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Tympanic membrane perforation: Complication of tympanic thermometry during general anesthesia
Tympanic membrane perforation: Complication of tympanic thermometry during general anesthesia Michael W. Tabor, D.D.S.,* Daniel M. Blaho, D.D.S.,** and William R. Sehriver, D:D.S.*** Fort Gordon, Ga. DWIGHT
DAVID EISENHOWER
ARMY MEDICAL CENTER
The tympanic temperature probe is an accurate and relatively safe method of monitoring c o r e body temperature. Irritation or perforation of the tympanic membrane may occur. A case of traumatic perforation of the tympanic membrane during oral and maxillofacial surgery is presented.
T h e tympanic temperature probe is an accurate, relatively safe method of monitoring core body temperature during general anesthesia (Fig. 1). The probe must physically contact the tympanic membrane; movement of the head, particularly during oral and maxillofacial surgery, may cause the probe to perforate the tympanic membrane (Fig. 2). Continuous monitoring of core body temperature during general anesthesia is routine. The infrequent but life-threatening consequences of malignant layperthermia necessitate monitoring of body temperature during anesthesia and surgery. ~-3 Early recognition of this phenomenon is essential to avoid physiologic decompensation, which has been reported to have a mortality rate of 60 to 70 per cent', 5 Various methods are available to monitor a patient' s temperature during general anesthesia, each approach having various advantages and disadvantages. The rectal temperature probe yields inconsistent readings, often recording temperatures
that are higher or lower than the core temperature. The rectum contains no thermoreceptors and harbors intense heat-producing bacteria. The rectal method also has numerous contraindications, including obstetric, gynecologic, and urologic procedures. The esophageal temperature probe yields the most accurate results but is extremely position sensitive, with contraindications in oral, nasal, laryngeal, and esophageal surgical procedures. The nasal pharyngeal probes behave in a sluggish and unpredictable fashion and usually yield low temperatures when compared to actual core temperature. ~ The tympanic temperature probe values correlate extremely well with esophageal values because of the proximity of the vascular supply of the tympanic membrane to the body temperature-regulating center in the hypothalamus. ~This method has few contraindications and is safe except for the possibility of tympanic membrane irritation or perforation. CASE REPORT
The opinionsor assertionscontainedherein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department Of Defense. *Resident, Oral and Maxillofacial Surgery. **AssistantChief, Departmentof Dentistryand Oral and Maxillofacial Surgery ***Chief, Department of Dentistry and Oral and Maxillofacial Service.
A 38-year-old white woman was admitted for surgical correction of mandibular retrognathia. Presurgical otoscopic examination revealed intact tympanic membranes free of inflammation or anatomic defects. A nitrous oxide-narcotic technique was used for general anesthesia. A tympanic probe placed in the right external auditory canal was used to monitor the core temperature during anesthesia. Four hours postoperatively the patient complained of severe pain in the right ear. Gross examination at that time revealed blood in the right external auditory 581
582
Tabor, Blaho, and Schriver
Ora: Surg.
Fig. 1. Tympanic temperature probe for monitoring core body temperature during general anesthesia.
Fig. 2. Required position of the tympanic temperature probe.
canal, and otoscopic examination revealed an injected tympanic membrane with laceration of the posterior inferior quadrant. A loose cotton earplug was inserted into the external auditory canal, and the patient was instructed to leave it in place for 2 weeks. Otoscopic examination was performed weekly and in 4 weeks the tympanic membrance was noted to have healed spontaneously.
tympanic thermometry during oral and maxillofacial surgery.
DISCUSSION
The tympanic temperature probe is an accurate, convenient, and safe method for monitoring core temperature during general anesthesia and surgery. Physical contact of the probe with the membrane is necessary to obtain accurate readings, and this requirement may result in irritation or perforation of the membrane. Proper insertion and maintenance of the position of the probe during surgery will minimize the frequency of these complications. The proper technique consists of inserting the probe superfically into the external auditory canal, pulling down the ear lobe, and gently inserting the probe with a twisting motion until the resisting tympanic membrane is encountered. Proper maintenance of the probe's position requires that attention be directed to the probe whenever movement of the head occurs (Fig. 1).~ Most oral and maxillofacial surgery procedures performed under general anesthesia require movement of the head, and numerous opportunities exist for the movement of the probe which can result in perforation of the tympanic membrane. Research is presently being directed toward the development of a noncontact tympanic thermometer using a thermal feedback approach? Development of this type of probe would greatly reduce the potential risks of
SUMMARY
The tympanic probe is one of many methods available to monitor patient temperature during general anesthesia. A case report has been presented to demonstrate that perforation of the tympanic membrane by the probe is a complication of tympanic thermometry. Attention should be directed to the tympanic probe at all times to avoid movement of the tympanic probe and potential attendant morbidity. CONCLUSION
Although the tympanic probe is at present the most advantageous and accurate method of measuring core body temperatur e , further development of the probe is required to prevent the possibility of perforation of the tympanic membrane. Tympanic thermometry is the preferred method of core temperature measurement at present, although further design improvement is indicated because of reported morbidity.
