Otitis Media, Myringotomy, Tympanostomy Tube, and Balloon Dilation in the Pediatric Population

History

• AOM with severe pain, leading to constant crying and the inability to sleep

• Persistent high fever (>104°F) despite the administration of analgesics and antipyretics for more than 48 hours

• Persistent AOM with ongoing fever (>102°F) and moderate to severe pain for more than 5 to 7 days

• Multiple failures of treatment with antibiotics in the presence of an AOM episode

• Newborn with an AOM (in the first 4 weeks of life) because of the likelihood of unusual bacteriology not suitable for routine antibiotic choices

• OME with sepsis even though there are no acute signs or symptoms of AOM

• AOM in the intensive care unit (ICU) or neonatal ICU (NICU), when it is not feasible or preferred to take the child to the operating room

• Fever of unknown origin in a child with middle ear effusion (MEE) in the ICU, as part of the work-up for fever of unknown origin in a child with middle ear effusion in the ICU

• Fever of unknown origin in an immunocompromised child with a MEE even in the absence of signs or symptoms of an AOM

• Suspicion of an otologic complication when an early sample of MEE for culture and sensitivity will be beneficial and/or for relief of pressure and pain from the OM. Other indications include a need for time for further re-evaluation (such as imaging) and/or when there will be a delay in initiating definitive surgical treatment.

• Presence of an otologic complication, when obtaining an MEE sample for culture and sensitivity, prior to the initiation of intravenous empiric antibiotic therapy will be beneficial. This is done first to obtain a stat Gram stain to narrow the antibiotic options instead of starting double or triple therapy and, second, to discontinue or change the previously initiated antibiotics.

Physical Examination

• High (>104°F) fever

• Severely bulging TM with an imminent perforation, manifested by localized bulging of the TM and/or the presence of one or multiple bullae on the TM filled with purulent material

• Behavior consistent with severe pain originating from the ear, such as holding or pulling at the ear with constant crying and the inability to sleep

• When there are signs and symptoms and/or imaging evidence of an extracranial or intracranial complication, tympanocentesis or myringotomy is considered for culture purpos and to create means of drainage through the TM in order to reduce the progression of the conditions that caused the complications, and/or to prevent additional complications.

Imaging

• Imaging is not necessary for the performance of tympanocentesis or myringotomy procedures; however, it may be necessary in order to assess the ear and possible complications.

Indications

• Severe otalgia. Tympanocentesis or myringotomy is a painful procedure. However, if there is severe ear pain from the OM or its complications, the procedure is considered to be justified because it can instantly resolve pain due to the stretch and pressure of the TM from the purulent exudate confined in the middle ear (ME). If the otalgia does not improve after tympanocentesis and myringotomy, there may be blockage of the drainage pathways between the mastoid and the opening on the TM. Limitation or complete blockage of the drainage pathways may be due to (1) lack of ME space owing to significant mucosal hypertrophy and/or the formation of granulation tissue (which is more commonly seen in Streptococcus pyogenes infections), (2) obstruction of the anterior and posterior isthmus connecting the epitympanum to the mesotympanum, (3) obstruction of the aditus ad antrum connecting the antrum to the epitympanum, and (4) blockage of aeration/drainage pathways within the mastoid, most commonly by Koerner’s septum between the lateral and medial groups of mastoid cells.

• To have a controlled TM perforation at a preferred location. The site of most TM fullness and bulging is commonly at the posterosuperior quadrant. This is more commonly the case if the mucosal folds between the stapes, incus, and malleus limit communication between the epitympanum and mesotympanum. If a perforation at the posterosuperior quadrant does not heal, sequelae and/or complications are more likely. If the TM heals, the healed TM section may be atrophic and therefore will be more prone to the development of retraction pockets, cholesteatoma, and erosion of the ossicles. Any secondary acquired (from perforation) or primary acquired (from a retraction pocket) cholesteatoma developing at the posterosuperior quadrant will pose a higher risk of ossicular erosion, hearing loss, extension to the attic and into the mastoid, and other complications. Therefore a controlled opening of the TM will likely relieve pressure on the TM in the posterosuperior quadrant and lessen the chance of sequelae and complications.

