|Tympanocentesis in the
Diagnosis and Treatment of Otitis Media
Published in INFECTIONS in MEDICINE, July 2001, Pgs. 363-366
Itzhak Brook, MD, MSc
Georgetown University School of Medicine, Washington, DC
Tympanocentesis is a procedure that can be used in the office
by trained primary caregivers. It can provide benefit to
patients by allowing for identification of the pathogens
and their antimicrobial susceptibility, distinguishing between
viral and bacterial infection, and draining the effusion
or abscess. It is indicated in febrile children with a toxic
appearance, those with ear pain and a bulging tympanic membrane,
and those whose otitis has failed to respond to sequential
antimicrobial therapy. [Infect Med. 2001;18:363-366]
the discovery of antimicrobial agents, tympanocentesis was a
common procedure used not only by otolaryngologists but also
by pediatricians.1 This was often the only effective
means of treating an ear infection. The procedure allows for
drainage of fluid from the middle ear, and it provides immediate
relief of symptoms such as pain, irritability, and fever.
In the preantimicrobial period, many practicing pediatricians
and family practitioners were familiar with this procedure and
performed it in their clinics. However, when antimicrobial agents
became available in the mid-1940s, the procedure became less
useful, since the antimicrobial agents were effective in most
patients, inducing rapid resolution of the infection. Subsequently,
tympanocentesis was used less often, being performed only in
select cases, and mostly by otolaryngologists.
In the past 2 decades, a significant increase in resistance to antimicrobial
agents has occurred.2 Resistance to many antimicrobials used for the
treatment of acute otitis media developed in the predominant organisms causing
this infection. Up to 40% of Haemophilus influenzae and more than 95%
of Moraxella catarrhalis strains are currently producing the enzyme ß-lactamase3;
30% to 50% of Streptococcus pneumoniae isolates resist penicillin4 through
alteration of their penicillin protein-binding site and concomitantly also resist
other antimicrobials (macrolides, trimethoprim-sulfamethoxazole, and third-generation
cephalosporins)4; and 5% to 10% of Streptococcus pyogenes strains
As a result of this growing resistance to antimicrobials, physicians have encountered
increased difficulty in treating otitis media, and several reports have described
an increased rate of complications such as mastoiditis.6 Because of
these changes, there has been a resurgence in the use of diagnostic and therapeutic
tympanocentesis. Training primary care physicians in this procedure offers them
the flexibility of performing it promptly without the need to refer the patient
to an otolaryngologist. This may save time, since such a referral can often delay
the procedure significantly, thus delaying the diagnostic and therapeutic benefit.
However, referral to an otolaryngologist is still appropriate for those physicians
who are unfamiliar with the procedure or are unwilling to perform it and in cases
where the procedure needs to be done by a specialist because of anatomic or other
Recommendations in the literature
Several recent authoritative publications have endorsed the use of tympanocentesis.
In 1997, the Committee on Infectious Diseases of the American Academy of Pediatrics
recommended its use in patients in whom standard therapy has failed and who are
at risk for infection with resistant S pneumoniae.7
More recently (in 1999), the Drug-resistant Streptococcus pneumoniae Therapeutic
Working Group of the CDC recommended that "in cases of clinically-defined
treatment failure, consideration should be given to identification of the etiologic
agent by tympanocentesis for susceptibility testing to guide alternative antibiotic
the details of office-performed tympanocentesis and suggested its use in children
with severe ear pain, those with recurrent infection, and those with chronic
infection in whom therapy fails. Howie and Ploussard9 used a secondary
ear tap to study antibiotic cure rates in 280 children. Brook10 described
a simple procedure that reduces the risk of contamination of the specimen by
ear canal flora and maintains anaerobiosis to allow for the identification of
anaerobic bacteria. Giebink et al11 suggested the use of tympanocentesis
to exclude viral infection; Berman12 recommended it for unresponsive
otitis media; Klein13 suggested it for an ill-appearing child who
may benefit from identification of pathogens and determination of their susceptibility;
and Block14 offered its use as an adjunctive intervention for refractory
Pichichero and Pichichero15 were able to define those patients who
had no bacteria in their middle ear and therefore required no antimicrobial therapy.
Such patients include about a third of those with acute otitis media and half
of those with persistent and recurrent infection. Hoberman et al16 reviewed
the proper technique of performing tympanocentesis using a disposable aspirator.
Brook and Gober17 demonstrated the usefulness of tympanocentesis in
determining the cause of failure of antimicrobials to clear the ear infection
and in determining antimicrobial susceptibility.
Indications in primary care
The indications for tympanocentesis include:
severe otalgia in the presence of a bulging tympanic membrane
(in children younger than 4 years).
complications (to establish the diagnosis and treatment).
of antimicrobial therapy to clear the infection. The higher
the number of failures, the more the procedure is indicated.
of unusual pathogens in neonates.
the ear can provide immediate pain relief and rapidly reduce
fever. We have been able to abort fever and seizures in children
who presented with febrile convulsions. The procedure also significantly
improves the clinical condition of a toxic-appearing child, in
whom accurate identification of the pathogen is of utmost importance.
