Myringotomy: What is it? History, Indications, Procedure, Care, Complications and Efficacy

A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated for a long time and to prevent re-accumulation of fluid.

A myringotomy is a surgical procedure in which a small incision is made in the eardrum (tympanic membrane) to relieve pressure caused by excess fluid buildup or to drain pus from the middle ear.

Without the insertion of a tube, the incision usually heals on its own in two to three weeks. Depending on the type, the tube extrudes naturally in 6 to 12 months or is removed during a minor procedure.

Those who require myringotomy generally have a blocked or dysfunctional Eustachian tube that cannot perform drainage or ventilation in the usual way.

Before the invention of antibiotics, tubeless myringotomy was also used as the main treatment for severe acute otitis media (middle ear infection).

Nomenclature

The words myringotomy, tympanotomy, tympanostomy, and tympanocentesis overlap in meaning. The first two are always synonymous, and the third is often used as a synonym.

The central idea with all of them is to open a hole in the eardrum to allow the fluid to pass through it.

A distinction is sometimes made between myringotomy / tympanotomy and tympanostomy, paralleling the general distinction between an -otomy (cut) and -ostomy (creating a stoma with some degree of permanence or semi-permanence).

In this distinction, only one tympanostomy involves tympanostomy tubes and creates a semi-permanent stoma. This distinction in use is not always made. The word tympanocentesis specifies that a cehesis (aspiration for sampling) is being done.

Etymologically, the myringotomy (myringo-, from the Latin myringa “eardrum”, + -tomia) and the tympanotomy (tympanum- + -tomy) mean “cutting the eardrum” and tympanostomy (tympanum- + -stomy means “making a stoma of the eardrum ».

History

In 1649, Jean Riolan the Younger accidentally pierced a patient’s eardrum while cleaning it with a spatula. Surprisingly, the patient’s hearing improved.

There are also reports from the 17th and 18th centuries that describe separate experiments exploring the function of the eardrum.

In particular, Thomas Willis’s animal experiments were expanded upon by Sir Astley Cooper , who submitted two papers to the Royal Society in 1801 about his observations that myringotomy might improve hearing.

First, it showed that two patients with perforations of both eardrums could hear perfectly, despite the conventional belief that this would lead to deafness.

Second, he showed that deafness caused by Eustachian tube obstruction could be alleviated with myringotomy, which equalizes pressure on each side of the tympanic membrane .

Widespread misuse of the procedure later caused it to fall out of use. However, it was reintroduced by Hermann Schwartze in the 19th century.

An inherent problem was recognized, namely the tendency of the tympanic membrane to heal spontaneously and rapidly, reversing the beneficial effects of perforation.

To avoid this, a tympanostomy tube, initially made of gold foil, was placed through the incision to prevent it from closing.

Ádám Politzer , a Hungarian-born otologist practicing in Vienna, experimented with rubber in 1886. The vinyl tube used today was introduced by Beverley Armstrong in 1954.

Indications

There are numerous indications for tympanostomy in the pediatric age group, the most common of which include chronic otitis media with effusion (OME) that does not respond to antibiotics and recurrent otitis media.

Indications in adults 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 flight, diving, or hyperbaric chamber treatment, may warrant consideration.

The most common reason for a myringotomy, or surgery to place a hole in the eardrum, is otitis media with effusion or a middle ear infection with fluid.

Infectious fluid collects behind the eardrum, where it can be so thick that it is known as a “glue ear.” This can interfere with hearing and, in some cases, slow speech development in children, especially if the problem is present in both ears.

Reasons for ear tube insertion surgery:

  • Ear infection that does not respond to antibiotics or ear medications.
  • Middle ear infection that is causing hearing loss or speech delays.
  • Acute repetitive otitis media (3 episodes in 6 months or 4 in 12 months) when it does not respond to continuous antibiotic treatment and affects speech, hearing, or both.
  • Barotrauma (damage from changes in pressure, such as diving or flying).
  • Congenital malformation of the ear (cleft paddle or Down syndrome, etc.).

Adults and myringotomy

A myringotomy with ear tube insertion is much less common in adults than in children. While the procedure can be done for a recurring ear infection, it is less likely in adults due to structural changes in the ear canal as it grows.

