Overview of Tympanocentesis
With the rise of antibiotics, some treatments for infections that were in high use before – such as tympanocentesis – have become less common. Tympanocentesis is a simple surgical procedure that helps treat otitis media (an infection in the middle ear), and several other ear disorders. The procedure is performed by making a small hole in the eardrum with a tiny needle and then extracting fluid from behind the eardrum. This can be done for both treatment reasons and diagnostic purposes – in other words, it can help doctors understand what might be causing ear problems. The technique has been in use ever since it was first documented in 1768, and it has improved quite a lot over the years.
Otitis media, or an infection/inflammation of the middle ear, is a rather common condition. Because of it, a lot of people end up seeking help from pediatricians, family doctors, and urgent-care medical experts. There are different types of otitis media, including acute otitis media, adhesive otitis media, otitis media with fluid accumulation, and chronic suppurative otitis media.
Nowadays, doctors use tympanocentesis to treat cases of otitis media that don’t respond to normal antibiotic treatments, especially for handling bacteria that are resistant to multiple drugs. It’s also used for managing other ear issues, such as when the eardrum retracts, Ménière disease, and sudden hearing loss that can’t be explained by factors outside the nervous system.
Because of the wide use of anti-infection drugs, a lot of doctors treat otitis media based on symptoms, without always checking the fluid in the middle ear to decide which antibiotic to use. However, tympanocentesis can help reduce the chance of treatment not working, getting otitis, needing a tympanostomy tube (a small tube placed in the eardrum to help fluid drain), or the exit of fluid from the ear.
Anatomy and Physiology of Tympanocentesis
The human ear plays a crucial role not only in our ability to hear, but also in maintaining our body’s balance. It consists of three main parts:
- The outer ear, which includes the visible part of the ear (known as the pinna or auricle) and the ear canal.
- The middle ear
- The inner ear, which houses the cochlea (the hearing organ) and the vestibular system (responsible for balance).
The middle ear is found within a hollowed-out section of one of the bones in our skull and helps amplify sounds that are picked up by our outer ear. These sounds then travel via the eardrum to tiny bones in the middle ear, which send the sound on to structures filled with fluid in the inner ear and then to the brain.
In addition to these bones, the middle ear also contains a couple of small windows, muscles, nerves, and an opening to a tube (the Eustachian tube) that connects the ear to the back of the nose. It also has an entryway to a cavity in the skull.
The tiny bones in the middle ear come from certain types of cells, while the cavity and the Eustachian tube have their roots in the forming of our organs before we’re born. The muscles in the middle ear come from specific layers of this early tissue and have the role of reducing the impact of loud noises on our hearing. The inner section of the cavity continues into small compartments in a bone at the side of the skull.
The eardrum is an oval, thin, slightly see-through membrane that’s about 1 cm in diameter in adults, acting as a divide between the ear canal and the middle ear. The upper part of the eardrum is less stiff and has fewer layers compared to the rest of the eardrum, which links to a bone in the middle ear and plays a crucial part in transmitting sound. In certain medical procedures, a needle is inserted into the lower section of the eardrum, steering clear of the upper area to prevent possible damage to the underlying bones.
If the Eustachian tube isn’t working properly, it can lead to a build-up of fluid in the middle ear, since the eardrum is air-tight and the tube is the only way for pressure in the middle ear to balance with the pressure in our surroundings. Too much fluid can make the eardrum less responsive to vibrations, causing hearing loss and giving bacteria a chance to grow, possibly leading to an infection. If this fluid is left for a long time, a thick, sticky substance can develop, a condition sometimes called ‘glue ear’.
The middle ear is indirectly connected to the inner ear via two ‘windows’. These links allow certain molecules to move between the middle and inner ear areas. There’s also a theory that, during a common cold, viruses can move from the middle ear to the inner ear, potentially damaging the structures that enable hearing.
Why do People Need Tympanocentesis
Tympanocentesis is a medical procedure that can be used for both diagnosis and treatment purposes. For diagnosis, it enables doctors to test and analyze fluid from the ear. The procedure can also be used therapeutically to give medication directly to the middle ear or to improve hearing by removing fluid from the middle ear.
When is Tympanocentesis used for treatment?
– Pain relief: Ear pain is often connected with various ear disorders. Otitis media, an inflammation of the middle ear, can cause pain along with other symptoms. This procedure can provide immediate pain relief for patients, especially children, who are experiencing severe ear pain due to acute otitis media (an ear infection). The relief is provided while waiting for antibiotics to take effect.
– Giving medication: Tympanocentesis can be used to administer certain medications directly into the ear. These medications include antibiotics and steroids, which are often used to treat serious ear disorders. For example, in severe cases of Ménière disease (an inner ear disorder), medication can be injected directly into the ear if other treatments do not work. Similarly, for patients with sudden hearing loss or Bell’s palsy, tympanocentesis can be used to inject steroids directly into their ear.
When is Tympanocentesis used for diagnosis?
