Tympanocentesis - A Minimally Invasive Solution for Ear Infections

Introduction

Tympanocentesis is a minor surgical procedure to aspirate or remove fluid from the middle ear to provide a route to administer medications. A fine needle is inserted through the tympanic membrane into the middle ear space. This was first described in 1768 and has been used to treat acute otitis media or AOM (middle ear infection). Therefore, during that era, it was popularly used to administer antibiotics.

However, nowadays, this is mostly used for other complex cases that do not respond to antibiotic therapy. Furthermore, this procedure is considered diagnostic and therapeutic, as the needle inserted through the tympanic membrane can aspirate fluid, which can be assessed later in laboratories.

What Is the Anatomy of Ear?

The ear is divided into three main parts, which include - the external ear, middle ear, and inner ear.

• The external ear comprises the auricle, the external auditory canal, and the external auditory meatus.

• The middle ear consists of air space, a tympanic membrane (ear drum), and three ossicles.

• The inner ear is the innermost part that consists of the cochlea, semicircular canals, fluids, and cranial nerve VIII (vestibulocochlear nerve).

The main function of the middle ear (tympanic cavity) is the conduction of sound waves by the auricle to the inner ear. The tympanic membrane (TM) is an oval, thin membrane that separates the external and middle ear.

What Are the Indications of Tympanocentesis?

Tympanocentesis is considered a diagnostic and therapeutic procedure that can be beneficial in the treatment of various disorders of the ear, such as

• Acute Otitis Media - Infection of the middle ear.

• Chronic Otitis Media With Effusion - Middle ear infection with fluid but no sign of early infection.

• Tympanic Membrane Retraction - A condition where part of the tympanic membrane is retracted into the middle ear cavity.

• Sensorineural Hearing Loss - Hearing loss is caused by damage to the inner ear structures.

• Meniere Disease - An inner ear disorder that leads to hearing loss and vertigo.

The therapeutic indications for tympanocentesis include -

• Otalgia (Ear Pain) Relief - Pain is one of the most common manifestations of various ear disorders. Acute otitis media can cause severe otalgia, mainly in pediatric patients. Therefore, with the help of tympanocentesis, this can be managed easily.

• Therapeutic Administration of Medications - Medicines can be administered in the intratympanic region of the ear with the help of tympanocentesis, such as antibiotics, corticosteroids, antifungals, and topical analgesic agents. These drugs help treat conditions such as Meniere disease and sensorineural hearing loss.

Diagnostic indications for tympanocentesis include -

• Acute Otitis Media in an Immunocompromised Patient - The diagnosis and treatment of acute otitis in an immunocompromised patient can be challenging. However, tympanocentesis can allow the clinic to perform microscopic culture and analysis of ear aspiration to provide a diagnosis.

• Acute Otitis Media in Neonates - Tympanocentesis can be helpful in the diagnosis of acute otitis media in neonates, as in such patients, the cause of the disease is unknown.

• Unresolved Acute Otitis Media - Patients with acute otitis media (AOM) are unresponsive to usual antibiotic treatment. Tympanocentesis can be used to identify pathogens and microorganisms causing the infection.

• Tympanic Membrane Retraction - Tympanocentesis can be helpful in the management of tympanic membrane retraction by assisting the insertion of a ventilation tube that helps elevate the membrane.

What Are the Contraindications of Tympanocentesis?

Tympanocentesis is a standard procedure that is done under local anesthesia. It is a safe procedure. However, it still has some contraindications, such as -

• This procedure requires absolute cooperation from uncooperative patients to achieve its diagnostic or therapeutic purpose.

• In a patient with an intact tympanostomy tube.

• An incomplete or poorly visualized tympanic membrane.

• Patients with intratympanic tumors such as facial neuromas and meningiomas should not have tympanocentesis performed.

• Blood dyscrasias (blood disorder) or anticoagulation.

What Equipment Is Required for Tympanocentesis?

The equipment required for tympanocentesis includes -

• Microscope.

• Ear specula of multiple sizes (a cone-shaped device to view the inside of the ear).

• Appropriate chair and treatment couch.

• Jobson Horne probe (designed for wax removal).

• Wax hook.

• Suction system.

• Topical anesthetic agent.

• Spinal needle, 21 gauge.

• Aspirating syringe, 3 mL.

• Culture swabs and media.

How Is This Procedure Performed?

First, the patient is positioned supine with the head rotated away from the operator, which helps visualize the tympanic membrane. Before starting the procedure, excess wax is removed to facilitate the successful procedure. Below are the steps involved in this procedure -

• Ensure the correct position of the patient for adequate visibility.

• After that, local anesthesia is administered using a topical gel.

• The next involves the aspiration of air, which is done by connecting a three cubic centimeter (cc) syringe to the 21 gauge spinal needles, and one cubic centimeter (cc) of air is aspirated. A 45-degree bend is made on the spinal needle to ensure adequate visualization.

• Then, the needle is advanced to the tympanic membrane very carefully.

• When the needle reaches the tympanic membrane, the fluid is gently aspirated, which can be assessed in the lab later.

• A secondary perforation (also called borehole) is made on the tympanic membrane for patients requiring medication administration. This also relieves the pressure as the medicine is being administered.

• After that, the needle and ear specula are retracted carefully, avoiding any damage.

• In the end, the ear canal is irrigated with a three percent solution of hydrogen peroxide, and a small amount of cotton or ear wick is placed to absorb extra fluid.

What Are the Complications of Tympanocentesis?

Even though it is a safe procedure, some complications can still occur, which include -

• Bleeding - A small amount of bleeding may also occur. However, it is usually minimal and stops on its own.

• Pain - Even with topical anesthesia, the patient can still feel some pain in the medial surface of the tympanic membrane, as it is a very sensitive area.

• Perforation - The perforation of the tympanic membrane or damage to the middle ear structures, such as ossicles or facial nerves, can also occur. But the chances are very low if the procedure is performed carefully.

• Healing - The tympanic membrane heals within days to weeks, but there is also a slight risk of permanent perforation. However, it can be beneficial in reducing the pressure, but in the long term, it can lead to infections due to water entering the middle ear space.

Conclusion

Tympanocentesis is a quick and simple procedure that is helpful in multiple ways. It helps provide immediate pain relief and can also help direct antimicrobial therapy by administrating medicines. This procedure itself carries minimal risks when performed by skilled healthcare professionals, it is essential to carefully weigh the potential benefits against these risks on a case-by-case basis. Furthermore, advancements in technology and medical practices continue to improve the precision and safety of tympanocentesis, making it an even more attractive option for managing middle ear conditions.