J Laryngol Otol 1992; 106:427-8.
  19. Zeiders JW, Syms CA, Mitskavich MT, et al. Tympanostomy tube placement in awake, unrestrained pediatric patients: a prospective, multicenter study. Int J Pediatr Otorhinolaryngol 2015; 79:2416-23.

Important Disclaimer Notice (Updated 7/31/14)

Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.

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