– Acute otitis media in an immunocompromised patient: For patients with a weakened immune system, tympanocentesis can be used to take a sample of fluid from their ear. This helps healthcare professionals identify the cause of an ear infection and find the most effective treatment.
– Unresolved ear infections: Sometimes an ear infection may not respond to the first courses of antibiotics. In such cases, tympanocentesis can be used to take a fluid sample to analyze which pathogens are present. This helps doctors select the most effective treatment.
– Ear infections in newborns: For newborns or infants, doctors might use tympanocentesis to see whether the baby has acute otitis media or an infection in the middle ear. This can be especially important for babies with unknown fever causes, since they can be more likely to get ear infections with atypical pathogens.
– Managing retracted eardrum: While tympanocentesis is not a standalone treatment for a retracted tympanic membrane (eardrum), it can help doctors determine if a ventilation tube might help in elevating the retracted membrane. For example, air can be gently added into the middle ear space to measure the response, particularly if other diagnostic tools aren’t available.
– Electrocochleography: Electrocochleography, a method used for diagnosing Ménière disease, involves an invasive approach where an electrode is passed through the eardrum to monitor the cochlear. Tympanocentesis allows this invasive approach and provides a clearer tracing of electrical potentials.
When a Person Should Avoid Tympanocentesis
In some situations, doctors advise against performing a procedure called tympanocentesis, which involves making a small hole in the eardrum to drain fluid. Here are some of the reasons why a person should not have this procedure:
1. If the patient is uncooperative: To safely perform this procedure, the patient needs to be fully cooperative.
2. If the patient has intact tympanostomy tubes: These are small tubes that are sometimes placed in the eardrum to help drain fluid. If these tubes are still in place, the procedure should not be carried out.
3. If the patient has an intratympanic tumor: This is a tumor located inside the eardrum. Procedures such as a tympanocentesis can lead to bleeding, facial paralysis, and leakage of cerebrospinal fluid (fluid around the brain and spinal cord).
4. If the patient suffers from acute otitis externa: This is an infection of the outer ear canal. In such cases, the procedure could potentially introduce bacteria or fungi into the middle ear, and swelling in the outer ear canal may make it difficult for the doctor to see the eardrum.
5. If the patient has vascular abnormalities: If there are abnormalities in the blood vessels, like a high-riding jugular bulb (a bulging vein in the neck), the procedure can risk causing bleeding.
6. If visibility is suboptimal: To safely perform tympanocentesis, the doctor needs a good view of important structures in the ear.
Equipment used for Tympanocentesis
Performing a successful tympanocentesis, a procedure to remove fluid from the middle ear, requires a variety of tools and equipment. These include:
A Jobson Horne probe or cerumen loop, which are tools specific for dealing with ear problems.
An otologic microscope, a special microscope designed for use in ear procedures.
For pain relief, we use a local anesthetic like 4% Lidocaine, which is introduced into the external ear canal. We also might use small cotton balls soaked in phenol or 4% cocaine solutions to numb the exact site where the tympanocentesis will be performed. Lidocaine combined with prilocaine (EMLA) cream is another option.
A small 3 cc syringe is used during the procedure.
We use sterile culture swabs and culture media to collect and test any fluid that is extracted.
A 3-inch-long, 20- or 21-gauge spinal needle is used with a tympanocentesis aspirator, a tool that helps remove the fluid.
An appropriate chair for the procedure and restraint board if needed.
Different-sized examination specula are used to view different parts of the ear.Suction is used to help remove fluid.
Tissue wicks and cotton balls are used for cleaning and absorbing fluid.
3% strength hydrogen peroxide is used for cleaning and disinfecting the area.
An iontophoresis device and electrodes are optional tools which can be used in certain cases.
Who is needed to perform Tympanocentesis?
Tympanocentesis is a procedure mostly done by ear, nose, and throat doctors (otolaryngologists), kids’ doctors (pediatricians), and family doctors. Most of the time, this procedure is done in a doctor’s office and uses local or applied-on-skin pain relievers (anesthetics). Usually, there’s a helper involved who prepares the medical tools and passes them during the procedure. A hearing healthcare specialist (audiologist) controls the testing in a technique called electrocochleography, while the ear, nose, and throat doctor places a device to monitor the ear.
Preparing for Tympanocentesis
If you’re going in for a tympanocentesis – a minor surgical procedure on your ear – your doctor will explain all the details to you. They’ll give you all the facts about the potential benefits, risks, and other methods that could be used instead. It’s important you understand this information so you can make an informed decision, and officially agree to the procedure by signing a consent form.
Good news is that you don’t need any antibiotics before this surgery. This is unlike other surgical procedures where antibiotics are used just in case of any infection risk.
What about pain? Don’t worry, there are several options for numbing the area during the procedure. It could be a general anesthetic that will make you sleep, or maybe just a local one that numbs only a part of your body while you stay awake but don’t feel pain. Some people might need general anesthesia if they get anxious or can’t stay still. Kids, folks with some disabilities, or some mental health conditions might fall in this group. For those who would remain calm and cooperative, numbing creams are used. These creams are great because they also reduce any chance of bleeding and are cheaper, so you’ll be up and about faster.
