Chapter 143

Tympanocentesis is a diagnostic and therapeutic procedure in which a needle is inserted through the tympanic membrane to aspirate fluid from the middle ear space. The procedure is considered diagnostic when the material obtained is sent for laboratory and/or micro-biological analysis. It is considered therapeutic in most instances because it relieves pressure, thereby reducing pain, and many times shortens the course of an acute otitis media. The procedure is quick, simple, and not as frequently performed as it should be. Note also that authors are calling for culture-directed antibiotic therapy for otitis media to reduce the need for broad-spectrum antibiotics and prevent, as much as possible, the emergence of multiresistant organisms.1–4

The ear is divided into the external, middle, and inner parts. The external ear is comprised of the auricle, the external auditory canal, and the external auditory meatus. The middle ear contains an air space and mastoid cells ventilated by the eustachian tube, the tympanic membrane, and the three ossicles. The inner ear is made up of the cochlea, semicircular canals, fluids, and cranial nerve VIII. The facial nerve courses through the middle ear space and mastoid process. It can be affected by a severe infection in these areas. Facial asymmetry during an acute ear infection is an indication of an unusually severe infection.

Inspection of the tympanic membrane will usually show it to be bulging during an acute infection with loss of mobility on pneumatic otoscopy. Conditions that are more chronic may show color changes of the tympanic membrane, with or without associated scarring and distortion.

Tympanocentesis is performed to obtain fluid for microbiological culture and antibiotic sensitivity testing to determine the infectious cause of a middle ear effusion. Tympanocentesis is warranted for patients with otitis media that is severe, unresponsive to conventional antimicrobial therapy, or in a child less than 8 weeks of age to rule out gram-negative organisms. Tympanocentesis is warranted for patients with an acute otitis media and either an acquired or congenital immunodeficiency as they will often require directed therapy. Patients who develop acute otitis media while taking appropriate antimicrobial therapy should be evaluated for the organism responsible and its sensitivity to antibiotics. Tympanocentesis is also performed when the patient has an otitis media associated with unusually severe pain, signs of toxicity, bullous myringitis, facial nerve palsy, mastoiditis, meningitis, encephalitis, brain abscess, or dural sinus thrombosis.

There are no absolute contraindications to tympanocentesis. It should not be performed in a patient who is uncooperative, as secondary injury may result. Uncooperative patients will require sedation, procedural sedation, or general anesthesia to perform this procedure. Tympanocentesis should be performed by an Otolaryngologist if the landmarks on the tympanic membrane are obscured.

• 21 gauge spinal needle
• 3 mL aspirating syringe
• Ear speculum
• Ear wax curette
• Culture swabs and media
• Laboratory tubes for fluid cell count and differential
• Topical anesthetic solution
• Intravenous extension tubing

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