View source for Myringotomy

{{short description|Surgical procedure involving a small incision in the eardrum to drain fluid}}
{{Infobox medical intervention |
  Name        = Myringotomy |
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  ICD9        = {{ICD9proc|20.0}}{{ICD9proc|20.01}}{{ICD9proc|20.09}} |
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A '''myringotomy''' is a surgical procedure in which an incision is created in the [[eardrum]] (tympanic membrane) to relieve pressure caused by excessive buildup of fluid, or to drain [[pus]] from the [[middle ear]]. A [[tympanostomy tube]] may be inserted through the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously within two to three weeks.  Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure.<ref name=Tube />

Those requiring myringotomy usually have an obstructed or dysfunctional [[eustachian tube]] that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe [[acute otitis media]] (middle ear infection).<ref name=Tube>{{cite journal | title=To tube or not to tube: indications for myringotomy with tube placement |vauthors=Smith N, Greinwald JR | year=2011 | journal=Current Opinion in Otolaryngology & Head and Neck Surgery | volume=19 | pages=363–366|pmid=21804383 | doi=10.1097/MOO.0b013e3283499fa8 | issue=5|s2cid=3027628 }}</ref>

==Nomenclature==
The words '''''myringotomy''''', '''''tympanotomy''''', '''''tympanostomy''''', and ''[[tympanocentesis]]'' overlap in meaning. The first two are always synonymous, and the third is often used synonymously.<ref name="Dorlands">{{Citation |author=Elsevier |author-link=Elsevier |title=Dorland's Illustrated Medical Dictionary |publisher=Elsevier |url=http://dorlands.com/ |postscript=.}}</ref> The core idea with each is cutting a hole in the eardrum to allow fluid to pass through it. Sometimes a distinction is drawn between myringotomy/tympanotomy and tympanostomy, in parallel with the general distinction between an [[list of -otomies|-otomy]] (cutting) and an [[wikt:-stomy#Suffix|-ostomy]] (creating a [[stoma (medicine)|stoma]] with some degree of permanence or semipermanence). In this distinction, only a tympanostomy involves [[tympanostomy tube]]s and creates a semipermanent stoma. This distinction in usage is not always made. The word ''[[tympanocentesis]]'' specifies that [[centesis]] (the removal of fluid<ref>{{Cite book |last=Andersson |first=David |title=Medical Terminology |publisher=Medical Creations |year=2018 |isbn=978-1-5190-6662-6 |pages=72 |language=English}}</ref>) is being done.

Etymologically, ''myringotomy'' (''[[wikt:myringo-#Prefix|myringo-]]'', from Latin {{Lang|la|myringa}} "eardrum",<ref>{{cite encyclopedia|url=http://medical-dictionary.thefreedictionary.com/myringotomy|title=myringotomy|encyclopedia=Mosby's Medical Dictionary|edition=8th|year=2009|publisher=Elsevier}}</ref> + ''[[wikt:-tomy#Suffix|-tomy]]'') and ''tympanotomy'' (''[[wikt:tympano-#Prefix|tympano-]]'' + ''[[wikt:-tomy#Suffix|-tomy]]'') both mean "eardrum cutting", and ''tympanostomy'' (''[[wikt:tympano-#Prefix|tympano-]]'' + ''[[wikt:-stomy#Suffix|-stomy]]'' means "making an eardrum stoma".

== History ==
In 1649, [[Jean Riolan the Younger]] accidentally pierced a patient's eardrum while cleaning it with an [[ear spoon]].  Surprisingly, the patient's hearing improved. There are also reports from the 17th and 18th centuries describing separate experiments exploring the function of the eardrum.<ref>{{cite journal | title=Der Trommelfellstich: Zur Geschichte von Parazentese und Paukenröhrchen|trans-title=Perforation of the eardrum. On the history of paracentesis and grommet insertion | vauthors=Brusis T, Luckhaupt H |  date=March 1995 | journal=Laryngo-Rhino-Otologie | volume=75| pages=178–83|pmid=8652036|language=German | doi=10.1055/s-2007-997559 | issue=3|s2cid=260205742 }}</ref>  In particular, the animal experiments of [[Thomas Willis]] were expanded upon by Sir [[Astley Cooper]], who presented two papers to the [[Royal Society]] in 1801 on his observations that myringotomy could improve hearing.<ref>{{cite journal | doi=10.1177/000348948409300601 | title=Sir Astley Cooper and His Otological Papers | year=1984 | last1=McGovern | first1=Francis H. | journal=Annals of Otology, Rhinology & Laryngology | volume=93 | issue=6 | pages=531–533 | pmid=6391339 | s2cid=42431618 }}</ref>  First, he showed that two patients with perforations of both eardrums could hear perfectly well, despite conventional wisdom that this would result in deafness. Second, he demonstrated that deafness caused by obstruction of the Eustachian tube could be relieved by myringotomy, which equalized the pressure on each side of the tympanic membrane.{{citation needed|date=January 2024}}

