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Tympanocentesis in Children with Acute Otitis Media


Nader Shaikh, M.D., M.P.H., Alejandro Hoberman, M.D., Diana H. Kearney, R.N., C.C.R.C., and Robert Yellon, M.D.
Overview

Tympanocentesis involves needle aspiration of fluid from the middle ear. Familiarity with this procedure enables primary care practitioners to effectively treat patients who have refractory acute otitis media.
Indications

In children with refractory acute otitis media, drainage of pus from the middle ear often results in a rapid and marked abatement of symptoms. In addition, identification of pathogens from the fluid specimen obtained enables tailored antimicrobial therapy. The American Academy of Pediatrics recommends that tympanocentesis be considered in children who have signs and symptoms of acute otitis media that persist after two courses of antibiotic treatment.1 In immunocompromised children and ill-appearing neonates with acute otitis media, unusual or resistant organisms can be identified through tympanocentesis. In children with suppurative complications of acute otitis media, such as mastoiditis or facial paralysis, tympanocentesis allows for drainage and can provide immediate relief from pressure and pain.
Contraindications

From the Department of Pediatrics (N.S., A.H., D.H.K.) and the Department of Pediatric Otolaryngology (R.Y.), Childrens Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine. Address reprint requests to Dr. Shaikh at Childrens Hospital of Pittsburgh of UPMC, One Childrens Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, or at nader.shaikh@chp.edu. This article (10.1056/NEJMvcm0706756) was published on January 12, 2011, at NEJM.org. N Engl J Med 2011.
Copyright 2011 Massachusetts Medical Society.

Tympanocentesis is contraindicated in children with tympanostomy tubes and in children with congenital stenosis of the external auditory canal.
Preparation

To prepare for the procedure, explain the risks and benefits to the parent or guardian and document informed consent in the medical record. Proper analgesia should be administered 30 minutes before the procedure. Acetaminophen plus codeine (1 mg of codeine per kilogram of body weight) can be used as oral analgesia. Alternatively, a cotton ball soaked with 8% tetracaine may be inserted into the external auditory canal 30 minutes before the procedure.
Equipment

The following equipment is necessary: a papoose board; a surgical otoscope with speculum; a mechanical suction device; a tympanocentesis aspirator with a 3-in., 18-gauge spinal-tap needle (Fig. 1); a second aspirator with flexible tubing; and cotton balls. The suction device can usually be set to medium, although the strength of the suction at any one setting will vary with the equipment used. If the suction is set at the maximal setting, the specimen may be drawn into the tubing and lost. If a tympanocentesis aspirator is not available, a 3-ml syringe can be connected to a 3-in., 18-gauge spinal-tap needle that is bent at its midpoint to a 30-degree angle. Given the manipulation required to bend the needle and the relatively weaker suction achieved when using a syringe, this is not the preferred method.
10.1056/nejmvcm0706756 nejm.org

Figure 1. Tympanocentesis Aspirator with Needle.

The New England Journal of Medicine Downloaded from nejm.org by AMIRULLAH MUAMAR on September 8, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reserved.

Tympanocentesis in Children with Acute Otitis Media

Procedure

Figure 2. Site of Needle Insertion. The needle should be inserted in the inferior portion (gray shading) of the tympanic membrane.

Fully immobilize the child on a papoose board and have an assistant secure the childs head. Cerumen should be removed before the procedure is begun. With your dominant hand, insert the otoscope into the external auditory canal and visualize the umbo and the annulus. Once the otoscope is in the proper position, switch hands, so that you are holding the instrument in place with your nondominant hand. Insert the needle that is attached to the tympanocentesis aspirator, which is attached to the suction device. Under direct visualization, advance the needle toward the tympanic membrane, keeping your thumb poised over the orifice of the tympanocentesis aspirator without occluding it. Insert the bevel of the needle through the inferior portion of the tympanic membrane, 2 to 3 mm above its inferior rim (Fig. 2). Immediately after penetrating the tympanic membrane, place your thumb on the orifice of the tympanocentesis aspirator and start suctioning fluid from the middle ear. Once pus is visualized in the aspirator, promptly remove your thumb from the aspirator to avoid losing the specimen to the suction tubing. Use a second tympanocentesis aspirator with a flexible catheter to suction any remaining pus from the middle ear. Insert the catheter through the speculum and place it over the opening in the tympanic membrane made by the needle. The catheter should not go through the tympanic membrane. This step also clears the debris in the external auditory canal and will enhance visualization of the tympanic membrane at future visits. Place a small cotton pledget in the external auditory canal to absorb any remaining blood or pus, and release the child from the restraint. Remove the plastic receptacle from the tympanocentesis aspirator and send the specimen for microbiologic evaluation.
Complications

The incidence of complications of tympanocentesis has not been studied systematically but appears to be extremely low. Complications include disruption of the ossicles, piercing of the oval or round windows, laceration of the facial nerve or the chorda tympani, bleeding from a high-riding bulb of the internal jugular vein, and chronic perforation of the tympanic membrane. The likelihood of incurring complications can be minimized by ensuring adequate immobilization, bracing the hands against the childs head, and paying careful attention to the point of needle insertion. Damage to the oval window, the ossicles, or the facial nerve can be prevented by ensuring that the needle is inserted in the inferior portion of the tympanic membrane (Fig. 2). Bleeding can be minimized by avoiding the umbo and annulus. In case of profuse bleeding from either the external auditory canal or a prominent jugular-vein bulb, the external auditory canal can be packed with a cotton ball soaked in oxymetazoline. Having the child sit up and having the parent soothe the child may also help to reduce bleeding.
Follow-up

Oral and topical antimicrobial therapy is generally initiated after the procedure, while the results of the culture are being awaited. Pathogenic bacteria are detected in the specimens from approximately 70 to 80% of patients with acute otitis media. The results of Grams staining of the specimen and the susceptibility pattern of the isolated bacteria (generally available within 2 days) should be used to guide antimicrobial therapy. The small perforation in the tympanic membrane made during tympanocentesis usually heals in 2 to 3 days; some serosanguineous drainage during this period is normal. For the first 3 days after the procedure, a cotton ball
2

10.1056/nejmvcm0706756 nejm.org

The New England Journal of Medicine Downloaded from nejm.org by AMIRULLAH MUAMAR on September 8, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reserved.

Tympanocentesis in Children with Acute Otitis Media

coated with petroleum jelly should be used during bathing to keep water out of the childs external auditory canal. A follow-up examination should be scheduled for 3 or 4 days after the procedure.
Summary

References 1. Diagnosis and management of acute otitis media. Pediatrics 2004;113:1451-65.


Copyright 2011 Massachusetts Medical Society.

Tympanocentesis is an underused procedure. Clinicians should become familiar with tympanocentesis so that they can safely perform the procedure in children with acute otitis media.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

10.1056/nejmvcm0706756 nejm.org

The New England Journal of Medicine Downloaded from nejm.org by AMIRULLAH MUAMAR on September 8, 2011. For personal use only. No other uses without permission. Copyright 2011 Massachusetts Medical Society. All rights reserved.