Myringotomy and tympanocentesis (CPT 69420): A lost skill revisited

October 2001

Myringotomy, the lancing of an eardrum to drain pus, serous, or mucoid fluid, was described in 1768. Until 1960, primary care pediatricians and general practitioners were skilled in the performance this procedure. A myringotomy knife in its stainless steel tube was carried in the doctor’s black bag during house calls; the procedure would be performed through a hand-held otoscope on the kitchen table. As the myringotomy knife vented the pus under pressure, many a young child with acute otitis media (AOM) would issue one last loud scream just prior to obtaining dramatic relief of his/her pain and suffering.

From 1970 through 1998, few pediatric programs offered tutorials on the technique of tympanocentesis. In 1999, a working group of experts for the AAP, American Academy of Family Medicine, the Society for Academic Emergency Medicine, Infectious Diseases Society of America, American College of Physicians, American Academy of Otolaryngology-Head and Neck Surgery, and the CDC met to provide consensus recommendations for the management of AOM.

The consensus document stated in part that “diagnostic tympanocentesis, with culture and susceptibility testing of isolates, although difficult to achieve in most practice settings, may be necessary to guide the choice of therapy in difficult AOM cases. In an era of increasing antimicrobial resistance, clinicians treating children with AOM should consider developing the capacity to perform tympanocentesis (or readily refer to a clinician with this capacity).”

A half-day training course on AOM, including training in proper technique for tympanocentesis, has been given 70-90 times each year for the past three years. It is accredited by the University of Rochester and is taught by experts. For information about the dates and locations of these tympanocentesis training courses, call (877) EAR-OMEW (877-327-6639) or go their Web site at www.omew.com.

Anatomical landmarks

The tympanic membrane (TM) is bisected into anterior and posterior halves by the manubrium (handle) of the malleus bone. When the right TM is examined, the manubrium points outward toward 2 o’clock and when the left TM is examined, the manubrium points outward toward 11 o’clock.

The TM is further bisected into superior and inferior halves by an imaginary line drawn through the umbo at a right angle to the axis of the manubrium. Using the axis of the manubrium and the umbo as your anatomic guides, the TM can be separated into four quadrants: two superior quadrants which are anterior/superior and posterior/superior and two inferior quadrants which are anterior/inferior and posterior/inferior. The superior quadrants, particularly the posterior/superior quadrant, should not be punctured. Many of the older textbooks explaining the procedure suggested that the posterior/inferior quadrant of the TM is the preferred site for myringotomy or tympanocentesis. However, the oval window is located deep in the posterior-inferior quadrant. As such, it is generally safer to aim the knife blade or needle toward the anterior-inferior quadrant.

When it comes to topical anesthesia or administration of analgesic/sedative medication, otolaryngologists sometimes apply one of several topical anesthetics to the surface of the tympanic membrane. One of the earliest compounds was 20% phenol solution or a mixture of phenol and cocaine (Bonaine’s Solution). A thin wisp of absorbent cotton was attached to a stainless steel wire applicator, dipped into the phenol solution, and the excess phenol solution shaken off. With due diligence, the cotton-tip of the wire carrier was gently applied to the point of maximal bulging in the inferior half of the tympanic membrane. This left a blanched anesthetized region through which the myringotomy knife was directed.

A commercially available merocellulose otowick can be inserted into the ear canal and saturated with topical lidocaine 15% solution or tetracaine 8% solution. This must be left in place for 20 to 30 minutes before the procedure to achieve local anesthesia of the TM. Lidocaine iontophoresis has been used for topical anesthesia but it requires purchase of the equipment and a waiting time of at least 12 minutes per ear while the child lies immobile on the examining table. EMLA cream (lidocaine and prilocaine eutectic mixture, AstraZeneca) has also been advocated for topical anesthesia of the TM but it is time consuming, messy, and requires careful suctioning of the cream after the mandatory waiting period for the anesthetic cream to take effect.