Widespread inappropriate use of the procedure later led to it falling out of use.  However, it was reintroduced by [[Hermann Schwartze]] in the 19th century.  An inherent problem became recognized, namely the tendency of the tympanic membrane to heal spontaneously and rapidly, reversing the beneficial effects of the perforation.  In order to prevent this, a tympanostomy tube, initially made of gold foil, was placed through the incision to prevent it from closing. In 1819 the French physician Antoine Saissy (1756–1822) tried to keep the myringotomy unsuccessfully open with Catgut.<ref>{{Cite book |author=Saissy, JA |title=An Essay on the Diseases of the Internal Ear |url=https://books.google.com/books?id=uN06AQAAMAAJ |translator=Smith, NR |location=Baltimore, MD |publisher=Hatch & Dunning |year=1829}}</ref><ref name=":0">{{Cite journal |last1=Rimmer |first1=J. |last2=Giddings |first2=C. E. B. |last3=Weir |first3=N. |date=2007-06-11 |title=History of myringotomy and grommets |url=https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/abs/history-of-myringotomy-and-grommets/37F4C3F3EB7AB1FFF00889277A1F8350 |journal=The Journal of Laryngology & Otology |language=en |volume=121 |issue=10 |pages=911–916 |doi=10.1017/S0022215107009176 |pmid=17559714 |s2cid=27874209 |issn=1748-5460|url-access=subscription }}</ref> [[Adam Politzer|Ádám Politzer]], a Hungarian-born [[otologist]] practicing in Vienna, experimented with rubber in 1886.  The German otologist Rudolf Voltolini (1819–1889) created in 1874 a grommet made of gold and later on one made of aluminium.<ref name=":0" /><ref>{{Cite journal |title=Voltolini, R. Über eine neue Operation am Trommefelle zur Verbesserung des Horvermogens. |journal=Monatsschrift für Ohrenheilkunde, 1874;8}}</ref> The vinyl tube used today was introduced by Beverly Armstrong in 1954.<ref name=":0" />

== Indications ==
[[File:Wiki TM retraction.jpg|thumbnail|right|x140px|Retracted eardrum]]
There are numerous indications for tympanostomy in the pediatric age group,<ref name = Tube /><ref name = OME>{{cite journal | title=Otitis media with effusion | author=American Academy of Family Physicians | author2=American Academy of Otolaryngology–Head and Neck Surgery | author3=American Academy of Pediatrics Subcommittee on Otitis Media With Effusion | date=May 2004 | journal=Pediatrics | volume=113|number=5 | pages=1412–29 | doi=10.1542/peds.113.5.1412| pmid=15121966 | doi-access=free }}</ref> the most frequent including chronic [[otitis media|otitis media with effusion (OME)]] which is unresponsive to antibiotics, and recurrent [[otitis media]].  Adult indications<ref name = Tube/><ref name=Titanium>{{cite journal | title=Comparison of characteristic of titanium and fluoropastic ventilation tubes in adults with healthy middle ears |vauthors=Kisser U, Gürkov R, Louza J, Schrötzlmair F, Adderson-Kisser C, Krause E | year=2012 | journal=Otology & Neurotology | volume=33 | pages=983–987|pmid=22772000 | doi=10.1097/MAO.0b013e318259b70b | issue=6|s2cid=33137759 }}</ref><ref>{{cite encyclopedia|url=https://www.medlineplus.gov/ency/article/003015.htm|title=Ear tube insertion|encyclopedia=MedlinePlus|publisher=U.S. National Library of Medicine}}</ref> differ somewhat and include Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss, [[vertigo]], [[tinnitus]], and a severe retraction pocket in the [[tympanic membrane]].  Recurrent episodes of [[barotrauma]], especially with flying, diving, or [[Hyperbaric medicine|hyperbaric chamber treatment]], may merit consideration.{{citation needed|date=February 2022}}

== Procedure ==
Myringotomy is usually performed as an outpatient procedure. [[General anesthesia]] is preferred in children, while [[local anesthesia]] suffices for adults.  The ear is washed and a small incision made in the eardrum.  Any fluid that is present is then aspirated, the tube of choice inserted, and the ear packed with cotton to control any slight bleeding that might occur.  This is known as conventional (or ''cold knife'') myringotomy and usually heals in one to two days.<ref name = Age>{{cite journal | title=Differences between children and adults with otitis media with effusion treated with CO(2) laser myringotomy |vauthors=Chang CW, Yang YW, Fu CY, Shiao AS | date= January 2012 | journal=Journal of the Chinese Medical Association| volume=75|issue=1 | pages=29–35|pmid=22240534 | doi=10.1016/j.jcma.2011.10.001 | doi-access=free }}</ref>