REFERENCES
1. Saidman,J. J., Howard, E. S., and Eger, E. 1.: Hyperthermia During Anesthesia,JAMA 190: 1029-1032, 1964. 2. Wilson,R. D., Dent, T. E., Traber, D. L,, McCoy,N. R., and Allen, C. R.: Malignant Hyperpyrexia With Anesthesia, J. A. M A. 202: 183, 1967. 3. Stephen,C. R.: Fulminant HyperthermiaDuring Anesthesia and Surgery,J. A. M. A. 202: 221, 1967. 4. Dripps, R. D., Eckenhoff, J. E., and Vandam, L. D.: Introduction to Anesthesia, Philadelphia 1977, W. B. Saunders Company, pp. 429-430.
Volume 51
Tympanic membraneperforation S$3
Number 6 5. Collins, J.: Principles of Anesthesiology, Philadelphia, 1976, Lea & Febiger, Publishers; pp. 1252-1258. 6. Benzinger, M.: Tympanic Thermometry in Surgery and Anesthesia, J. A. M. A. 209: 1207-1212, 1969. 7. Wilson, R. D., Knapp, C., Traber, D. C., et al.: Tympanic Thermography: A Chnical and Research Evaluation of A New Technic, South. Med. J. 64: 1452-1455, 1971. 8. Wallace, C. T., et al.: Perforation of the Tympanic Membrane, a Complication of Tympanic Thermometry During Anesthesia, Anesthesiology 41: 290-291, 1974.
9. Moore, J. W., and Newbower, R. S.: Noncontact Tympanic Thermometer, Med. Biol. Eng. Comput 16: 580-584, 1978.
Reprint requests to: Dr. Michael W. Tabor Oral and Maxillofacial Surgery Dwight David Eisenhower Army Medical Center Fort Gordon, Ga. 30905
DAVID EISENHOWER
ARMY MEDICAL CENTER
The tympanic temperature probe is an accurate and relatively safe method of monitoring c o r e body temperature. Irritation or perforation of the tympanic membrane may occur. A case of traumatic perforation of the tympanic membrane during oral and maxillofacial surgery is presented.
T h e tympanic temperature probe is an accurate, relatively safe method of monitoring core body temperature during general anesthesia (Fig. 1). The probe must physically contact the tympanic membrane; movement of the head, particularly during oral and maxillofacial surgery, may cause the probe to perforate the tympanic membrane (Fig. 2). Continuous monitoring of core body temperature during general anesthesia is routine. The infrequent but life-threatening consequences of malignant layperthermia necessitate monitoring of body temperature during anesthesia and surgery. ~-3 Early recognition of this phenomenon is essential to avoid physiologic decompensation, which has been reported to have a mortality rate of 60 to 70 per cent', 5 Various methods are available to monitor a patient' s temperature during general anesthesia, each approach having various advantages and disadvantages. The rectal temperature probe yields inconsistent readings, often recording temperatures
that are higher or lower than the core temperature. The rectum contains no thermoreceptors and harbors intense heat-producing bacteria. The rectal method also has numerous contraindications, including obstetric, gynecologic, and urologic procedures. The esophageal temperature probe yields the most accurate results but is extremely position sensitive, with contraindications in oral, nasal, laryngeal, and esophageal surgical procedures. The nasal pharyngeal probes behave in a sluggish and unpredictable fashion and usually yield low temperatures when compared to actual core temperature. ~ The tympanic temperature probe values correlate extremely well with esophageal values because of the proximity of the vascular supply of the tympanic membrane to the body temperature-regulating center in the hypothalamus. ~This method has few contraindications and is safe except for the possibility of tympanic membrane irritation or perforation. CASE REPORT
The opinionsor assertionscontainedherein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department Of Defense. *Resident, Oral and Maxillofacial Surgery. **AssistantChief, Departmentof Dentistryand Oral and Maxillofacial Surgery ***Chief, Department of Dentistry and Oral and Maxillofacial Service.
