Transcript Introduction - Society of PAs in ORL-HNS

April 26-28, 2013
New York-Presbyterian
Hospital/Weill Cornell
Medical Center
Otology Workshop
Jeffrey Fichera, PhD, PA-C
Ashutosh Kacker, MD, FACS
Otology Workshop
Basic instruction
Clear demonstration
Hands-on doing!
Removal of Cerumen
Removal of Foreign
Bodies
Manual Otoscopy
Myringotomy
Ventilation Tube Insertion
Intratympanic Injection
Introduction
There are multiple methods and techniques available
to successfully complete all the topics presented in
this workshop. Some are based on patient request,
available equipment or supervising physician’s
preference.
The goal of this workshop is to correctly demonstrate
the most common methods and give participants time
for hands on training.
Otology Workshop
Learning Objectives
• Demonstrate techniques for cerumen removal.
• Demonstrate techniques for foreign body
removal from ear.
• Perform manual pneumatic otoscopy
examination
• Perform myringotomy
• Perform ventilation tube insertion.
• Perform intra-tympanic membrane injection
Removal of Cerumen
Cerumen
Removal of cerumen or wax from the ear forms a significant
part of the workload of an otolaryngologist and is, therefore,
an essential skill for physician assistants (PA) to master.
There are multiple methods and techniques for removal of
cerumen. Some are based on
–patient request,
–consistency of cerumen or
–supervising physician’s preference.
Cerumen
Removal of cerumen impaction options include;
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Observation
cerumenolytic agents
Irrigation
Manual removal other than irrigation may be performed with a curette, probe,
hook, forceps, or suction under direct visualization with headlight, otoscopy, or
microscopy.
– Combinations of treatment options such as cerumenolytic followed by irrigation;
irrigation followed by manual removal, etc.
The training, skill, and experience of the clinician plays a
significant role in the treatment option selected.
Patient presentation, preference, and urgency of the clinical
situation also influence choice of treatment
McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician 2007;75:1523– 8.
Browning G. Ear wax. BMJ Clin Evid 2006;10:504.
Guest JF, Greener MJ, Robinson AC, et al. Impacted cerumen: composition,
production, epidemiology and management. QJM 2004;97: 477–88.
Burton MJ, Dorée CJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev 2003:
Complications
Though generally safe, cerumen removal can result in
significant complications. An estimated 8,000 complications
occur annually and likely require further medical services:
Complications that have been reported include
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tympanic membrane perforation
ear canal laceration
infection of the ear
hearing loss
pain
dizziness
syncope
Freeman RB. Impacted cerumen: how to safely remove earwax in an office visit. Geriatrics 1995;50:52–3.
Browning G. Ear wax. BMJ Clin Evid 2006;10:504.
Bapat U, Nia J, Bance M. Severe audiovestibular loss following ear syringing for wax removal. J Laryngol Otol 2001;115:410 –1.
Positioning
The patient should be semireclined. Although having the
patient sitting upright saves time
and may seem more convenient,
the attic region is difficult to
access in this position.
The supine position also aids in
patient stability in case patient
experiences vertigo during the
microsuction, as is often the
case after mastoidectomy.
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Modified semireclined
position allows
visualization of
attic space.
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Positioning
Positioning children on
parent’s lap with legs and
arms secured.
Head should be stabilized to
minimize movement.
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Visualization
The speculum should be the largest size
that fits. It should be placed deep enough
to clear the hair-bearing skin but not
deeper, as unnecessary pain may result.
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The speculum should be held with the
first and second fingers. Use the other
fingers to retract the pinna up and
backward in an adult (retract the pinna up
and downward in a child).
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Visualization
• Inspect the ear canal and
middle ear structures locating
landmarks and noting any
redness, drainage, or
deformity.
• Visualize membrane and
identify landmarks.
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Instruments
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Suction
Alligator Forceps
Ear Speculum
Bayonet Forceps
Blunt Hook
Loop Currette
Curved Forceps
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Technique
Suction device capable of
300 mm Hg suction
pressure, with a reservoir
and built-in filter.
Suctioning may create a
cooling effect and elicit a
caloric response from the
inner ear, causing
nystagmus and vertigo.
Anchor hand on patient in
case patient moves
Mitka M. Cerumen removal guidelines wax practical. JAMA. Oct 1 2008;300(13):1506.
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Technique
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Insert speculum deep enough to clear the hair-bearing skin.
Push the wax away from the ear canal walls toward the
middle and then remove it
Consider pulling it out with alligator forceps.