The procedure

A bulging TM caused by AOM ruptures with the nick of a myringotomy knife or tympanocentesis needle, thereby relieving pressure. The procedure in this regard is not dissimilar from lancing a pustule, furuncle or carbuncle. There is essentially no pain, but rather relief of pain once the pus pressure is released. Nevertheless, children (and parents) may be anxious regarding the procedure. Sedation with orally administered Tylenol with codeine (12 mg per 5 cc) plus diazepam (2.5 mg per 5 cc) dosed at 1.3 mg/Kg of the Codeine component is a useful sedative. Midazolam or Lorazepam orally or intranasally are other alternatives. The need for pulse oximetry and continuous nurse observation in association with the administration of in office sedation may be subject to state law and/or standard of practice in various communities. This should be investigated and compliance is strongly recommended. Virtually all children cry during the procedure but in 85%, the cry is less than a few minutes’ duration. Moreover, the addition of the diazepam seems to reduce the unpleasant memories of the event so that the next office visit is not heralded by the child screaming as soon as the car arrives in the office parking lot.

What is the difference?

Myringotomy involves incising the TM with a knife or bevel of a needle. Material for culture is then obtained by insertion, under direct vision, of a dacron or calcium alginate-tipped nasopharyngeal swab. Tympanocentesis is the needle aspiration of purulent, serous, or mucoid liquid through a hole made in the TM. Both procedures are done in a controlled manner for diagnostic and/or therapeutic reasons. The main advantages of tympanocentesis are less discomfort and bleeding and a better culture from one procedure.

Myringotomy or tympanocentesis should be performed with a surgical otoscope head with a #3, #4, or #5 aural speculum attached to it. Myringotomy can be done with the aid of a disposable myringotomy blade (Beaver Corp. #71) attached to a chuck vise handle (Storz). Tympanocentesis can be performed with a 2.5 to 3.5 inch spinal needle with a 45^o bend either near the hub of the needle or at a point about 1/3 from the hub. For middle ear effusions under pressure as occurs in AOM, a simple stab at any point in the inferior half of the TM is sufficient to establish relief of pressure. For bacterial culture purposes, there may be insufficient middle ear effusion adherent to the myringotomy blade. Therefore, it is often necessary to withdraw the myringotomy blade from the field of view and replace it with a dacron or rayon-tipped nasopharyngeal culture swab. The culture swab is inserted into middle ear exudate that has egressed through the incision site.

Primary care physicians are being encouraged to learn (or re-learn) the myringotomy/tympanocentesis procedure to aid diagnosis, treatment and antibiotic selection for AOM. The procedure should not be performed for otitis media with effusion (OME) by primary care providers; for OME otolaryngologists should be consulted. With OME, thick liquids or gel-like middle ear effusions are the rule. Myringotomy with a smiley face curvilinear incision stretching from four o’clock to eight o’clock on the tympanic membrane may be required. OME is not associated with positive middle ear pressure so suction is used for removal of viscous gel. It may be necessary to turn up the suction pressure or to make an additional hole in the TM to function as an air hole. With chronic OME ventilation of the middle ear space for 1-3 days as occurring with myringectomy/tympanocentesis is not sufficient to allow the middle ear to return to normal. Tympanostomy tubes are necessary to provide more prolonged time for the middle ear mucosa to return to normal. Due to more discomfort, bleeding, the longer time to perform the procedure, the need for suction and anesthesia, TM tube insertion should not be performed by pediatricians or general practitioners. (An exception may be in areas of the country where properly trained general practitioners perform this procedure).

Restraint

Just as in a lumbar puncture, the myringotomy/tympanocentesis procedure requires proper restraint. Inadvertent movement of the patient’s head while the myringotomy knife/tympanocentesis needle is in place provides the main opportunity for significant complications. Thus, the child should have the arms and legs restrained and the head held firmly by an assistant. We recommend a papoose board for this purpose. The parent may remain in the room, if the practitioner is comfortable, to provide reassurance to the child.

Risks

The tympanocentesis procedure has long been a procedure within the purview of primary care physicians and general practitioners. Its risks are no greater than those associated with lumbar puncture as such; most malpractice carriers do not increase premiums as a consequence of adding this procedure to a primary care practitioner’s repertoire.

A number of potential problems are associated with myringotomy or tympanocentesis (see table). However, these are exceedingly small and more theoretical than real so long as the procedure is properly performed. Just as in a lumbar puncture, one would not undertake the procedure without proper restraint, good anatomical localization for needle placement, and sedation if necessary. The only real risk in the procedure so long as the needle is properly placed would be for a sudden movement of the child’s head while the needle has penetrated the TM and is within the middle ear space. In a survey of prominent practitioners of the in-office tympanocentesis procedure involving over 10,000 cases, no significant complications were observed.