A 38-year-old white woman was admitted for surgical correction of mandibular retrognathia. Presurgical otoscopic examination revealed intact tympanic membranes free of inflammation or anatomic defects. A nitrous oxide-narcotic technique was used for general anesthesia. A tympanic probe placed in the right external auditory canal was used to monitor the core temperature during anesthesia. Four hours postoperatively the patient complained of severe pain in the right ear. Gross examination at that time revealed blood in the right external auditory 581
582
Tabor, Blaho, and Schriver
Ora: Surg.
Fig. 1. Tympanic temperature probe for monitoring core body temperature during general anesthesia.
Fig. 2. Required position of the tympanic temperature probe.
canal, and otoscopic examination revealed an injected tympanic membrane with laceration of the posterior inferior quadrant. A loose cotton earplug was inserted into the external auditory canal, and the patient was instructed to leave it in place for 2 weeks. Otoscopic examination was performed weekly and in 4 weeks the tympanic membrance was noted to have healed spontaneously.
tympanic thermometry during oral and maxillofacial surgery.
DISCUSSION
The tympanic temperature probe is an accurate, convenient, and safe method for monitoring core temperature during general anesthesia and surgery. Physical contact of the probe with the membrane is necessary to obtain accurate readings, and this requirement may result in irritation or perforation of the membrane. Proper insertion and maintenance of the position of the probe during surgery will minimize the frequency of these complications. The proper technique consists of inserting the probe superfically into the external auditory canal, pulling down the ear lobe, and gently inserting the probe with a twisting motion until the resisting tympanic membrane is encountered. Proper maintenance of the probe's position requires that attention be directed to the probe whenever movement of the head occurs (Fig. 1).~ Most oral and maxillofacial surgery procedures performed under general anesthesia require movement of the head, and numerous opportunities exist for the movement of the probe which can result in perforation of the tympanic membrane. Research is presently being directed toward the development of a noncontact tympanic thermometer using a thermal feedback approach? Development of this type of probe would greatly reduce the potential risks of
SUMMARY
The tympanic probe is one of many methods available to monitor patient temperature during general anesthesia. A case report has been presented to demonstrate that perforation of the tympanic membrane by the probe is a complication of tympanic thermometry. Attention should be directed to the tympanic probe at all times to avoid movement of the tympanic probe and potential attendant morbidity. CONCLUSION
Although the tympanic probe is at present the most advantageous and accurate method of measuring core body temperatur e , further development of the probe is required to prevent the possibility of perforation of the tympanic membrane. Tympanic thermometry is the preferred method of core temperature measurement at present, although further design improvement is indicated because of reported morbidity.
REFERENCES
1. Saidman,J. J., Howard, E. S., and Eger, E. 1.: Hyperthermia During Anesthesia,JAMA 190: 1029-1032, 1964. 2. Wilson,R. D., Dent, T. E., Traber, D. L,, McCoy,N. R., and Allen, C. R.: Malignant Hyperpyrexia With Anesthesia, J. A. M A. 202: 183, 1967. 3. Stephen,C. R.: Fulminant HyperthermiaDuring Anesthesia and Surgery,J. A. M. A. 202: 221, 1967. 4. Dripps, R. D., Eckenhoff, J. E., and Vandam, L. D.: Introduction to Anesthesia, Philadelphia 1977, W. B. Saunders Company, pp. 429-430.
Volume 51
Tympanic membraneperforation S$3
Number 6 5. Collins, J.: Principles of Anesthesiology, Philadelphia, 1976, Lea & Febiger, Publishers; pp. 1252-1258. 6. Benzinger, M.: Tympanic Thermometry in Surgery and Anesthesia, J. A. M. A. 209: 1207-1212, 1969. 7. Wilson, R. D., Knapp, C., Traber, D. C., et al.: Tympanic Thermography: A Chnical and Research Evaluation of A New Technic, South. Med. J. 64: 1452-1455, 1971. 8. Wallace, C. T., et al.: Perforation of the Tympanic Membrane, a Complication of Tympanic Thermometry During Anesthesia, Anesthesiology 41: 290-291, 1974.
9. Moore, J. W., and Newbower, R. S.: Noncontact Tympanic Thermometer, Med. Biol. Eng. Comput 16: 580-584, 1978.
Reprint requests to: Dr. Michael W. Tabor Oral and Maxillofacial Surgery Dwight David Eisenhower Army Medical Center Fort Gordon, Ga. 30905