Myringotomy with Ear Tube Insertion Consent

# Myringotomy with Ear Tube Insertion Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Surgeon / Otolaryngologist:** ___________ **Facility:** ___________ **Child's Name:** ___________ ("Patient") **Child's Date of Birth:** ___________ **Parent / Legal Guardian Name:** ___________ ("Parent/Guardian") **Relationship to Patient:** ___________ **Ear(s) to Be Treated:** ___________ **Tube Type Planned:** ___________ --- ## 1. Description of the Procedure (a) **Myringotomy** is a small incision made in the eardrum (tympanic membrane) to allow fluid to drain from the middle ear space. The procedure is performed under brief general anesthesia (most commonly a mask inhalation induction without IV access in young children) and typically takes 10–15 minutes. (b) **Tympanostomy tube (ear tube) insertion** involves placing a small hollow tube through the myringotomy incision. The tube ventilates the middle ear, equalizes pressure, and allows ongoing drainage of fluid and secretions. Short-term tubes are designed to fall out on their own as the eardrum heals (typically within 6–18 months); long-term tubes remain in place longer and may require surgical removal. (c) The procedure is most often performed in an outpatient surgery center or hospital operating room but may be performed in an office setting under topical or local anesthesia in select cooperative older children or adults. --- ## 2. Indications Ear tube insertion is recommended for this Patient for the following reason(s): **Primary Indication(s):** ___________