Reimbursement

This procedure is reimbursed as a myringotomy (CPT Code 69420) and there is a modifier code for a bilateral myringotomy (CPT Code 69420-50). Most managed care organizations will require certification of technical competence to perform a myringotomy/tympanocentesis procedure. Such certification can be obtained by attending a continuing medical education course conducted by Outcomes Management Education Workshops (www.omew.com). OMEW can be contacted by telephone (1-877-EAR-OMEW) to determine a location for a course near you; accredited workshops are given at multiple sites 70 to 90 times per year.

An alternative to attending the OMEW course is to receive training by an already certified physician who performs myringotomy and tympanocentesis. Most frequently, this would be a local otolaryngologist in a practitioner’s community, often the one to which the practitioner refers patients. The training would involve joining the otolaryngologist in the operating suite during a session of placement of tympanostomy tubes. The practitioner would perform the procedure under supervision and the otolaryngolists would thereafter provide a letter in writing indicating that the primary care practitioner had been supervised and directly observed to perform the procedure and was now capable to perform the procedure independently.

Culture and Sensitivity Testing

Most physician office laboratories no longer seek or have obtained CLIA level III certification to allow bacteriology identification and antibiotic susceptibility testing. Therefore, once tympanocentesis fluid is obtained, a Gram’s stain might be performed either at the physician’s office or at their referral laboratory center. In this way, a near immediate determination can be made whether gram positive or gram-negative organisms are predominantly involved in the infection. For precise bacterial identification and subsequent susceptibility testing, the easiest way to deal with the sample is to squirt the tympanocentesis needle aspirate into an aerobic blood culture bottle. It may be necessary to rinse the needle in order to secure the small sample obtained and then send the blood culture bottle off to a reference laboratory indicating that the sample is from a middle ear effusion in order to facilitate proper plating for the likely suspected pathogens. Another alternative is to squirt the sample onto a transportable culturette swab and send the sample in this manner. However, prompt processing by the reference laboratory would be quite beneficial as Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis may not survive for a long interval without nutrient transport media.

Indications for office myringotomy or tympanocentesis

• Severe otalgia with screaming or crying for several hours, including at the doctor’s office.
• An infant with high fever, toxic appearance, and bulging, opacified, tympanic membrane(s).
• AOM in a neonate, particularly recent discharge from the NICU.
• AOM in an immunocompromised child (AIDS, acute leukemia).
• AOM (bulging, opacified, poorly mobile TM) persisting after two courses of antibiotics, including one broad-spectrum antibiotic (amoxicillin-clavulanate, cefuroxime axetil, cefprozil, cefpodoxime proxetil, cefdinir, or ceftriaxone).
• Allowing a child with symptomatic acute otitis media to fly in an airplane.
• Acute otitis media with suppurative complications such as acute mastoiditis acute seventh nerve palsy or bacterial meningitis.

Relative contraindications tympanocentesis

There are some contraindications to performing tympanocentesis. Those complications include inability to securely restrain child; inability to remove obstructing cerumen and debris; inability to visualize circumference of tympanic membrane; unavailability of surgical otoscope head; a blue color behind the tympanic membrane (may be jugular bulb); and patient history of bleeding diathesis.

Problems associated with myringotomy or tympanocentesis

There are as many as 10 potential problems with myringotomy or tympanocentesis. First is penetration of the knife or needle into the canal wall instead of the tympanic membrane. This usually occurs when novices are in their learning curve. The bleeding may appear brisk but is easily controlled by insertion of a cotton tampon wick into the ear canal.

Second is partial penetration through two of three layers of the TM. Again, this occurs during the learning curve of novices.

Third is a frightened struggling child who will not hold still. The child either requires a bit more sedation or procedure should be aborted.

Fourth is a child who continues to scream more than five minutes after procedure. Consider giving a bit more analgesic.

Fifth is excessive bleeding from incised vascular TM. Reassure mother that it is not harmful. Consider suctioning out the blood and applying phenylephrine or adrenaline solution on a cotton pledget for a few minutes, then remove the pleget. Pack the ear canal with a wick of dry absorbent cotton.

Next is puncture through the oval window (posterior/inferior quadrant). May cause persistent otorrhea. Exceedingly rare occurrence.

Seven is disarticulation of the incudostapedial joint (posterior/superior quadrant). Exceedingly rare occurrence. May cause nystagmus, unsteadiness, and mild conductive hearing loss of about 40 dB.