Removal of pus from the middle ear may reduce systemic toxicity.
Removal of fluid that may continue to accumulate and cause serious
otitis media may be beneficial. Although this is not yet proved,
tympanocentesis may prevent complications, such as the development
of mastoiditis, bacteremia, and meningitis.
In instances in which antimicrobials have failed to resolve the infection,
the identification of bacterial pathogens and their antimicrobial susceptibility
makes possible the proper selection of antimicrobial therapy.15 In
instances in which no bacterial pathogens (aerobic or anaerobic) are identified,
a viral infection can be assumed to be present. Since the microbial causes
of otitis media in immunocompromised patients and newborns may be diverse and
may include atypical or low-virulence organisms, and the risk of complication
is higher, myringotomy may be indicated in those patients even before the first
course of therapy. It should also be done in hospitalized patients in the presence
of suppurative complications, including mastoiditis and meningitis.
The procedure should not be done in the office in those with bleeding diathesis,
in those who cannot be safely restrained, or when the tympanic membrane cannot
be visualized or is thick or scarred. Those cases should be referred to an
otolaryngologist for performance of the procedure.
We do not routinely use topical anesthesia and only rarely use mild sedation
in the performance of tympanocentesis. Analgesia can be used when indicated,
with acetaminophen and codeine or with diazepam. (When diazepam is used, the
child must be on an oxygen monitor with 2 persons trained in cardiopulmonary
resuscitation present, because there is a risk of aspiration.) After the child
is restrained appropriately (a papoose should be used for restraint in those
younger than 4 years), the external auditory canal is cleaned with a blunt
Cleansing of the canal is the most crucial determinant of success
with the procedure. Without clear visualization of the tympanic membrane,
is contraindicated. When complete antisepsis is warranted, the external auditory
canal can be cleaned with povidone-iodine solution, followed by copious irrigation
with saline. Thereafter, the external auditory canal is dried of excess fluid
using sterile cotton swabs and is allowed to dry for 2 to 3 minutes. After
antisepsis of the external ear canal, a culture should be obtained to ensure
An 18- or 20-guauge spinal needle is used. After the sylet is removed, it is
bent to a 45-degree angle about an inch from the syringe and is connected to
a 2-mL syringe. Alternatively, an intravenous cannula set (Medicut, Sherwood
Medical Instrument, Inc., St. Louis) can be used; this consists of an 18- or
20-gauge needle attached to a 2-mL syringe covered by a plastic cannula that
is slipped forward to cover the bevel.
An operating otoscope should be used. The otoscope is held by the
left hand, and the cannula set by the right. The needle is then directed
through the otoscope
to the tympanic membrane. When the needle is adjacent to the tympanic membrane,
the cannula is retracted and the membrane is penetrated in the anterior inferior
quadrant; negative pressure is then applied to the syringe. The needle tip
does not make contact with the speculum or auditory canal. There is no need
to seal the ear canal. However, if drainage persists, cotton can be temporarily
placed. Alternatively, a disposable aspirator connected to a suction device
can be used.
The removed fluid is cultured as soon as possible (preferably immediately)
for aerobic and facultative bacterial using blood and chocolate agar media.
In instances of chronic infection, it is advisable to culture also for anaerobic
organisms.18 Gram stain should be done. If only a small amount of
fluid is aspirated, the needle should be rinsed with sterile saline (without
inhibitory substances). The content of the syringe should be plated on a solid
agar medium, not into blood culture fluid. This will ensure semiquantitave
identification of the pathogen(s) and rapidly differentiate multiple pathogens
The procedure and its benefits and risks should be openly discussed with parents
and when possible also with the child, and informed consent should be obtained.
Patients generally tolerate the procedure well. In instances in which the drum
is bulging and the tympanic membrane is thin, there seems to be no perception
of pain. However, minimal discomfort may be experienced in other instances.
The perforation in the membrane generally seals itself within 24 to 48 hours.
The procedure can be taught by an experienced physician or an otolaryngologist.
A short hands-on course that teaches the tympanocentesis is offered now across
the country by a group of specialists (OMEW).
Once the procedure is mastered, it can be performed in the clinic.
Risks and complications
Complications associated with tympanocentesis occur only rarely. They
include dislocation of ossicles; entering an aberrant jugular bulb
and causing excessive
bleeding; persistent perforation; leakage of blood and pus for several hours
or, rarely, for several days. When present, bleeding is generally self-limited
and ceases within 1 to 2 hours. A follow-up visit to examine the ear is recommended
7 to 10 days later, or sooner if indicated.
In more than 1000 tympanocentesis procedures performed over the past 25 years,
I have encountered no major complications; minor, self-limited bleeding occurred
in fewer than 5% of the procedures.
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