Myringotomy 

Updated: Jan 06, 2016
Author: Brian Kip Reilly, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Myringotomy is a surgical procedure of the eardrum or tympanic membrane. The procedure is performed by making a small incision with a myringotomy knife through the layers of tympanic membrane (see the image below). This surgical procedure permits direct access to the middle ear space and allows the release of middle-ear fluid, which is the end product of otitis media with effusion (OME), whether acute or chronic. OME is classified as serous, mucoid, or purulent.

Myringotomy (radial incision). Myringotomy (radial incision).

The fluid is suctioned from the middle ear through the incision and, if indicated, sent for bacterial or viral cultures. Currently, bilateral myringotomy is often used in conjunction with placement of middle-ear ventilation tubes, which permits the incised drum to remain open and allows better drainage of middle-ear fluid.[1] This approach facilitates instillation of antibiotic otitic drops, and ultimately results in faster resolution of the OME.[2]

OME may spontaneously occur as a result of inadequate ventilation of the middle-ear space related to poor eustachian tube function or a persistent inflammatory response to acute otitis media (AOM). Additional contributors to the development of OME include the immaturity both of the infant or young child’s immune system and of the anatomy of the eustachian tube.

The eustachian tube is the communication between the middle ear and the nasopharynx. Its function is to equalize pressure across the tympanic membrane. Contraction of the tensor veli palatini and the salpingopharyngeus outside of the tympanic cavity (middle ear) dilate and open the auditory tube.

In children, the eustachian tube is shorter, more horizontally oriented, and less functionally mature, and these differences can predispose children to OME. Inflammation of the mucosa of the eustachian tube orifice (from conditions such as upper respiratory infection [URI] or allergy) and improper functioning of the eustachian tube musculature lead to negative middle-ear pressure. Thus, when the eustachian tube opens, bacteria and viruses from the nasopharynx are drawn into the middle-ear space and generate an inflammatory response.

OME has a strong correlation with URI. Children with craniofacial abnormalities that affect eustachian tube function (eg, Down syndrome and cleft palate) are at increased risk for otitis media. Immune deficiency should be suspected in children with OME that occurs in association with recurrent sinusitis, bronchitis, or gastrointestinal (GI) abnormalities.

Other predisposing conditions include allergy, adenoid hypertrophy, ciliary dysfunction, and gastroesophageal reflux. OME may be seen in patients with prolonged nasal intubation or nasogastric tubes.[2]

Relevant Anatomy

The tympanic membrane is an oval, thin, semi-transparent membrane that separates the external and middle ear (tympanic cavity). The tympanic membrane is divided into 2 parts: the pars flaccida and the pars tensa. The manubrium of the malleus is firmly attached to the medial tympanic membrane; where the manubrium draws the tympanic membrane medially, a concavity is formed. The apex of this concavity is called the umbo. The area of the tympanic membrane superior to the umbo is termed the pars flaccida; the remainder of the tympanic membrane is the pars tensa (see the image below).

Tympanic membrane (TM): pars flaccida (superior to Tympanic membrane (TM): pars flaccida (superior to insertion manubrium) and pars tensa (remainder of TM).

The eustachian tube is the communication between the middle ear and the nasopharynx. Its function is to equalize pressure across the tympanic membrane. Contraction of the tensor veli palatini and the salpingopharyngeus outside of the tympanic cavity (middle ear) dilate and open the auditory tube. The image below depicts middle ear anatomy.

Middle ear anatomy. Middle ear anatomy.

For more information about the relevant anatomy, see Ear Anatomy.

Indications

Myringotomy may be indicated in cases of AOM, recurrent AOM with effusion (RAOME), and chronic otitis media with effusion (COME). Patients with AOM that is refractory to medical therapy or associated with signs of toxicity require myringotomy with or without middle-ear culture. Children with recurrent acute episodes of otitis media (usually understood as more than 4-5 infections in 6 months) benefit from myringotomy. The most common indication is for children with COME of more than 3 months’ duration.

Because of the rapid healing properties of the tympanic membrane, myringotomy with aspiration of effusion has a shorter-lived benefit than myringotomy performed in conjunction with ear tube placement. Studies have advocated myringotomy with tube insertion over myringotomy alone to decreased the time of effusion and improve hearing.[3]

A child who displays speech and language delay secondary to otitis should undergo prompt myringotomy with or without ear tubes. Additionally, certain subsets of children are more likely to need prompt surgical intervention (ie, myringotomy), including the following:

  • Children with permanent hearing loss independent of OME

  • Children with autism-spectrum disorder and other pervasive developmental disorders

  • Children with syndromes (eg, Down syndrome) or craniofacial disorders that result in eustachian tube dysfunction

  • Children who are blind or have uncorrectable visual impairment

  • Children who have cleft palate with or without cleft lip[4]

 

Periprocedural Care

Preprocedural Planning

Pneumatic otoscopy by a physician is the primary diagnostic method for otitis media with effusion (OME) and acute otitis media (AOM). In addition, tympanometry can be performed by the audiologist to help diagnose and confirm fluid behind the eardrum. Alternatively, the ear can be examined under magnification.

