Myringotomy | |
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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]
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]
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".
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]
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 ]
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 ]
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.
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]
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.
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.
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 thence to the oval window in the fluid-filled cochlea. The ear thereby 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.
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.
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.
Conductive hearing loss (CHL) occurs when there is a problem transferring sound waves anywhere along the pathway through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles). If a conductive hearing loss occurs in conjunction with a sensorineural hearing loss, it is referred to as a mixed hearing loss. Depending upon the severity and nature of the conductive loss, this type of hearing impairment can often be treated with surgical intervention or pharmaceuticals to partially or, in some cases, fully restore hearing acuity to within normal range. However, cases of permanent or chronic conductive hearing loss may require other treatment modalities such as hearing aid devices to improve detection of sound and speech perception.
Tympanoplasty is the surgical operation performed to reconstruct hearing mechanism of middle ear.
Ádám Politzer was a Hungarian and Austrian physician and one of the pioneers and founders of otology.
Ear pain, also known as earache or otalgia, is pain in the ear. Primary ear pain is pain that originates from the ear. Secondary ear pain is a type of referred pain, meaning that the source of the pain differs from the location where the pain is felt.
Patulous Eustachian tube is the name of a physical disorder where the Eustachian tube, which is normally closed, instead stays intermittently open. When this occurs, the person experiences autophony, the hearing of self-generated sounds. These sounds, such as one's own breathing, voice, and heartbeat, vibrate directly onto the ear drum and can create a "bucket on the head" effect, making it difficult for the patient to attend to environmental sounds. Patulous Eustachian tube is a form of Eustachian tube dysfunction, which is said to be present in about 1 percent of the general population.
Tympanostomy tube, also known as a grommet,myringotomy tube, or pressure equalizing tube, is a small tube inserted into the eardrum via a surgical procedure called myringotomy to keep the middle ear aerated for a prolonged period of time, typically to prevent accumulation of fluid in the middle ear. The tube itself is made in a variety of designs, most often shaped like a grommet for short-term use, or with long flanges and sometimes resembling a T-shape for long-term use. Materials used to manufacture the tubes are often made from fluoroplastic or silicone, which have largely replaced the use of metal tubes made from stainless steel, titanium, or gold.
Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear. The mastoid process contains open, air-containing spaces. Mastoiditis is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times.
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:
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.
A perforated eardrum is a prick 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.
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.
Tympanic membrane retraction describes a condition in which a part of the eardrum lies deeper within the ear than its normal position.
Endoscopic ear surgery (EES) is a minimally invasive alternative to traditional ear surgery and is defined as the use of the rigid endoscope, as opposed to a surgical microscope, to visualize the middle and inner ear during otologic surgery. During endoscopic ear surgery the surgeon holds the endoscope in one hand while working in the ear with the other. To allow this kind of single-handed surgery, different surgical instruments have to be used. Endoscopic visualization has improved due to high-definition video imaging and wide-field endoscopy, and being less invasive, EES is gaining importance as an adjunct to microscopic ear surgery.
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.