Technique
• Warm irrigation under
direct visualization (cold
water stimulates calorics
may cause vertigo)
• Must ensure TM is in
intact!
• Review of completed
trials did NOT
demonstrate a significant
difference between using
water or commercially
available drops
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[Best Evidence] Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan 21 2009;CD004326.
Contraindications
Contraindications to irrigation include the presence or
history of a tympanic membrane perforation, previous
pain on irrigation, or previous surgery to the middle ear.
A relative contraindication to probing is the inability to
visualize the ear canal.
Relative contraindications to microsuction are severe
previous exacerbation of tinnitus, very hard cerumen,
and an uncooperative patient.
Exceptional caution has to be used when clearing cerumen
in patients who have undergone a mastoidectomy in the
past, during which sensitive anatomical structures like
the facial nerve and semicircular canals may have been
exposed.
Pearl
Adjust to the individual patient’s needs.
Meticulous cleaning is required in
patients with otitis externa, but less
so if they are having a mold made for
a hearing aid.
However, for patients who simply
present with excessive wax buildup,
the clinician only needs to remove
most of the cerumen, and the rest
can be cleared with weekly drops.
Practice mannequins
available to practice
cerumen and ear foreign
body removal technique.
Removal Foreign Bodies Ear
Foreign Bodies
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Foreign Bodies – eraser heads, beads, cotton tips, bugs, etc…
Bugs - drown insects with mineral oil or lidocaine before attempting
removal.
Removal – requires direct visualization prior to removal either via warm
irrigation with syringe, or instruments like an alligator forceps.
Bull T.R., A Color Atlas of E.N.T. Diagnosis 2nd Edition Hazel Books, England 1992
Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002
Removal Foreign Body (Ear)
Direct visualization
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Removal with Alligator
Forceps
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Manual Pneumatic Otoscopy
Manual Pneumatic Otoscopy
Pull the ear upwards and backwards
to straighten the canal before
inserting otoscope.
Insert the otoscope to a point just
beyond the protective hairs in
the ear canal. Use the largest
speculum that will fit
comfortably.
Anchor otoscope - hold the otoscope
with your thumb and fingers so
that your hand makes contact
with the patient.
Insufflate with non-dominant hand.
Observe movement of tympanic
membrane.
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Manual Pneumatic Otoscopy
Practice mannequins available to practice manual
pneumatic otoscopy technique.
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Myringotomy with Ventilation
Tube Insertion
Otitis Media
Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002
Acute otitis media--fluid in the middle ear accompanied by signs or
symptoms of ear infection (bulging eardrum usually accompanied by
pain; or perforated eardrum, often with drainage of purulent material).
Otitis Media
Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002
Otitis media with effusion--fluid in the middle ear without
signs or symptoms of ear infection. Note air bubble.
Tympanometry Testing
Normal Type “A”
Flat Type “B”
Negative/Positive Pressure
Type “C”
A peaked tympanogram
indicates normal tympanic
function or that the tube is
clogged or has been
extruded with an intact TM.
A flat tympanogram with a
small volume indicates a
nonfunctioning tube with a
middle ear effusion.
Negative pressure (red)
suggests poor Eustachian
tube function. Positive
pressure (blue) is seen with
Valsalva.
AAO and AAP recommend the use of tympanometry to confirm
tympanic membrane mobility.
Types of Tubes
Shepard Grommet
Soileau Tytan®
Titanium Ventilation Tubes
Goode T-Tubes®
Spoon Bobbins
A
Armstrong Beveled
Grommets, Modified
Paparella-Type Vent Tubes
TriuneTubes
Most grommets are short term 6-12 months but may last up to 36 months. For
longer duration use “T” tubes (Triune tubes) or grommets of wider diameter and
flange.
Myringotomy Tray
Sterile Kits Generally
Include:
5 sizes of ear specula
2 sizes of curettes
1 myringotomy knife, sickle
blade
1 suction
Myringotomy Blades
Spear Blade
Lance Blade
Upcutting, Angled
Operating Microscope
1. An operating microscope with a 250-mm lens is brought into the field and
focused on the external auditory meatus.
2. A speculum of a size appropriate for visualizing the tympanic membrane is
placed into the external auditory canal, and any cerumen is removed so that
the entire tympanic membrane can be visualized. For narrow canals consider
inserting grommet BEFORE speculum.