A new variation (called ''tympanolaserostomy'' or ''laser-assisted tympanostomy'') uses a [[carbon dioxide laser|CO<sub>2</sub> laser]], and is performed with a computer-driven laser and a video monitor to pinpoint a precise location for the hole.  The laser takes one-tenth of a second to create the opening, without damaging surrounding skin or other structures.  This perforation remains [[wikt:patent#Etymology 2|patent]] for several weeks and provides ventilation of the middle ear without the need for tube placement.<ref>{{cite journal | doi=10.1002/lary.28612 | title=In-Office Tympanostomy Tube Placement in Children Using Iontophoresis and Automated Tube Delivery | year=2020 | last1=Lustig | first1=Lawrence R. | last2=Ingram | first2=Amy | last3=Vidrine | first3=D. Macy | last4=Gould | first4=Andrew R. | last5=Zeiders | first5=Jacob W. | last6=Ow | first6=Randall A. | last7=Thompson | first7=Christopher R. | last8=Moss | first8=Jonathan R. | last9=Mehta | first9=Ritvik | last10=McClay | first10=John E. | last11=Brenski | first11=Amy | last12=Gavin | first12=John | last13=Waldman | first13=Erik H. | last14=Ansley | first14=John | last15=Yen | first15=David M. | last16=Chadha | first16=Neil K. | last17=Murray | first17=Michael T. | last18=Kozak | first18=Frederick K. | last19=York | first19=Christopher | last20=Brown | first20=David M. | last21=Grunstein | first21=Eli | last22=Sprecher | first22=Robert C. | last23=Sherman | first23=Denise A. | last24=Schoem | first24=Scott R. | last25=Puchalski | first25=Robert | last26=Hills | first26=Susannah | last27=Calzada | first27=Audrey | last28=Harfe | first28=Dan | last29=England | first29=Laura J. | last30=Syms | first30=Charles A. | journal=The Laryngoscope | volume=130 | issue=Suppl 4 | pages=S1–S9 | pmid=32160320 | pmc=7187287 }}</ref>

Though laser myringotomies maintain patency slightly longer than cold-knife myringotomies (two to three weeks for laser and two to three days for cold knife without tube insertion),<ref>{{cite journal | title=Duration of patency of laser-assisted tympanic membrane fenestration |vauthors=Prokopakis EP, Hajiioannou JK, Velegrakis GA, Christodoulou PN, Scordalakis C, Helidonis ES | date=Feb 25, 2002 | journal=Int J Pediatr Otorhinolaryngol | volume=62 | pages=207–14 | pmid=11852122 | issue=3|doi=10.1016/s0165-5876(01)00613-9 }}</ref> they have not proven to be more effective in the management of effusion.  One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME.<ref>{{cite journal | title=Laser myringotomy versus ventilation tubes in children with otitis media with effusion: a randomized trial |vauthors=Koopman JP, Reuchlin AG, Kummer EE, Boumans LJ, Rijntjes E, Hoeve LJ, Mulder PG, Blom HM | year=2004 | journal=Laryngoscope | volume=114 | issue=5|pages=844–9|pmid=15126741 | doi=10.1097/00005537-200405000-00010 |s2cid=73100585 }}</ref>  Multiple occurrences in children, a strong history of allergies in children, the presence of thick [[mucus|mucoid]] effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective.<ref name= Age />

Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes.  More recent ones are coated with antibiotics and [[phosphorylcholine]].{{citation needed|date=February 2022}}

==Aftercare==
There is little scientific evidence to guide the care of the ear after tubes have been inserted.  A single, randomized trial found statistical benefit to using ear protective devices when swimming although the size of the benefit was quite small.<ref>{{cite journal | title=Water precautions and tympanostomy tubes: a randomized, controlled trial |vauthors=Goldstein NA, Mandel EM, Kurs-Lasky M, Rockette HE, Casselbrandt ML | year=2005 | journal=Laryngoscope | volume=115 | pages=324–30 | pmid=15689760 | doi=10.1097/01.mlg.0000154742.33067.fb | issue=2|s2cid=36426890 }}</ref>  In the absence of strong evidence, general opinion has been against the use of ear protection devices.  However, protection such as cotton covered with petroleum jelly, ear plugs, or ear putty is recommended for swimming in dirty water (lakes, rivers, oceans, or non-chlorinated pools) to prevent ear infections.  For bathing, shampooing, or surface-water swimming in chlorinated pools, no ear protection is recommended.