Radiologic imaging and confirmatory blood chemistry studies usually are not indicated. Exceptions that benefit the patient occur if postauricular swelling or mental status changes develop or if the patient appears severely ill and toxic. In these clinical situations, computed tomography (CT) scans of the temporal bone can be done to confirm temporal bone diseases, such as mastoiditis, cholesteatoma, or a malignant process.

Unilateral effusions are less common and may indicate a nasopharyngeal mass or disease process, particularly in children older than 6 years. These circumstances mandate that a nasopharyngoscopy be performed.

Equipment

Equipment used in myringotomy includes the following:

  • Pneumatic otoscope

  • Operative microscope

  • Speculum

  • Myringotomy blade (see the image below)

  • Ear tubes (if required)

    Myringotomy blade. Myringotomy blade.

Monitoring and Follow-up

Postoperatively, the patient is placed on antibiotic ear drops. In most cases, oral acetaminophen suffices for analgesia.

The patient is seen in follow-up after the procedure. Cultures taken from the time of surgery can be used to determine what antibiotics are most appropriate. Children with effusions or otitis media refractory to myringotomy alone should undergo tympanostomy tube placement in addition to myringotomy.

 

Technique

Incision of Tympanic Membrane

For adult patients, the procedure can be done in the outpatient setting with the use of phenol and topical lidocaine; young adolescents, children, and infants require brief general anesthesia.

The patient’s head is tilted slightly toward the ear opposite the one undergoing myringotomy. The operative microscope is brought into the field and focused on the external auditory meatus. An appropriately sized speculum is carefully placed into the external auditory canal, and cerumen is removed so that the entire tympanic membrane can be visualized.

Either the anteroinferior quadrant or the posteroinferior quadrant of the tympanic membrane is carefully incised with a myringotomy knife; the incision should be approximately 3-5 mm in length (see the image and the first video below). Next, a 3-mm, 5-mm, or 7-mm tube is inserted and used to release the serous or mucoid effusion (see the second and third videos below).[5]

Myringotomy (radial incision). Myringotomy (radial incision).
Myringotomy. Video courtesy of Hamid R Djalilian, MD.
Myringotomy and ear tube placement. Video courtesy of Hamid R Djalilian, MD.
Myringotomy with aspiration of mucoid fluid.

The tympanic membrane usually heals spontaneously. Repeat myringotomy or insertion of ear tubes may be needed if otitis persists.

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Analgesics, Other

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain. In most cases, oral acetaminophen suffices for analgesia in this setting.

Acetaminophen (Aspirin Free Anacin, FeverAll, Tylenol, Mapap)

Acetaminophen is the drug of choice for treating pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

It is effective in relieving mild to moderate acute pain; however, acetaminophen has no peripheral anti-inflammatory effects. It may be preferred in elderly patients because of fewer GI and renal adverse effects.

Antibiotics, Otic

Class Summary

An otic antibiotic suspension may be used intraoperatively, or the patient is placed on antibiotic eardrops postoperatively.

In December 2015, an otic suspension of ciprofloxacin was approved by the FDA for pediatric patients with bilateral otitis media with effusion undergoing tympanostomy tube placement. In a double-blind, randomized clinical trial, 83 children (mean age 2.8 y) were administered intraprocedural otic drops or placebo. Through day 15 postprocedure, treatment failures accounted for ~15% in the antibiotic group compared with 43-45% in the placebo group.[6]

Ciprofloxacin otic (Otiprio)

Ciprofloxacin is an ototopical fluoroquinolone. This class of antimicrobial has a broad spectrum of activity. Additionally, fluoroquinolones do not cause vestibular or cochlear toxicity recognized with aminoglycosides. The sustained-exposure ciprofloxacin suspension (Otiprio) is indicated for pediatric patients with bilateral otitis media with effusion undergoing tympanostomy tube placement. It is administered as a single intratympanic administration of 0.1 mL (6 mg) into each affected ear, following suctioning of the middle ear effusion.

Ofloxacin Otic

Ofloxacin is an ototopical fluoroquinolone. This class of antimicrobial has a broad spectrum of activity. Additionally, fluoroquinolones do not cause vestibular or cochlear toxicity recognized with aminoglycosides.

Anesthetics, Topical

Class Summary

Local anesthetics are used for local pain relief.

Lidocaine (Xylocaine)

Lidocaine decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses. It is used for relief of pain associated with postherpetic neuralgia and has been used for pain relief of many other types of pain generators as well.