What is the difference between Tympanostomy and Myringotomy?

What is Tympanostomy?

Tympanostomy is also known as ear tube insertion. This is a surgical procedure which is used in removing fluid accumulated in middle ear space that may lead to acute or chronic otitis media. In this procedure, the surgeon places a pressure equalizer tube into the tympanic membrane (ear drum) of the ear, in order to remove the middle ear fluid and prevent the condition called otitis media.7

What are tubes in ears called?

How to place an ear tube in eardrum?

A variant of ear tube replaced with a traditional plastic ventilation tube due to successful ear of antibiotics. Ear tube insertion is very frequent in children in the United States.

  • A plastic grommet is inserted and is made to remain within the tympanic membrane.
  • It prevents the earlier closure of incision that made with myringotomy.
  • These grommets are tiny and easily tolerated by the tympanic membrane.
  • The main function of this plastic grommet is to maintain a ventilator port for middle ear space for almost 1 to 2 years.
  • Your surgeon may describe the shape and size of ear tube that needs to be inserted as per the anatomy of the ear of a patient.
  • Alternatives to ear tube insertion are myringotomy and tympanocentesis.

What are the indications of tympanostomy?

The most common indication for ear tube insertion is:

  • Persistent (> 3 mo) otitis media with effusion (OME), or serous otitis media (SOM)
  • Acute Otitis Media
  • Complications of Otitis media such as meningitis
  • Facial nerve palsy
  • Otomastoiditis
  • Hearing loss

If serous otitis media does not resolve after 3 months of clinical observation of antibiotic therapy, tympanostomy is opted. Middle ear fluid can cause speech and language delay, if left untreated or if the fluid remains inside the ear for prolonged period. Ear tube insertion is mainly done in order to promote the drainage of ear fluid. Middle ear fluid also predisposes to recurrent infections. In acute otitis media, the ear tube insertion is done to treat the infection that is resistant to antibiotic therapy. Moreover, Ear tube insertion is also preferable in persons, who do not tolerate antibiotic therapy well as it promotes the outward drainage of ear fluid and allows accurate and easy delivery of topical antibiotic medication to the infected ear space.

In patients with complications associated with otitis media, ear tube can abruptly stops the injury to tympanic membrane and associated hearing loss. Prompt insertion of tympanostomy tubes ventilates the middle ear space and prevents further retraction of an eardrum under the negative pressure.

What are expected outcomes of tympanostomy?

In children, the episodes of otitis media are less frequent, it is also observed that the otitis media can be treated with antibiotic ear drops. It showed small benefit in language development in children with bilateral OME and hearing loss.

What is Myringotomy?

Unlike tympanostomy, myringotomy is a surgical procedure that involves a small incision with knife called “myringotomy knife” in the layers of tympanic membrane (eardrum). With the help of this procedure, the surgeon can get direct access to the middle ear space and it is easier to withdraw the middle ear fluid (an end product of otitis media with effusion). Otitis media with effusion is also classified as serous, mucoid or purulent.

Myringotomy and Ear Tubes - procedure, blood, removal, pain, adults

Myringotomy an incision is made through the tympanic membrane and middle ear fluid is suctioned from middle ear.

  • The collected middle ear fluid is sent for bilateral and viral cultures.
  • A bilateral myringotomy is used along with placement of middle ear ventilation tubes.
  • Current use of this combined technology is helpful in:
    • allowing the incised drum to remain open
    • allows better drainage of middle ear fluid
    • approach facilitates instillation of antibiotic otitic drops
    • results in faster resolution of the OME (Otitis media effusion)

What are the reasons behind OME?

The ear in the human anatomy is made up of various constituents and Eustachian tube is one of them. The Eustachian tube is the communication between middle ear and the nasopharynx.

It is mainly works to equalize the pressure across the tympanic membrane.

  • In children, the Eustachian tube is not mature due to the shorter length and horizontal placement in the ear. These conditions may cause the complications like OME.
  • A poor function of Eustachian tube, a persistent inflammatory response, and inadequate ventilation of middle ear space can result in acute otitis media.
  • Additional contributors to the development of OME include the immaturity both of the infant or young child’s immune system and of the anatomy of the Eustachian tube.
  • Upper respiratory tract infections or allergy are also a cause of OME. The bacteria and virus are withdrawn in the middle-ear space and stimulate an inflammatory response.

