Paracentesis

PARACENTESIS (from Greek kenteo-to pierce, French paracentese-puncture, incision), artificial puncture of the eardrum, was first introduced into practice in the early 18th century with the aim of improving hearing by the English surgeon Cheselden (1720), who based his work on experiments previously conducted on dogs by Valsalva. In Paris, this operation was first performed on a deaf patient by the traveling doctor Eli (EN) in 1760. Paracentesis entered science through the works of the Göttingen ophthalmologist Himly and the London physician Cooper, who almost simultaneously at the beginning of the 19th century began to apply this operation on a large scale and more or less systematically for hardness of hearing, especially in connection with the obstruction of the Eustachian tube. Due to unsatisfactory results, the operation was soon forgotten and reappeared in medicine already as a surgical means for emptying secretions from the middle ear since the time of the works of Schwartze, who gave it proper evaluation, developed indications for it on scientific grounds and described the technique (1862). Paracentesis is performed in acute inflammations of the middle ear, in cases of suspicion of the presence of an inflammatory exudate in the tympanic cavity, with the aim of giving the exudate or pus an outlet into the external auditory canal. Indications are severe pain in the ear, fever, hearing impairment and data from objective examination. Otoscopic picture: the eardrum appears more or less reddened, without clear contours, bulging; often it takes on a yellowish-pink or grayish color due to the transmission of purulent exudate. In some cases, it is not possible to clearly see all these signs, as the surface of the eardrum is partially or completely covered by detached, loosened epidermis. It often happens that with weakly expressed symptoms on the eardrum without bulging, pus is obtained on puncture, and conversely, with a violent picture of inflammation, the process ends without fluid effusion. In such doubtful cases, the accompanying pain in the ear, high temperature and general pathological phenomena decide in favor of paracentesis. An absolute indication should be in infectious diseases, especially in scarlet fever and measles. Some disagreement exists among physicians regarding the time of performing the operation: some advocate early paracentesis, others prefer to wait and perform paracentesis only in extreme cases after using all conservative measures. Although it is impossible to establish the exact time for performing the puncture in general, it should not be postponed in typical cases for more than 2-3 days, especially it is not recommended to delay if acute otitis develops during scarlet fever or measles, in order to avoid large destruction of the eardrum with its spontaneous perforation. It is also dangerous to wait with paracentesis if acute otitis is accompanied by symptoms indicating irritation of the meninges (as observed in children), with severe tenderness in the area of the mastoid process, with signs of irritation of the vestibular apparatus, with the appearance of facial nerve paralysis. Paracentesis should be regarded as a safe surgical intervention if it is performed according to all the rules of asepsis. Paracentesis in the early stage of the disease often stops the progression of inflammatory phenomena, even if purulent content from the ear is not secreted; on the other hand, a timely performed paracentesis can prevent the development of life-threatening intracranial and intralabyrinthine complications; this must be especially noted in relation to small children, in whom meningeal phenomena often disappear quickly as soon as pus receives a free outlet from the tympanic cavity. Most physicians believe that after early paracentesis, the course of acute otitis is more favorable, inflammation of the mastoid process occurs less frequently, and chronic purulent discharge from the ear develops less frequently. If the perforation opening heals, it is necessary to resort to repeated incision of the eardrum, sometimes several times; it is also often necessary to perform additional paracentesis when a spontaneous perforation is located in the upper parts of the eardrum or is too small; in these cases, the retention of pus can cause a rise in temperature. Purulent or serous discharge usually occurs immediately after puncture, less often it appears after some time, sometimes only after a day. Sometimes after paracentesis, pus is not obtained, and the result occurs only after repeated puncture after 1-2 days. In early childhood, the question of paracentesis in acute inflammations of the middle ear is decided much more difficult than in adults. If one adheres to the rule of waiting for the classical signs on the eardrum - redness and bulging - it is easy to make a mistake and miss the time to the detriment of the patient. The diagnosis in children is complicated by the absence of indications of subjective sensations, the absence of anamnesis and difficulties in otoscopy. The examination of the eardrum is hindered by the narrowness of the external auditory canal and the fact that in children the eardrum is located almost horizontally and is as if a continuation of the upper wall of the external auditory canal; in color, the eardrum often does not differ from the skin of the auditory canal. Special difficulty for diagnosis, and therefore for paracentesis, are the so-called latent forms of otitis in early childhood, which can occur with a completely normal eardrum or with insignificant changes in its color, when the only objective symptom is some cloudiness of it or an indistinctly expressed light reflex. Such a hidden otitis can be easily overlooked if there are other data to explain the elevated temperature, restlessness and crying of the child, insomnia and gastrointestinal phenomena. Paracentesis performed at this time sometimes quickly leads to a drop in temperature and improvement in the general condition. Taking into account the peculiarities of the course of acute otitis in early childhood, it is often necessary to resort to paracentesis in cases where the objective picture does not give reliable indications. Technique of the operation. For performing paracentesis, straight or curved at an obtuse angle spear-shaped needles are used (see the figure). During otoscopy with artificial illumination through as wide a funnel as possible, the eardrum is examined and the puncture site is marked. Under visual control, the needle is inserted into the auditory canal and with a quick movement all layers of the eardrum are cut at once; it is not dangerous if the tip of the needle touches the inner wall of the middle ear during this. The best place for puncture is the lower-posterior quadrant, as from here the outflow of liquid content can most easily occur; the incision is made in a vertical direction from top to bottom along the entire posterior part of the eardrum. Due to the oblique position of the eardrum and its funnel shape, the paracentesis needle often slips off its surface before the incision reaches the intended length, which may require re-intervention. Anesthesia in paracentesis is rarely used, as it significantly lengthens the procedure of the operation, and most importantly, it is not reliable: the inflamed eardrum poorly absorbs anesthetic substances. In extreme cases in restless patients, one can resort to short-term anesthesia with ether or chloroform. After paracentesis is performed, usually the instillation of any drops into the ear is canceled, pieces of sterile gauze or cotton wool are introduced into the auditory canal, which are changed several times a day as they become saturated with fluid; a heating compress is applied to the entire area of the ear or a hot water bottle is used. The opening in the eardrum has a great tendency to heal as soon as the purulent discharge stops; after a short time, the scar at the site of the incision becomes almost imperceptible.

