Do You Do Tympanocenteses?
In this month's issue of Pediatrie Annals, our guest editor, Raymond C. Baker, MD, and his team of authors address complications of acute otitis media (AOM) in infants and children. This will be familiar ground for primary care practitioners who deal with AOM and its complications every working day. Next to child health supervision, otitis media in its various forms is the most common reason for visits to pediatricians' offices.1 Acute otitis media strikes early and often, with 67% of all children experiencing one or more episodes during their first year of life, 50% having three or more episodes by the age of 3, and almost 40% suffering six or more episodes by the age of 7.2,3 I say suffer because:
* more than half of AOM episodes do not resolve quickly with antibiotic therapy - most of these children develop otitis media with effusion (OME), lasting 6 to 1 2 weeks, or recurrent acute infection,
* AOM is painful and is accompanied by fever, irritability, sleeplessness, and anorexia, and
* if AOM and OME do not resolve, chronic infection ensues, with damage to the middle ear, hearing loss, speech and learning difficulties, and the need for surgical interventions such as tympanostomy tube placement, adenoidectomy, and mastoidectomy.
The management of AOM includes treating the infection with an antibiotic for 10 to 14 days, controlling otalgia and fever, and reexamining the affected ear(s) when antibiotic therapy is completed, or sooner if the symptoms have not resolved, to determine if the antibiotic treatment has been successful. The choice of antibiotic, usually amoxicillin, trimethoprim-sulfamethoxazole or doxycycline, is based on studies of bacterial pathogens isolated from the middle ears of patients with previously untreated AOM, which have shown these organisms to be susceptible to these particular antibiotics.4
Otalgia and fever are usually controlled successfully with the administration of acetaminophen. In the past, myringotomy or tympanocentesis to drain the middle ear effusion (MEE) that accompanies AOM or instillation of a topical analgesic, in the external auditory canal were used to relieve the otalgia. Myringotomy and tympanocentesis are rarely used today to relieve pain because most primary care practitioners are not adept at performing either procedure, and most infants and children with AOM do not require it. I don't know why topical analgesics aren't used more often. They are inexpensive, easy to administer, very effective, and free of side effects, except for rare instances of sensitivity to benzocaine.
When it is determined that the treatment of AOM with the antibiotic chosen has been unsuccessful, a second course of antibiotic treatment with one of the agents not chosen for the first course, or another antibiotic such as the combination of amoxicillin and clavulanate, cefuroxime axetil, or cefixime should be instituted for another 10 to 14 days. These drugs are chosen on the basis of studies of bacterial pathogens isolated from the middle ears of patients with AOM previously treated empirically with amoxicillin, trimethoprim-sulfamethoxazole, erythromycin/sulfisoxazole, or cefaclor.5
Figure. Tympanocentesis. A) A 3-inch, 22-gauge spinal needle that has been shaped to allow direct visualization of the tympanic membrane through the operating otoscope. A tuberculin syringe barrel is attached to the needle, and tubing is attached to the syringe barrel. B) The preferred site on the right tympanic membrane for puncture and aspiration of the middle ear. Once the middle ear has been entered, the operator applies negative pressure through the end of the tubing, as illustrated. Reprinted with permission from Custer JR. Special procedures. In: Hoekelman RA, Fnedman SB, Nelson NM, Seidel HM, eds. Primary Pediatrie Care. 2nd ed. ©1991 , Mosby Yearbook.
