Myringotomy

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Myringotomy
ICD-9-CM 20.0 20.01 20.09

A myringotomy is a surgical procedure in which an incision is created in the eardrum (tympanic membrane) to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear. A tympanostomy tube may be inserted through the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously within two to three weeks. Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure. [1]

Contents

Those requiring myringotomy usually have an obstructed or dysfunctional eustachian tube that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection). [1]

Nomenclature

The words myringotomy, tympanotomy, tympanostomy, and tympanocentesis overlap in meaning. The first two are always synonymous, and the third is often used synonymously. [2] The core idea with each is cutting a hole in the eardrum to allow fluid to pass through it. Sometimes a distinction is drawn between myringotomy/tympanotomy and tympanostomy, in parallel with the general distinction between an -otomy (cutting) and an -ostomy (creating a stoma with some degree of permanence or semipermanence). In this distinction, only a tympanostomy involves tympanostomy tubes and creates a semipermanent stoma. This distinction in usage is not always made. The word tympanocentesis specifies that centesis (the removal of fluid [3] ) is being done.

Etymologically, myringotomy ( myringo- , from Latin myringa "eardrum", [4] + -tomy ) and tympanotomy ( tympano- + -tomy ) both mean "eardrum cutting", and tympanostomy ( tympano- + -stomy means "making an eardrum stoma".

History

In 1649, Jean Riolan the Younger accidentally pierced a patient's eardrum while cleaning it with an ear spoon. Surprisingly, the patient's hearing improved. There are also reports from the 17th and 18th centuries describing separate experiments exploring the function of the eardrum. [5] In particular, the animal experiments of Thomas Willis were expanded upon by Sir Astley Cooper, who presented two papers to the Royal Society in 1801 on his observations that myringotomy could improve hearing. [6] First, he showed that two patients with perforations of both eardrums could hear perfectly well, despite conventional wisdom that this would result in deafness. Second, he demonstrated that deafness caused by obstruction of the Eustachian tube could be relieved by myringotomy, which equalized the pressure on each side of the tympanic membrane.[ citation needed ]

Widespread inappropriate use of the procedure later led to it falling out of use. However, it was reintroduced by Hermann Schwartze in the 19th century. An inherent problem became recognized, namely the tendency of the tympanic membrane to heal spontaneously and rapidly, reversing the beneficial effects of the perforation. In order to prevent this, a tympanostomy tube, initially made of gold foil, was placed through the incision to prevent it from closing. In 1819 the French physician Antoine Saissy (1756–1822) tried to keep the myringotomy unsuccessfully open with Catgut. [7] [8] Ádám Politzer, a Hungarian-born otologist practicing in Vienna, experimented with rubber in 1886. The German otologist Rudolf Voltolini (1819–1889) created in 1874 a grommet made of gold and later on one made of aluminium. [8] [9] The vinyl tube used today was introduced by Beverly Armstrong in 1954. [8]

Indications

Retracted eardrum Wiki TM retraction.jpg
Retracted eardrum

There are numerous indications for tympanostomy in the pediatric age group, [1] [10] the most frequent including chronic otitis media with effusion (OME) which is unresponsive to antibiotics, and recurrent otitis media. Adult indications [1] [11] [12] differ somewhat and include Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss, vertigo, tinnitus, and a severe retraction pocket in the tympanic membrane. Recurrent episodes of barotrauma, especially with flying, diving, or hyperbaric chamber treatment, may merit consideration.[ citation needed ]

Procedure

Myringotomy is usually performed as an outpatient procedure. General anesthesia is preferred in children, while local anesthesia suffices for adults. The ear is washed and a small incision made in the eardrum. Any fluid that is present is then aspirated, the tube of choice inserted, and the ear packed with cotton to control any slight bleeding that might occur. This is known as conventional (or cold knife) myringotomy and usually heals in one to two days. [13]

A new variation (called tympanolaserostomy or laser-assisted tympanostomy) uses a CO2 laser, and is performed with a computer-driven laser and a video monitor to pinpoint a precise location for the hole. The laser takes one-tenth of a second to create the opening, without damaging surrounding skin or other structures. This perforation remains patent for several weeks and provides ventilation of the middle ear without the need for tube placement. [14]

Though laser myringotomies maintain patency slightly longer than cold-knife myringotomies (two to three weeks for laser and two to three days for cold knife without tube insertion), [15] they have not proven to be more effective in the management of effusion. One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME. [16] Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective. [13]

Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes. More recent ones are coated with antibiotics and phosphorylcholine.[ citation needed ]

Aftercare

There is little scientific evidence to guide the care of the ear after tubes have been inserted. A single, randomized trial found statistical benefit to using ear protective devices when swimming although the size of the benefit was quite small. [17] In the absence of strong evidence, general opinion has been against the use of ear protection devices. However, protection such as cotton covered with petroleum jelly, ear plugs, or ear putty is recommended for swimming in dirty water (lakes, rivers, oceans, or non-chlorinated pools) to prevent ear infections. For bathing, shampooing, or surface-water swimming in chlorinated pools, no ear protection is recommended.