• In order to identify the pathogen prior to starting antibiotic treatment. If an intravenous antibiotic is administered, it will pose the risk of producing a negative culture result. In an infectious condition where selection of the correct antibiotic as quickly as possible has critical importance, accurate identification is secured by tympanocentesis or myringotomy. This procedure also narrows the spectrum of antibiotics by getting a stat Gram stain, which not only differentiates between gram positives and gram negatives but also points to characteristics of the organisms that may help in narrowing down the possibilities, thus helping to determine the choice of antibiotic.

• To relieve the pressure in the presence of an otologic complication until imaging is performed and/or the patient/preoperative workup/surgical team is ready. A patient may have or be suspected to have a complication from OM. To verify the presence of a complication or for surgical planning or preparation, there may be a need extra time, during which the purulent exudate under pressure from OM that is suspected to have caused or has the potential to cause a complication has the potential to progress and worsen. To release the purulent effusion under pressure in the middle ear, in the presence or suspicion of an otologic comuntil imaging is performed and/or the patient/ operating room/ surgical team are ready, tympanocentesis or myringotomy can buy time and also lessen the risk for progression of complications until definitive treatment can be administered.

• To identify the pathogen precisely in a patient with a high risk for a fulminant or aggressive infectious course (immunocompromised, ICU, NICU). While awaiting identification of the pathogen in such patients, it is more important to instantly identify the group and likely species of the pathogen.

• To identify a pathogen that is likely to be highly resistant. Because many bacteria are highly resistant today, it is helpful to have a sample for culture and sensitivity with results obtainable within days.

Contraindications

• When the indications are not strong enough to justify a painful procedure to be done in an awake patient. These procedures are painful. In the absence of concern for a complication, the sole justification is extreme pain and the goal of relieving it. If there is not much pain, the procedure is not necessary.

• When it is not possible to perform such a procedure safely (applicable to awake procedures). Performing tympanocentesis or myringotomy safely requires almost complete immobility of the patient. This is achieved by restraining the child with the help of parents or support staff. Additional restraint can be achieved by using a papoose or by swaddling a newborn or an infant with a sheet. Such restraints may not be acceptable to the parents.

• When a child is above 2 or 3 years of age, this painful procedure under restraint may be too traumatic, having a lasting negative effect on the child’s relationship with the physicians and even the parents who permitted it.

• When a child is very strong, almost complete restraint may not be possible, making it unsafe to instrument the ear canal and TM with sharp instruments. Any sudden movement, even of a few millimeters, can lead to inadvertent ear canal trauma and bleeding, making instrumentation even more challenging. Furthermore, if a larger than planned opening or an irregular incision in the TM is produced, it could pose a greater risk for permanent perforation or cholesteatoma formation with inversion of irregular edges of the TM.

• When the patient and/or parents have previously experienced similar procedures under restraint, it may be impossible to convince them of the need of tympanocentesis or myringotomy.

• Topical anesthesia with lidocaine solution takes a long time to implement and is not very effective. The use of phenol may pose a risk for spilling or spreading inadvertently and therefore may be dangerous in a noncompliant child.

• When these procedures cannot be done without anesthesia or if the “nothing by mouth” (NPO) status is a contraindication

• When preparation/performance of these procedures may delay the necessary workup or initiation of treatment

• When there is already an indication for VT placement, a separate procedure of tympanocentesis or myringotomy may not be justified. Therefore the need and timing of these procedures may be adjusted according to the circumstances.

Preoperative Preparation

• Assess the optimal conditions for the procedure based on the indications and priorities. The options are performing the procedure under general anesthesia, with topical anesthesia, or with no anesthesia but possible analgesia. These decisions will be made based on the indications, alternatives, risks, and the timeline of planned evaluation and treatment.

• If the procedure is to be done under general anesthesia, verify NPO status and the potential contraindications for general anesthesia.

• If the procedure is to be done under topical anesthesia or no anesthesia, it is necessary to spend sufficient time with the child and family to prepare them, explaining what to expect, and to consider administering analgesia.