Eight is laceration of an aberrantly positioned high-lying jugular bulb or carotid artery (posterior/inferior quadrant). Exceedingly rare occurrence.

Nine is laceration of the facial nerve (superior quadrants protected by bony canal). Exceedingly rare occurrence.

Last is persistent perforation of the tympanic membrane. Rare occurrence and perforation should close within 3 weeks.

We are unaware of any malpractice litigation against Pediatricians or General Practitioners relating to the adverse effects of performing a myringotomy/tympanocentesis procedure.

Errors associated with myringotomy/tympanocentesis

Regarding errors associated with myringotomy and tympanocentesis, there are five: neglecting to remove all obstructing cerumen or desquamated skin from the ear canal; using a diagnostic otoscope head instead of a surgical head; using a smaller than #22 gauge needle or a needle length less than two inches; attempting the procedure when there is stenosis of the ear canal or a hump in the floor of the ear canal precluding complete visualization of the lower half of the TM; and attempting procedure in an inadequately restrained child.

Prerequisites

Prerequisites to the procedures are as follows: criteria fulfilled for the procedure to be attempted; parental consent (written preferred); restraint of child (restraint board); topical analgesia of the TM or sedation/analgesia of the child; removal of cerumen and squamous debris; surgical otoscope head; and visualization of the entire tympanic membrane throughout the procedure.

Benefits of myringotomy/tympanocentesis

Benefits of the myringotomy/tympanocentesis are many. They include immediate relief of pressure and pain from a bulging inflamed TM; differentiation of pyogenic infection from sterile middle ear effusion; detection of unusual pathogens in neonates or immunocompromised children; and determination of antibiotic susceptibilities and targeted treatment based on in-vitro testing.

While this procedure is beneficial to many patients, there are things the procedure doesn’t do. It doesn’t completely drain the middle ear cleft or reduce the frequency of persistent otitis media with effusion. In addition, it doesn’t eliminate the need for antibiotic therapy in all cases or reduce the frequency of recurrences of AOM.

For more information:

• Richard H. Schwartz, MD, is from the department of pediatrics at Inova Fairfax Hospital for Children, Falls Church, Va.
• Michael E. Pichichero, MD, is from the Univeristy of Rochester Medical Center, Rochester, N.Y.

• Hoberman A, Paradise JL, Wald ER. Tympanocentesis technique revisited. Pediatr Infect Dis J. 1997;16 (Suppl 2): S25-S26.
• Hoekelman RA. Do you do tympanocentesis? [Editorial]. Pediatr Ann. 1991; 20:285-7.
• Poole MD. It’s time to bring back diagnostic tympanocentesis. Ear Nose Throat J. 1994; 73:49-50.
• Stool SE. Myringotomy: an office procedure. Clin Pediatr. 1968; 7:470-73.
• Brook I. A practical technique for tympanocentesis for culturing aerobic and anaerobic bacteria. Pediatrics. 1980; 65:626-7.
• Block SL Tympanocentesis: Why, when, how. Contemporary Pediatrics. 1999; 16:103-125.
• Roddey OF Jr, Earle R Jr, Haggerty R. Myringotomy in acute otitis media: A controlled study. JAMA. 1966; 197:849-853.
• Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. 1991; 87:466-74.
• Kaplan SL, Feigin RD. Simplified technique for tympanocentesis. Pediatrics. 1978; 62:418-19.
• Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance - a report from the drug resistant Streptococcus pneumoniae therapeutic working group. Pediatr Infect Dis J. 1999; 18:1-9.
• Schwartz RH, Rodriguez WJ, Schwartz DM. Office myringotomy for acute otitis media. Its value in preventing middle ear effusion. Laryngoscope. 1981; 91:616-19.
• Schwartz RH. Myringotomy: A neglected office procedure. Am Family Physician. 1979; 20:102-108.
• Engelhard D, Cohen D, Strauss N, et al. Randomized study of myringotomy, amoxicillin/clavulanate, or both for acute otitis media in infants.
• Pichichero M. Acute Otitis Media: Part I: Improving diagnostic accuracy. Am Family Physician. 2000; 61:2051-2056.
• Brook, I. Tympanocentesis in the diagnosis and treatment of otitis media. Infect Med. 2001; 18:363-366.
• Pichichero, ME. Assessing accuracy and tympanocentesis skills in management of otitis media among pediatricians. Archives Pediatr Adol Med. 2001, in press.