Complications

The placement of tubes is not a cure. If middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection. There may be early drainage through the tube (tube otorrhea) in about 15% of patients in the first two weeks after placement, and developing in 25% more than three months after insertion, although usually not a longterm problem. [18] Otorrhea is considered to be secondary to bacterial colonization. The most commonly isolated organism is Pseudomonas aeruginosa , while the most troublesome is Methicillin-resistant Staphylococcus aureus (MRSA). Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial biofilm. [1] A laboratory study showed that tubes covered in the antibiotic vancomycin prevented in-vitro formation of MRSA biofilm as compared to noncoated ones, [19] although no study has been conducted on humans yet. Comparing phosphorylcholine-coated fluoroplastic tympanostomy tubes to uncoated fluoroplastic tympanostomy tubes showed no statistically significant difference in the incidence of post-operative otorrhea, tube blockage, or extrusion. [20]

Efficacy

Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have no other serious medical problems. No effect on speech and language development has yet been shown. [21]

A retrospective study of success rates in 96 adults and 130 children with otitis media treated with CO2 laser myringotomy showed about a 50% cure rate at six months in both groups. [13] To date, there have been no published systematic reviews.

Balloon dilation eustachian tuboplasty (BDET), a new treatment, has proven to be effective in treating OME secondary to eustachian tube dysfunction. [22] [23] [24] However, the number of patients in the studies cited, 22 and 8 respectively and 18 in the tympanometric study, is extremely small and simply points to the need for large, well-controlled studies.

See also

Related Research Articles

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Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Cholesteatomas are not cancerous as the name may suggest, but can cause significant problems because of their erosive and expansile properties. This can result in the destruction of the bones of the middle ear (ossicles), as well as growth through the base of the skull into the brain. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal.

<span class="mw-page-title-main">Eardrum</span> Membrane separating the external ear from the middle ear

In the anatomy of humans and various other tetrapods, the eardrum, also called the tympanic membrane or myringa, is a thin, cone-shaped membrane that separates the external ear from the middle ear. Its function is to transmit sound from the air to the ossicles inside the middle ear, and then to the oval window in the fluid-filled cochlea. Hence, it ultimately converts and amplifies vibration in the air to vibration in cochlear fluid. The malleus bone bridges the gap between the eardrum and the other ossicles.

<span class="mw-page-title-main">Otitis media</span> Inflammation of the middle ear

Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. The other main type is otitis media with effusion (OME), typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present. All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not learn sign language, it may affect their ability to learn.

<span class="mw-page-title-main">Eustachian tube</span> Tube connecting middle ear to throat

The Eustachian tube, also called the auditory tube or pharyngotympanic tube, is a tube that links the nasopharynx to the middle ear, of which it is also a part. In adult humans, the Eustachian tube is approximately 35 mm (1.4 in) long and 3 mm (0.12 in) in diameter. It is named after the sixteenth-century Italian anatomist Bartolomeo Eustachi.

<span class="mw-page-title-main">Conductive hearing loss</span> Medical condition

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<span class="mw-page-title-main">Tympanoplasty</span> Surgical operation on the ear

Tympanoplasty is the surgical operation performed to reconstruct hearing mechanism of middle ear.

<span class="mw-page-title-main">Ear pain</span> Pain in the ear

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<span class="mw-page-title-main">Tympanostomy tube</span> Medical device inserted into the eardrum

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<span class="mw-page-title-main">Mastoiditis</span> Middle ear disease

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<span class="mw-page-title-main">Otitis</span> Medical condition

Otitis is a general term for inflammation in ear or ear infection, inner ear infection, middle ear infection of the ear, in both humans and other animals. When infection is present, it may be viral or bacterial. When inflammation is present due to fluid build up in the middle ear and infection is not present it is considered Otitis media with effusion. It is subdivided into the following:

<span class="mw-page-title-main">Tympanometry</span>

Tympanometry is an acoustic evaluation of the condition of the middle ear eardrum and the conduction bones by creating variations of air pressure in the ear canal.

<span class="mw-page-title-main">Perforated eardrum</span> Injury leading to a hole in the eardrum

A perforated eardrum is a hole in the eardrum. It can be caused by infection, trauma, overpressure, inappropriate ear clearing, and changes in middle ear pressure. An otoscope can be used to view the eardrum to diagnose a perforation. Perforations may heal naturally or require surgery.