Topical Anesthetic
• Phenol is in aqueous • A topical solution of
form of 20-25%
8% tetracaine base in
solution
70% isopropyl
alcohol. Five to 10
• effect of the phenol
drops of the solution
anesthesia lasts
applied to the
about 15-20 minutes
tympanic membrane
• Also has
for 10 to 15 minutes
bacteriostatic (0.2%),
and aspirated.
bacteriocidal (1.0%)
and fungcidal (1.3%) • Lidocaine
properties.
1. http://archive.ispub.com/journal/the-internet-journal-of-otorhinolaryngology/volume-4-number-2/use-of-phenol-in-anaesthetizingthe-eardrum.html#sthash.U0RZKePK.dpuf
2. . Hoffman, R. A. and Li, C.-L. J. (2001), Tetracaine Topical Anesthesia for Myringotomy. The Laryngoscope, 111: 1636–1638
Procedure
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A horizontal incision is made in the anteroinferior quadrant. It should be deep enough to
incise the eardrum but not so deep that it injures the middle structures.
The incision should be slightly smaller than the diameter of the tube’s inner flange.
Microsuction effusion with a 3, 5 or 7 French Baron suction cannula.
A ventilation tube is introduced by holding the posterior surface of the inner flange with
small alligator forceps.
If necessary, insertion is completed with a curved or straight pick. Most tubes can be
inserted directly with small alligator forceps.
Residual effusion or blood is aspirated.
Otic antibiotic drops are instilled to reduce bleeding and loosen any thickened secretions
that were not removed by suction
Myringotomy & Tympanostomy Tube
Myringotomy
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Tympanostomy Tube
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Tympanostomy Tube Management
• The average functional duration of a standard "short-term"
ventilation tube has been estimated to range between 6
and 18 months with a mean of 13 months.
• Follow-up care should be every 4 to 6 months to ensure
tube patency.
• Tympanostomy tubes should be removed when there is
chronic infection or granulation tissue that fails to respond
to topical and systemic antibiotics or if they have been in
place longer than 3 years. The longer the tubes remain, the
greater the risk of persistent perforation.
Follow-up Management of Children with Tympanostomy Tubes, AAP Guidelines, Pediatrics 2002; 109: 328-329
Pribitkin EA, Handler SD, Tom LW, et al. Ventilation Tube Removal, Arch Otolaryngol Head Neck Surg. 1992; 118: 495-497
Otorrhea with Tympanostomy Tubes
Otorrhea occurs in 21% to 34%
of patients who have undergone
tympanostomy tube placement.
Ototopical Antimicrobials
vs.
Oral Antibiotics
Asymptomatic = ototopical
Symptomatic = ototopical first
line, then oral or
combination
Deitmer T, Topical and systemic treatment for chronic supportive otitis media. ENT Journal 08/02 · VOL. 81, NO. 8, SUPPLEMENT 1: 16-17
Hannley MT, Denneny JC, Holzer SS, Use of ototopical antibiotics in treating 3 common ear diseases (Consensus Panel Reprt) Otolaryngol Head Neck
Surg 2000;122:934-940
Force RW, Hart MC, Plummer SA, et al. Topical ciprofloxacin for Otorrhea after tympanostomy tube placement. Arch Otolaryngol Head Neck Surg. 1995;
121:880-884
Intratympanic Injection
Intratympanic Injection
http://www.dana.org/news/cerebrum/detail.aspx?id=758
Intratympanic Injection
• Gentamicin injection into the ear is presently the
most common destructive procedure for vertigo
(http://americanhearing.org/disorders/destructive-treatments-ofvertigo/)
• Intratympanic (IT) methylprednisolone and oral
prednisone are equally effective for treatment of
idiopathic sudden sensorineural hearing loss.
(http://www.medscape.com/viewarticle/743423)
http://www.enttoday.org/details/article/531821/Pills_vs__Injections_Which_Steroids_Are_Best_for_Sudden_Hearing_Loss.ht
ml
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Intratypmanic (IT) injections of steroid
can be given through the ear drum via
a small needle. IT steroids allows for
unilateral treatment and does not
interfere with unaffected ear. It also
avoids complications of systemic
steroids, may avoid surgery, and may
work when other treatments fail.
Most patients begins with a single
intratympanic injection of
dexamethasone (12 mg/ml).
Follow up in 2-3 weeks. Repeat the
injection at 6-8 weeks if vertigo recurs.
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The dexamethasone solution should
be prepared fresh (preservatives
cause intense pain).
A mixture last about 1 week. Make two
small incisions - -one for the injection
and one for ventilation. Allow the
dexamethasone to warm to room
temperature (to avoid dizziness).
Inject the dexamethasone through the
posterior incision.
http://www.dizziness-and-balance.com/treatment/it-steroids.htm