In most cases, a myringotomy is performed in adults due to barotrauma. Barotrauma is the result of a significant difference in pressure inside the ear (behind the eardrum) and outside the ear.

The main differences in pressure can occur with changes in altitude, such as riding an elevator in a tall building or flying. Diving can also cause barotrauma.

A myringotomy can be done as a temporary measure in adults, with the procedure done to temporarily place a hole in the eardrum that will close once the pressure is released. The tube may or may not be placed depending on the reasons for the surgery.

Process

Myringotomy is usually done as an outpatient procedure. General anesthesia is preferred in children, while local anesthesia is sufficient for adults. The ear is washed and a small incision is made in the eardrum.

Then all the fluid present is aspirated, the tube of choice is inserted, and the ear is covered with cotton to control any minor bleeding that may occur. This is known as a conventional myringotomy (or cold knife) and it usually heals within a day or two.

A new variation (called tympanolaserostomy or laser-assisted tympanostomy) uses CO2 laser and is performed with a computer-controlled laser and video monitor to identify a precise hole location.

The laser takes a tenth of a second to create the opening, without damaging the surrounding skin or other structures. This perforation remains patent for several weeks and provides ventilation of the middle ear without the need to place the tube.

Although laser myringotomies maintain patency slightly longer than cold blade myringotomies (two to three weeks for laser and two to three days for cold knife without tube insertion), they have not been shown to be more effective in the spill treatment.

A randomized controlled study found that laser myringotomies are safe but less effective than the ventilation tube in treating chronic otitis media with effusion.

Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and a history of tympanostomy tube insertion in adults make laser tympanostomy ineffective.

Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes. The newer ones are coated with antibiotics and phosphorylcholine.

Types of incision

Cut type : given in the posterior lower quadrant, this is done in case of acute otitis media.

Division type : administered in the anteroinferior quadrant, this is done in case of serous otitis media, (adhesive ear) this type of incision is suitable for the insertion of the washer

The incision is j-shaped (hockey) or curvilinear and is administered from the bottom up to facilitate drainage.

important care

There is little scientific evidence to guide ear care after inserting the tubes. A single randomized trial found a statistical benefit for the use of hearing protection devices when swimming, although the size of the benefit was quite small.

In the absence of strong evidence, general opinion has been against the use of hearing protection devices.

However, protection such as cotton wool covered with petroleum jelly, ear plugs, or ear putty is recommended for swimming in dirty waters (lakes, rivers, oceans, or pools without chlorine) to prevent ear infections.

For bathing, shampooing, or swimming in surface waters in chlorinated pools, hearing protection is not recommended.

Complications

Tube placement is not a cure. If the middle ear disease has been severe or long enough to warrant tube placement, there is a strong chance that the child will continue to have bouts of middle ear inflammation or fluid build-up.

There may be early drainage through the tube (tube otorrhea) in approximately 15% of patients in the first two weeks after placement, and develops in 25% more than three months after insertion, although it is generally not a long-term problem.

Otorrhea is considered secondary to bacterial colonization. The most commonly isolated organism is Pseudomonas aeruginosa, while the most problematic is methicillin-resistant staphylococcus aureus (MRSA).

Some doctors use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial biofilm.

A laboratory study showed that tubes coated in the antibiotic vancomycin prevented the formation of the methicillin-resistant Staphylococcus aureus biofilm in vitro compared to uncoated tubes, although no human study has yet been conducted.

Comparison of phosphorylcholine-coated fluoroplastic tympanostomy tubes with uncoated fluoroplastic tympanostomy tubes did not show a statistically significant difference in the incidence of postoperative otorrhea, tube blockage, or extrusion.

Other common early complications are tube displacement or obstruction, while late complications include deposition of fat or dead cells, cholesteatoma, or persistent thinning or perforation of the tympanic membrane.

Effectiveness

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

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

Balloon dilation of eustachian tube dilatation (BDET), a new treatment, has been shown to be effective in treating otitis media with effusion secondary to Eustachian tube dysfunction.

However, the number of patients in the cited studies, 22 and 8 respectively and 18 in the tympanometric study, is extremely small and simply points to the need for large and well-controlled studies.