Myringoplasty is the closure of the perforation of pars tensa of the tympanic membrane. When myringoplasty is combined with removal of scar tissue, it is called tympanoplasty. The operation is performed with the patient supine and face turned to one side. The graft material most commonly used for the surgery is temporalis fascia. The tragal cartilage and tragal perichondrium are also used as the graft by some surgeons.

<span class="mw-page-title-main">Tympanosclerosis</span> Medical condition

Tympanosclerosis is a condition caused by hyalinization and subsequent calcification of subepithelial connective tissue of the tympanic membrane and middle ear, sometimes resulting in a detrimental effect to hearing.

<span class="mw-page-title-main">Tympanic membrane retraction</span> Medical condition

Tympanic membrane retraction describes a condition in which a part of the eardrum lies deeper within the ear than its normal position.

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Granular myringitis is a long term condition in which there is inflammation of the tympanic membrane in the ear and formation of granulation tissue within the tympanic membrane. It is a type of otitis externa.

Eustachian tube dysfunction (ETD) is a disorder where pressure abnormalities in the middle ear result in symptoms.

Middle ear barotrauma (MEBT), also known to underwater divers as ear squeeze and reverse ear squeeze, is an injury caused by a difference in pressure between the external ear canal and the middle ear. It is common in underwater divers and usually occurs when the diver does not equalise sufficiently during descent or, less commonly, on ascent. Failure to equalise may be due to inexperience or eustachian tube dysfunction, which can have many possible causes. Unequalised ambient pressure increase during descent causes a pressure imbalance between the middle ear air space and the external auditory canal over the eardrum, referred to by divers as ear squeeze, causing inward stretching, serous effusion and haemorrhage, and eventual rupture. During ascent internal over-pressure is normally passively released through the eustachian tube, but if this does not happen the volume expansion of middle ear gas will cause outward bulging, stretching and eventual rupture of the eardrum known to divers as reverse ear squeeze. This damage causes local pain and hearing loss. Tympanic rupture during a dive can allow water into the middle ear, which can cause severe vertigo from caloric stimulation. This may cause nausea and vomiting underwater, which has a high risk of aspiration of vomit or water, with possibly fatal consequences.