The mucosa of the eustachian tubes get inflamed due to attack of virus or bacteria and became infected thereby give rise to OME.

OME has a strong correlation with URI. Children with craniofacial abnormalities that affect eustachian tube function (eg, Down syndrome and cleft palate) are at increased risk for otitis media. Immune deficiency should be suspected in children with OME that occurs in association with recurrent sinusitis, bronchitis, or gastrointestinal (GI) abnormalities.

Other predisposing conditions include allergy, adenoid hypertrophy, ciliary dysfunction, and gastroesophageal reflux. OME may be seen in patients with prolonged nasal intubation or nasogastric tubes.

What are the indications of myringotomy?

  • Myringotomy may be indicated in:
  • AOM (Acute Otitis media)
  • RAOME (Recurrent AOM with effusion)
  • Acute episodes of Otitis media
  • COME (Chronic otitis media with effusion)
  • Hearing loss
  • Speech or language delay secondary to otitis

An immediate myringotomy (with or without tubes) is needed in children with speech and language delay secondary to otitis.

Additionally, children are more likely to need prompt surgical intervention ( i e, myringotomy), including the following:

  • Children with permanent hearing loss independent of OME
  • Children with autism-spectrum disorder and other pervasive developmental disorders
  • Children with syndromes (eg, Down syndrome) or craniofacial disorders that result in Eustachian tube dysfunction
  • Children who are blind or have uncorrectable visual impairment
  • Children who have cleft palate with or without cleft lip.

What is the difference between Tympanostomy and Myringotomy?

Basic difference:

Tympanostomy is the insertion of an ear tube in the tympanic membrane in order to drain the fluid out from the middle ear, where as Myringotomy is the procedure of making an incision in the tympanic membrane to withdraw the middle ear fluid.

Functional differences:

In myringotomy, an incision was made to draw the middle ear fluid from the ear, which is now replaced by the incision in the ear drum and then placement of tympanostomy tube in the ear drum. The ear tube is left in the ear for 6 to 12 weeks for supply of fresh air inside the ear and to maintain and equalize the balance in the ear.

Whereas Tympanostomy is the surgical procedure that is designed to treat otitis media and removing the middle ear fluid with the help of ear tubes only.

Associated complications:

Bacterial colonization is the main complication associated with myringotomy whereas the otorrhea (ear discharge) is the main complication associated with tympanostomy.

Duration of tubes insertion:

Making an incision on ear drum in myringotomy technique is the traditional one. Nowadays the incision is done on eardrum along with the insertion of tympanostomy tubes. It is done in order to prevent the closing of the incision.

So, the duration of placement of ear tube in case of myringotomy is 6 to 12 months. Sometimes these tubes clog again due to excessive middle ear fluid, and needs replacement. Whereas in tympanostomy the ear tube placed in the eardrum is for longer periods such as 3 to 4 years. This gives the benefits of complete clearance of fluid, infection and removes the risk of recurrence.

Harms:

Studies showed following harms during this procedures performances. Perforation occurred similarly between tubed and myringotomy patients (1.2% vs. 1.3%, p=NS) through 24 months in one trial. Mandel reported that perforation occurred in 11.2% to 13.7% of all patients (including tympanostomy, WW, and myringotomy), but did not separate results out by treatment group. Persistent otorrhea requiring hospitalization, intravenous antibiotics, and daily suctioning occurred similarly in the tympanostomy and myringotomy groups in one trial (2% vs. 0%, p=NS). This adverse event occurred in 2% of all patients (including those randomized to tympanostomy, WW, and myringotomy groups) following TT insertion in another trial. Koopman reported one case of severe otalgia in the myringotomy ear two days post-surgery (0.4% myringotomy ears) as well as one patient with an epidermal pearl on the tympanic membrane that was removed by suction in an outpatient visit (0.4% myringotomy ears). Kent reported no cases of post-operative nystagmus.

Across all patients in the study (including those who underwent adenoidectomy) Gates reported tube extrusion into the middle ear in 0.5% of patients; these patients required myringotomy and insertion of a new tube. The same trial also reported one case of necrosis of the long process of the incus in the TT group (0.8%) which required ossiculoplastic repair. Mandel reported no problems with anesthesia in either treatment group, D’Eredita and Kent reported no surgical complications, and Gates reported no death.

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