== Complications ==
The placement of tubes is not a cure.  If middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection.  There may be early drainage through the tube (''tube otorrhea'') in about 15% of patients in the first two weeks after placement, and developing in 25% more than three months after insertion, although usually not a longterm problem.<ref>{{cite journal | title=Meta-analysis of tympanostomy tube sequelae |vauthors=Kay DJ, Nelson M, Rosenfeld RM | date=April 2001 | journal=Otolaryngol Head Neck Surg | volume= 124|issue=4 | pages=374–80 | pmid=11283489 | doi=10.1067/mhn.2001.113941|s2cid=25287112 }}</ref>  Otorrhea is considered to be secondary to bacterial colonization.  The most commonly isolated organism is ''[[Pseudomonas aeruginosa]]'', while the most troublesome is [[Methicillin-resistant Staphylococcus aureus|Methicillin-resistant ''Staphylococcus aureus'' (MRSA)]]. Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial [[biofilm]].<ref name = Tube />  A laboratory study showed that tubes covered in the antibiotic [[vancomycin]] prevented in-vitro formation of MRSA biofilm as compared to noncoated ones,<ref>{{cite journal | title=Effect of vancomycin-coated tympanostomy tubes on methicillin-resistant Staphylococcus aureus biofilm formation: In vitro study |vauthors=Jang CH, Park H, Cho YB, Choi CH | year=2010 | journal=The Journal of Laryngology & Otology | volume=124|issue=6 | pages=594–598|pmid=20056010 | doi=10.1017/S0022215109992672 |s2cid=24655349 }}</ref> although no study has been conducted on humans yet.  Comparing phosphorylcholine-coated fluoroplastic tympanostomy tubes to uncoated fluoroplastic tympanostomy tubes showed no statistically significant difference in the incidence of post-operative otorrhea, tube blockage, or extrusion.<ref>{{cite journal | title=A randomized double-blind controlled trial of phosphorylcholine-coated tympanostomy tube versus standard tympanostomy tube in children with recurrent acute and chronic otitis media |vauthors=Hong P, Smith N, Johnson LB, Corsten G | year=2011 | journal=Laryngoscope | volume=121|issue=1 | pages=214–219|pmid=21072756 | doi=10.1002/lary.21156 |s2cid=22624953 }}</ref>

== Efficacy ==
Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have no other serious medical problems.  No effect on speech and language development has yet been shown.<ref>{{cite journal | title=Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children |vauthors=Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ | year=2010 | journal= Cochrane Database of Systematic Reviews | issue=10 |  doi=10.1002/14651858.CD001801.pub3 | pmid=20927726 | article-number=CD001801}}.</ref>

A retrospective study of success rates in 96 adults and 130 children with otitis media treated with CO<sub>2</sub> laser myringotomy showed about a 50% cure rate at six months in both groups.<ref name = Age />  To date, there have been no published systematic reviews.

[[Balloon dilation]] eustachian tuboplasty (BDET), a new treatment, has proven to be effective in treating OME secondary to [[eustachian tube]] dysfunction.<ref>{{cite journal | title=Eustachian tube balloon dilation surgery |vauthors=McCoul ED, Anand VK | date=May–June 2012 | journal=International Forum of Allergy & Rhinology | volume=2 | issue=3 | pages=191–8 | doi=10.1002/alr.21007 | pmid=22253073 |s2cid=20637776 }}</ref><ref>{{cite journal | title=Balloon dilatation eustachian tuboplasty: a clinical study |vauthors=Ockermann T, Reineke U, Upile T, Ebmeyer J, Sudhoff HH | date=July 2010 | journal=Laryngoscope | volume=120 |issue=7 | pages=1411–6 |pmid=20564474 | doi=10.1002/lary.20950 |s2cid=7976041 }}</ref><ref name="Williams et al 2016">{{cite journal|last1=Williams|first1=Blair|first2=Benjamin A. |last2=Taylor |first3=Neil |last3=Clifton |first4=Manohar |last4=Bance|date=12 February 2016|title=Balloon dilation of the eustachian tube: a tympanometric outcomes analysis|journal=Journal of Otolaryngology–Head & Neck Surgery|publisher=BioMed Central|volume=45|issue=13|page=13|issn=1916-0216|doi=10.1186/s40463-016-0126-6|pmid=26869258|pmc=4751715 |doi-access=free }}</ref> However, the number of patients in the studies cited, 22 and 8 respectively and 18 in the tympanometric study, is extremely small and simply points to the need for large, well-controlled studies.

==See also==
* [[Myringoplasty]]
* [[Otitis media]]
* [[List of surgeries by type]]

==References==
{{reflist|30em}}

{{Operations and other procedures on the ear}}

[[Category:Ear surgery]]
[[Category:Auditory system]]
[[Category:Surgical procedures and techniques]]
[[Category:Otorhinolaryngology]]
[[Category:Otology]]