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. 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).
Nomenclature The words myringotomy, tympanotomy, tympanostomy, and tympanocentesis overlap in meaning. The first two are always synonymous, and the third is often used synonymously. 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 -otomy (cutting) and an -ostomy (creating a stoma with some degree of permanence or semipermanence). In this distinction, only a tympanostomy involves tympanostomy tubes and creates a semipermanent stoma. This distinction in usage is not always made. The word tympanocentesis specifies that centesis (the removal of fluid) is being done. Etymologically, myringotomy (myringo-, from Latin myringa "eardrum", + -tomy) and tympanotomy (tympano- + -tomy) both mean "eardrum cutting", and tympanostomy (tympano- + -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. 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. 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. 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. 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. The vinyl tube used today was introduced by Beverly Armstrong in 1954.
Indications
There are numerous indications for tympanostomy in the pediatric age group, the most frequent including chronic otitis media with effusion (OME) which is unresponsive to antibiotics, and recurrent otitis media. Adult indications 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 chamber treatment, may merit consideration.
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. A new variation (called tympanolaserostomy or laser-assisted tympanostomy) uses a CO2 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 patent for several weeks and provides ventilation of the middle ear without the need for tube placement. 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), 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. Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective. 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.
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