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Hosai Hesham

Gregory J. Milmoe

21 Tympanocentesis

A. Indications

Diagnostic tympanocentesis is indicated in neonatal acute

otitis media (AOM) to target antibiotic therapy (1,2).

Tympanocentesis may be used for both diagnostic and

drainage purposes (3). The specific indications include

1. AOM not responding to antibiotics after 72 hours

2. AOM in severely immunocompromised infant

3. AOM in infant already on antibiotics

4. AOM with suppurative complications (e.g., mastoiditis,

facial paralysis, sepsis)

5. To confirm the diagnosis when the clinical exam is not

clear

6. To relieve severe otalgia

B. Contraindications

1. Difficulty in confirming ossicular landmarks. One must

be able to identify the malleus and the annulus of the

tympanic membrane (TM) (Fig. 21.1).

2. Suggestion of abnormal anatomy. This is more likely in

patients with congenital malformation syndromes.

3. Suggestion of alternate pathology (e.g., cholesteatoma

or neoplasm)

C. Equipment

All Sterile

1. Surgical gloves

2. Otoscope with open operating head and good light

3. Largest speculum that will fit the canal (2, 3, or 4 mm)

4. 18-gauge 3-inch spinal needle with 1-mL or 3-mL

syringe

5. Blunt ear curette

6. 70% isopropyl alcohol in 3-mL syringe for cleaning and

antisepsis of ear canal

7. Suction setup with 5-Fr Frazier ear suction

8. Culturettes with transport media

D. Precautions

1. Patient safety and comfort require proper restraint, adequate light, and appropriate instruments.

2. The kindest way is to be quick, and this means having

the child immobile.

3. Conscious sedation is feasible only if the child is stable

and has no issues with airway obstruction. It is not

needed past the point of puncturing the TM; usually no

medication is used.

4. Good visualization is paramount. Sufficient cleaning

must be done so that the malleus and the anterior

aspect of the annulus are clearly visible.

5. Avoid the posterior aspect of the tympanic membrane.

This is where the round window, stapes, and incus are

located.

E. Technique (4,5)

1. Restrain infant (see Chapter 4).

2. Position infant with the head turned so that the involved

ear is up. The assistant must keep the head still.

3. Rinse ear canal with alcohol solution from a 3-mL

syringe. This will provide antisepsis and initiate cleaning.

4. Let fluid run out or use suction.

5. Use otoscope to visualize canal and remove debris with

curette or suction.

6. Align speculum to get best view of TM landmarks.

Pulling superiorly and laterally on the pinna will

improve visibility (Fig. 21.2).

7. Attach spinal needle to syringe, after bending it 45 to

60 degrees at the hub. This keeps the syringe out of

the line of sight.

8. Hold needle at the hub and introduce it through the

otoscope. Puncture the drum anterior to the malleus at

or below the umbo level (Figs. 21.2 and 21.3).

9. Hold needle securely and have assistant draw back on

the syringe to obtain sample.

10. Place sample in appropriate transport medium.