There are other options too; a patch or EMLA cream could offer pain relief with least intervention. Additionally, acetaminophen with codeine can be taken orally for pain relief. There are also other intravenous drugs available that need special administration usually by an anesthesiologist or a nurse specially trained for it, and are normally given if the procedure is done in an operating theater.
Lastly, how will you be positioned during the operation? You’ll be asked to lie down or lean back comfortably. Your head will be tilted away from the surgeon, allowing them to see your eardrum clearly with a medical instrument designed for this purpose called an ear speculum.
How is Tympanocentesis performed
The tympanocentesis is a procedure your doctor or health provider will utilize to remove any fluid from the middle of your ear. This might be necessary if you have a persistent or severe ear infection. Here’s how it’s usually done:
1. First, you’ll be positioned correctly to make the procedure easier. This will likely be sitting up with your head turned slightly to one side.
2. Using a special tool, the doctor will gently put an aural speculum into your ear to have a better look inside. They’ll also remove any earwax in your ear canal if necessary.
3. They will then apply a numbing agent to the inside of your ear to make sure you are comfortable during the procedure. Sometimes these numbing agents can kill bacteria, so any leftover numbing liquid will be removed before the doctor takes a sample.
4. A small syringe connected to a needle will be used for this next step. The needle is shaped a certain way (45-degree angle) to allow the doctor to see past it when it’s in your ear.
5. The needle will be carefully inserted into the eardrum. This is done very gently and under control.
6. Once the needle is in the right place, the fluid will be pulled out from the middle ear if there is any present.
7. If the procedure involves giving you ear medication, a second hole might be made in the eardrum to help the ear manage that medication. This is to both allow air to come out as the medication goes in, and to avoid putting too much pressure on a part of the ear called the “round window”. Drugs given this way will be warmed up beforehand to be body temperature, because cold fluids can make you feel dizzy. After giving the drug, the needle and speculum will be carefully taken out of your ear.
8. If needed, a small hole can also be made in the eardrum with a special laser tool. If there is any fluid left in your ear after this, your ear canal might be cleaned with a hydrogen peroxide solution and a piece of tissue might be put in your ear to soak up the extra fluid.
At the end of this procedure, the fluid that was removed will be sent for testing in a lab. This is important to find out what kind of infection you have and what kind of treatment will work best for it.
Possible Complications of Tympanocentesis
Although the process of draining fluid from the eardrum, or tympanocentesis, is generally considered safe, it does come with a few potential issues:
Bleeding: While it’s typical for there to be a bit of bleeding during this procedure, usually it stops quickly and without any problems. However, if there’s a chance that a large vein in the neck (known as a high-riding jugular bulb) might be affected, the procedure shouldn’t be pursued.
Pain: Even with the use of numbing medicine on the skin, the area inside the eardrum might still feel some pain or discomfort.
Chronic perforation of the eardrum: There’s a small risk that the hole made in the eardrum during this procedure won’t heal properly, which could possibly lead to damage to structures inside the middle ear, like the ossicles (tiny bones that help with hearing) and the facial nerve. This usually doesn’t happen if the procedure is done correctly and carefully.
Damage to the ossicles: Harm to the tiny bones in the ear (ossicles) is avoided by not inserting any tools into a specific part of the eardrum where these bones are located.
What Else Should I Know About Tympanocentesis?
Otitis media, or an infection or inflammation of the middle ear, can sometimes be wrongly diagnosed. This could lead to unnecessary prescriptions for antibiotics, which may increase the risk of antibiotic resistance in the local population. While confusing the symptoms of otitis media with those of a non-infectuous fluid buildup in the middle ear can happen anywhere, some studies have shown notable differences between clinicians from different countries.
For example, in a 2015 study comparing pediatricians from Greece, Italy, South Africa, and the United States, 50% of pediatricians could accurately distinguish between otitis media and ear fluid buildup. Comparatively, about 73% of ear specialists, or otolaryngologists, could accurately make the distinction. Despite this, more otolaryngologists (89%) accomplished these tests regularly than pediatricians (83%).
According to a 2000 study, the best way to confirm otitis media is through a procedure known as tympanocentesis. This procedure involves taking a fluid sample from the middle ear to look for the presence of microbes, which would indicate an infection. However, not many clinicians are trained to perform this procedure nowadays.
A 2004 survey of Canadian pediatricians and family physicians found that only 4% of the participants had received training to perform tympanocentesis and none had performed it at the time of the study. This suggests that the procedure is no longer a common practice.
Thus, with the decline of this diagnostic skill, clinicians often opt to treat suspected cases of otitis media with antibiotics right off the bat and monitor cases of fluid buildup in the ear unless language development is affected, at which point a pressure equalization tube is often used. This could lead to more prescriptions for antibiotics than necessary. To prevent this, it would be beneficial for clinicians to learn to use tympanocentesis as a diagnostic tool. This procedure can lead to more targeted treatment, helping to alleviate symptoms and mitigate resistance to antibiotics by reducing unnecessary prescriptions.