Anesthesia

• General

• Awake sedation

• Topical anesthesia

• No anesthesia with analgesia

Although this procedure can be done with the patient awake or under sedation, general anesthesia is preferred for patient comfort. Based on the indications, conditions, and limitations, one of the previously mentioned options may be preferred. When there is an urgency to perform tympanocentesis or myringotomy in the clinic, emergency department, ICU, or NICU for the reasons outlined earlier, the options should be discussed with the family, the child (if of an appropriate age), and the other physicians/health care professionals and services as applicable.

Positioning

• Supine: The patient is positioned supine with the head turned away from the surgeon for each ear.

Perioperative Antibiotic Prophylaxis

• None necessary

Monitoring

• None necessary

Instruments and Equipment to Have Available

• Operating microscope

• Otoscope for outpatient or bedside tympanocentesis or myringotomy

• Speculum, curette, myringotomy knife, suction, 5-, 7-, and 3-Fr suction catheters

• For culture purposes, an attached suction trap for collecting the effusion or a swab to touch the effusion by inserting it into the canal

• For tympanocentesis in the office or at bedside, an 18-gauge spinal needle attached to a tuberculin syringe to withdraw after going through the TM

Key Anatomic Landmarks

• Manubrium malleus, parts of umbo, and lateral process ( Fig. 203.1 )

  

• Pars flaccida and pars tensa

• Pars tensa quadrants

• Annulus

Prerequisite Skills

• Microscope use and handling of the instruments ( Fig. 203.2A to E )

  

• Cleaning of the ear canal

Operative Risks

• The procedure has risks mostly associated with either inadequate restraining, inexperience, or both. These risks include trauma and bleeding from the ear canal, TM, and/or ME mucosa. One very serious but extremely rare risk is damaging the TM and/or disrupting the ossicular chain. Failure to identify the anatomic landmarks, especially with an inflamed swollen ear canal and TM, may increase the risk for misplaced opening of the TM, especially in less experienced hands.

Surgical Technique

• Stabilize the child and the head.

• Use the third finger of the holding hand to push the concha posterosuperiorly in order to straighten the ear canal (see Fig. 203.2A and B ).

• Place the fourth and fifth fingers at the edge of ear speculum and on the head, respectively, in order to stabilize the instrumentation and to prevent inadvertent injury from movement of the anesthesiologist or the patient.

• Clean the ear canal for complete visualization of the TM.

• Reorient the center of the field of the microscope toward the anteroinferior (or any other preferred) site.

• If the microbiologic information is critical, sterilize the ear canal with 70% alcohol for 1 minute, then dry it completely before making the incision.

• Make a circumferential incision parallel to the annulus, halfway between the umbo and the annulus. If the myringotomy is to be kept open, create a smile-shaped incision at the inferior part of the TM.

• If a tympanocentesis is performed, anteroinferior or anterosuperior quadrants are preferred, where there is a greater distance between the TM and the promontory.

Common Errors in Technique

• Inadequate stabilization of the child and/or the head

• Suboptimal use of microscope for visualization and magnification

• Failure to work atraumatically

Postoperative Management

• Ear drops

• Gram stain- and culture-directed antibiotic treatment as indicated

Complications

• Trauma to the external ear canal is usually due to inadequate restraint. Such trauma is rarely serious, but it is often painful and makes the procedure more challenging owing to worsened movement and obstruction of landmarks from the bleeding.

• Although extremely rare, with a traumatic procedure there is a potential risk of disrupting the ossicular chain.

• If a caustic agent such as phenol is used for local anesthesia on the TM, inadvertent application on a broad area may result in a large perforation. Inadequate securing of the phenol bottle may result in spillage and a chemical burn at the spilled site.

• Complications are extremely rare in trained hands.

Alternative Management Plan

• 1.

  Initiation of antibiotic treatment without obtaining an effusion sample for culture and sensitivity is an option.

• 2.

  Similarly, more optimal pain management may obviate the need for tympanocentesis or myringotomy.

Evidence-Based Medicine Question

Does the culture obtained with a tympanocentesis or myringotomy affect the outcome?

In infants and children with AOM with a high risk of having an unusual or a resistant bacterium or in the presence of suspected serious complications, culture and sensitivity can facilitate an earlier and better outcome. Immediate Gram stain results can narrow the guesswork regarding the likely organism and guide a more accurate selection of antibiotic treatment.