References

  1. 1 2 3 4 5 Smith N, Greinwald JR (2011). "To tube or not to tube: indications for myringotomy with tube placement". Current Opinion in Otolaryngology & Head and Neck Surgery. 19 (5): 363–366. doi:10.1097/MOO.0b013e3283499fa8. PMID   21804383. S2CID   3027628.
  2. ↑ Elsevier, Dorland's Illustrated Medical Dictionary, Elsevier.
  3. ↑ Andersson, David (2018). Medical Terminology. Medical Creations. p. 72. ISBN   9781519066626.
  4. ↑ "myringotomy". Mosby's Medical Dictionary (8th ed.). Elsevier. 2009.
  5. ↑ Brusis T, Luckhaupt H (March 1995). "Der Trommelfellstich: Zur Geschichte von Parazentese und Paukenröhrchen" [Perforation of the eardrum. On the history of paracentesis and grommet insertion]. Laryngo-Rhino-Otologie (in German). 75 (3): 178–83. doi:10.1055/s-2007-997559. PMID   8652036. S2CID   260205742.
  6. ↑ McGovern, Francis H. (1984). "Sir Astley Cooper and His Otological Papers". Annals of Otology, Rhinology & Laryngology. 93 (6): 531–533. doi:10.1177/000348948409300601. PMID   6391339. S2CID   42431618.
  7. ↑ Saissy, JA (1829). An Essay on the Diseases of the Internal Ear. Translated by Smith, NR. Baltimore, MD: Hatch & Dunning.
  8. 1 2 3 Rimmer, J.; Giddings, C. E. B.; Weir, N. (2007-06-11). "History of myringotomy and grommets". The Journal of Laryngology & Otology. 121 (10): 911–916. doi:10.1017/S0022215107009176. ISSN   1748-5460. PMID   17559714. S2CID   27874209.
  9. ↑ "Voltolini, R. Über eine neue Operation am Trommefelle zur Verbesserung des Horvermogens". Monatsschrift für Ohrenheilkunde, 1874;8.
  10. ↑ American Academy of Family Physicians; American Academy of Otolaryngology–Head and Neck Surgery; American Academy of Pediatrics Subcommittee on Otitis Media With Effusion (May 2004). "Otitis media with effusion". Pediatrics. 113 (5): 1412–29. doi: 10.1542/peds.113.5.1412 . PMID   15121966.
  11. ↑ Kisser U, Gürkov R, Louza J, Schrötzlmair F, Adderson-Kisser C, Krause E (2012). "Comparison of characteristic of titanium and fluoropastic ventilation tubes in adults with healthy middle ears". Otology & Neurotology. 33 (6): 983–987. doi:10.1097/MAO.0b013e318259b70b. PMID   22772000. S2CID   33137759.
  12. ↑ "Ear tube insertion". MedlinePlus. U.S. National Library of Medicine.
  13. 1 2 3 Chang CW, Yang YW, Fu CY, Shiao AS (January 2012). "Differences between children and adults with otitis media with effusion treated with CO(2) laser myringotomy". Journal of the Chinese Medical Association. 75 (1): 29–35. doi: 10.1016/j.jcma.2011.10.001 . PMID   22240534.
  14. ↑ Lustig, Lawrence R.; Ingram, Amy; Vidrine, D. Macy; Gould, Andrew R.; Zeiders, Jacob W.; Ow, Randall A.; Thompson, Christopher R.; Moss, Jonathan R.; Mehta, Ritvik; McClay, John E.; Brenski, Amy; Gavin, John; Waldman, Erik H.; Ansley, John; Yen, David M.; Chadha, Neil K.; Murray, Michael T.; Kozak, Frederick K.; York, Christopher; Brown, David M.; Grunstein, Eli; Sprecher, Robert C.; Sherman, Denise A.; Schoem, Scott R.; Puchalski, Robert; Hills, Susannah; Calzada, Audrey; Harfe, Dan; England, Laura J.; Syms, Charles A. (2020). "In‐Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery". The Laryngoscope. 130 (Suppl 4): S1–S9. doi:10.1002/lary.28612. PMC   7187287 . PMID   32160320.
  15. ↑ Prokopakis EP, Hajiioannou JK, Velegrakis GA, Christodoulou PN, Scordalakis C, Helidonis ES (Feb 25, 2002). "Duration of patency of laser-assisted tympanic membrane fenestration". Int J Pediatr Otorhinolaryngol. 62 (3): 207–14. doi:10.1016/s0165-5876(01)00613-9. PMID   11852122.
  16. ↑ Koopman JP, Reuchlin AG, Kummer EE, Boumans LJ, Rijntjes E, Hoeve LJ, Mulder PG, Blom HM (2004). "Laser myringotomy versus ventilation tubes in children with otitis media with effusion: a randomized trial". Laryngoscope. 114 (5): 844–9. doi:10.1097/00005537-200405000-00010. PMID   15126741. S2CID   73100585.
  17. ↑ Goldstein NA, Mandel EM, Kurs-Lasky M, Rockette HE, Casselbrandt ML (2005). "Water precautions and tympanostomy tubes: a randomized, controlled trial". Laryngoscope. 115 (2): 324–30. doi:10.1097/01.mlg.0000154742.33067.fb. PMID   15689760. S2CID   36426890.
  18. ↑ Kay DJ, Nelson M, Rosenfeld RM (April 2001). "Meta-analysis of tympanostomy tube sequelae". Otolaryngol Head Neck Surg. 124 (4): 374–80. doi:10.1067/mhn.2001.113941. PMID   11283489. S2CID   25287112.
  19. ↑ Jang CH, Park H, Cho YB, Choi CH (2010). "Effect of vancomycin-coated tympanostomy tubes on methicillin-resistant Staphylococcus aureus biofilm formation: In vitro study". The Journal of Laryngology & Otology. 124 (6): 594–598. doi:10.1017/S0022215109992672. PMID   20056010. S2CID   24655349.
  20. ↑ Hong P, Smith N, Johnson LB, Corsten G (2011). "A randomized double-blind controlled trial of phosphorylcholine-coated tympanostomy tube versus standard tympanostomy tube in children with recurrent acute and chronic otitis media". Laryngoscope. 121 (1): 214–219. doi:10.1002/lary.21156. PMID   21072756. S2CID   22624953.
  21. ↑ Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database of Systematic Reviews (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID   20927726..
  22. ↑ McCoul ED, Anand VK (May–June 2012). "Eustachian tube balloon dilation surgery". International Forum of Allergy & Rhinology. 2 (3): 191–8. doi:10.1002/alr.21007. PMID   22253073. S2CID   20637776.
  23. ↑ Ockermann T, Reineke U, Upile T, Ebmeyer J, Sudhoff HH (July 2010). "Balloon dilatation eustachian tuboplasty: a clinical study". Laryngoscope. 120 (7): 1411–6. doi:10.1002/lary.20950. PMID   20564474. S2CID   7976041.
  24. ↑ Williams, Blair; Taylor, Benjamin A.; Clifton, Neil; Bance, Manohar (12 February 2016). "Balloon dilation of the eustachian tube: a tympanometric outcomes analysis". Journal of Otolaryngology - Head & Neck Surgery. BioMed Central. 45 (13): 13. doi: 10.1186/s40463-016-0126-6 . ISSN   1916-0216. PMC   4751715 . PMID   26869258.
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