Artificial lighting through as wide a funnel as possible, the eardrum is examined and the puncture site is marked. Under visual control, the needle is inserted into the auditory canal and with a quick movement all layers of the eardrum are cut at once; it is not dangerous if the tip of the needle touches the inner wall of the middle ear during this. The best place for puncture is the lower-posterior quadrant, as from here the outflow of liquid content can most easily occur; the incision is made in a vertical direction from top to bottom along the entire posterior part of the eardrum. Due to the oblique position of the eardrum and its funnel shape, the paracentesis needle often slips off its surface before the incision reaches the intended length, which may require re-intervention. Anesthesia in paracentesis is rarely used, as it significantly lengthens the procedure of the operation, and most importantly, it is not reliable: the inflamed eardrum poorly absorbs anesthetic substances. In extreme cases in restless patients, one can resort to short-term anesthesia with ether or chloroform. After paracentesis is performed, usually the instillation of any drops into the ear is canceled, pieces of sterile gauze or cotton wool are introduced into the auditory canal, which are changed several times a day as they become saturated with fluid; a heating compress is applied to the entire area of the ear or a hot water bottle is used. The opening in the eardrum has a great tendency to heal as soon as the purulent discharge stops; after a short time, the scar at the site of the incision becomes almost imperceptible.

Complications during P. usually do not occur, as the inner ear cannot be wounded, since the round window is closed by a niche, and the oval window by the stapes. In exceptional cases, the needle may enter the bulb of the jugular vein if it abnormally protrudes into the floor of the tympanic cavity. Sudden profuse bleeding quickly stops with tamponade of the auditory canal. Hearing cannot be impaired by the artificial puncture of the eardrum. A second indication for P. may be the accumulation of a non-inflammatory transudate in the middle ear due to closure of the Eustachian tube and reduction of air pressure in the tympanic cavity, if, despite all measures taken, the secretion in the ear does not disappear. The eardrum appears more or less retracted, of a cloudy color, with hyperemia in the area of the short process and the malleus; often a linear border of the accumulated transudate can be distinguished on it. The puncture shortens the treatment time and preserves the hearing function, which can be impaired by the prolonged presence of secretion in the ear. After an incision in the postero-inferior quadrant of the eardrum, during insufflation through a catheter, a large amount of clear fluid may sometimes flow from the ear into the auditory canal; some advise performing insufflation through the external auditory canal, as the fluid is more easily removed through the Eustachian tube into the nasopharynx. After several insufflations performed over 2-3 days, in uncomplicated cases, normal acuity of hearing is restored, and the perforation heals without a trace. Strictest asepsis is necessary during the puncture and subsequent treatment.