Atlas of Procedures in Neonatology, 4th Edition
Gregory J. Milmoe
Diagnostic tympanocentesis is indicated in neonatal acute otitis media (AOM) in order to target antibiotic therapy. Myringotomy may be used for both diagnostic and drainage purposes. The specific indications include:
- AOM not responding to antibiotics after 72 hours
- AOM in severely immunocompromised infant
- AOM in infant already on antibiotics
- AOM with suppurative complications, e.g., mastoiditis, facial paralysis, sepsis
- To confirm the diagnosis when the clinical exam is not clear
- To relieve severe otalgia
- Difficulty in confirming ossicular landmarks. One must be able to identify the malleus and the annulus of the tympanic membrane (TM) (Fig. 20.1).
- Suggestion of abnormal anatomy. This may be more likely in patients with congenital malformation syndromes.
- Suggestion of alternate pathology, e.g., cholesteatoma or neoplasm
- Surgical gloves
- Otoscope with open operating head and good light
- Largest speculum that will fit the canal (2, 3, or 4 mm)
- 18-gauge 3-in spinal needle with 1-mL or 3-mL syringe
- Blunt ear curette
- 70% isopropyl alcohol in 3-mL syringe for cleaning and antisepsis of ear canal
- Suction setup with No. 5 Frazier ear suction
- Culturettes with transport media
- Patient safety and comfort require proper restraint, adequate light, and appropriate instruments.
- The kindest way is to be quick, and this means having the child still.
- Conscious sedation is feasible only if the child is stable and has no issues with airway obstruction. It is not needed past the point of puncturing the TM, so most often no medicine is used.
- Good visualization is paramount. Sufficient cleaning must be done so that the malleus and the anterior aspect of the annulus are clearly seen.
- Avoid the posterior aspect of the tympanic membrane. This is where the round window, stapes, and incus are present.
- Restrain child fully with hospital linen wrapped around the torso and arms.
- Position child with the head turned so that the involved ear is up. The assistant must keep the head still.
- Rinse ear canal with alcohol solution from a 3-mL syringe. This will provide antisepsis and initiate cleaning.
- Let fluid run out or use suction.
- Use otoscope to visualize canal and remove debris with curette or suction.
- Align speculum to get best view of TM landmarks. Pulling superiorly and laterally on the pinna will help immensely (Fig. 20.2).
- Attach spinal needle to syringe after bending it 45 to 60 degrees at the hub. This keeps the syringe out of your line of sight.
- Hold needle at the hub and introduce it through the otoscope. Puncture the drum anterior to the malleus at or below the umbo level (Fig. 20.3).
- Hold needle securely and have assistant draw back on the syringe to obtain the sample.
- Place sample in appropriate transport medium.
- If more drainage is required, a myringotomy blade can be used to widen the opening. This will still close in 48 to 72 hours.
FIG. 20.1. Normal newborn eardrum. View through speculum.
- Most common is bleeding from canal wall. This will stop but is preferably avoided.
- TM perforation that persists. Initially this is actually helpful for drainage and ventilation of the middle ear space.
- Disruption of the ossicles from malpositioned needle (see D, “Precautions”)
- Major bleeding from dehiscent jugular bulb or carotid artery—rare (see D, “Precautions,” and B, “Contraindications”)
FIG. 20.2. Tympanic membrane in the adult (A) and infant (B). The portion of the tympanic membrane that may be visualized through the speculum at one time is within the dotted line.
FIG. 20.3. Tympanocentesis. Aspirating the middle ear using a 3-mL syringe. Needle is penetrating eardrum inferiorly.
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