All too often, this second antibiotic treatment regimen does not resolve persistent or recurrent AOM. What then? Should we go on to a third course of antibiotics, chosen on empiric grounds? I think not. At this point, it is most appropriate to go back to the basics and try to determine what organism is or which organisms are still present and active in the MEE and to determine which antibiotics they are sensitive to. This can only be done in one way - by tympanocentesis, in which the tympanic membrane (TM) is punctured and the MEE aspirated. Removal of the MEE will improve the likelihood of the newly prescribed antibiotic's effectiveness, once it reaches the middle ear through the bloodstream. If an abscess (infected fluid in a contained space) is present, surgical therapeutic principle dictates its drainage. One might argue that tympanocentesis, which does this, should be performed initially when AOM first presents or after the failure of the initial course of antibiotic treatment. However, the procedure with its attendant bactériologie studies is costly (between $75 and $100), and the frequency with which it would be required is too high to make this practical. After two treatment failures with one, two, or more antibiotics, however, tympanocentesis is indicated. In addition to an unsatisfactory response to antimicrobial therapy, other indications for tympanocentesis include:
* a bulging TM with purulent MEE in order to relieve pain and prevent spontaneous rupture through a portion of the TM that might not heal rapidly or at all,
* a child with suspected concomitant sepsis, meningitis, mastoiditis, or arthritis and
* a neonate or an immunocompromised patient in whom an unusual organism may be present.
Tympanocentesis is neither a new nor unique procedure. It is more effective in removing the MEE than myringotomy because negative pressure can be applied in the process, and it is more precise in identifying the organisms within the MEE because the fluid removed is less likely to be contaminated by organisms present in the external auditory canal. A review of the literature reveals several ways tympanocentesis can be performed. Bjuggren and Tunevall used a straight needle set on a handle and attached to a stiff plastic balloon compressed prior to puncture of the TM and then released to generate negative pressure following puncture.6 Mortimer and Watterson used a short-beveled no. 20 needle bent 30° at its hub and attached to a glass adapter and a rubber tube to which oral suction was applied.7 Kaplan and Feigen used a straight, short -beveled, 1½", no. 20 needle attached to a tuberculin syringe from which the plunger had been removed and to which a 5-µ. filter connector and rubber pipette tubing were attached to enable the application of oral suction.8 In recent years, this latter method has been slightly modified, as shown in the Figure.
In order to perform tympanocentesis properly without injury or undue discomfort to the patient, he or she must be restrained by use of a "papoose" board and with the aid of an assistant. The external auditory canal should be cleansed with moist cotton swabs, and two drops of 10% cocaine hydrochloride, which will sterilize the canal and anesthetize the TM, should be instilled a few minutes prior to performing the procedure. The aspirated fluid should be cultured on blood agar and chocolate agar plates and in a blood broth bottle, and a Gram stain prepared. If there is no visible fluid in the syringe, the needle and syringe should be flushed with 2 to 3 mL of blood broth and cultured in the broth bottle.
Tympanocentesis is not a difficult procedure to learn or perform. If primary care physicians are not prepared or equipped to do tympanocentesis, they should consider referring those patients who require the procedure to someone who is.
1. Hoekelraan ElA, Starfield BS, McCormJcIc MA, et al. A predile of pediatrie practice in the United States. AmJ Dis CWU, 1983; 137: 1057- 1060.
2. Pichichero ME Management of persistent, recurrent, and chronic oritìs media with effusion. Research and Clinical fononi. 1990; 12: 7 5-84.
3. Tecle DW, Klein JO. Rosner B, Greater Boaton Otitis Media Study Group. Epidemiology during die first 7 years of life in children in greater Boston: a prospective, cohort study J Infect Du 1989; 160:83-94.
4. Giebink GS. The microbiology of otitis media. Peaatr Infect Dis J. 19T9;T;518-520.
5. Harrison CJ, Marks MI, Welch DF. Microbiology of recently treated versus untreated otitis media. Pediatr Infect Dis J. 1985;4:641-646.
6. Bjuggren C, Tunevall G. Otitis medía in childhood. Acto Otoíorjngol. 1952;42:31I328.
7. Mortimer EA Jr, Watterson RL Jr. A bactériologie investigation of ocitis media in infency. Pediatrics. 1956; 17:359-366.
8. Kaplan SL, Feigen RD. Simplified technique for tympanocentesis. Pediatrics. 1978:62:418-419.