ENT for the PA 2017 Workshops - entpa.org ENT for... · 2. Check equipment, ensure cuff functions....

ENT for the PA‐C 2017Workshops

Stacey Ishman, MD, MPH

Program Co‐Director (AAOA‐HNSF)

Marie Gilbert, PA‐C, DFAAPA

Program Co Director (SPAO‐HNS)

Kevin Prater, PA‐CWorkshop Co Director (SPAO‐HNS)

Jennifer Brooks, PA‐C

Workshop Co Director (SPAO‐HNS)

April 21, 2017Chicago, Illinois

Co Sponsored by

Table of ContentsIntroduction…………………………………………………….

Workshop Schedule……………………………………………

Airway Workshop –ADULT…………………………….

Airway Workshop – PEDI………………………………….

ENT Coding Workshop…………………………………

ENT Procedures Workshop………………………………………..

Flexible Fiberoptic Workshop –Basic………………….

Flexible Fiberoptic Workshop – Advanced………….

Otology Workshop – Basic………………………………….

Otology Workshop – Advanced………………………….

Vertigo Workshop………………………………………………

Videostroboscopy Workshop………………………………

Recommended Reading……………………………………..

1

2

3

11

17

25

33

38

44

50

55

59

69

Introduction

There are multiple methods and techniques available to successfully complete all the topics presented in these

workshops. Some are based on patient request, available equipment or supervising physician’s preference.

The goal of these workshop is to correctly demonstrate the most common methods and give participants time for hands on

training.

Workshop topics have been selected based on relevancy, practice need and audience requests from over seven years of lecture series. This entire program has been reviewed and is

approved for a maximum of 26 earnable hours of AAPA clinical Category I CME credit by the Physician Assistant Review Panel.

The activity was planned in accordance with AAPA’s CME Standards for Live Programs and for Commercial Support of Live

Programs.

Workshops Schedule APRIL 21, 2017

Miami 5th floor

Belmont 4th floor

Armitage 4th floor

Denver 5th floor

Houston+KC 5th floor

Scottsdale 5th floor

McHenry 3rd floor

Los Angeles 5th floor

Vertigo 1 7:30 a.m.

1-2 proctors 20 attendees Valdez, PA-C

2 hrs.CME

Basic Flex Scope 1 7:30 a.m.

4-5 proctors 20 attendees Parnell, PA-C

2 hrs.CME

Advanced Otology 1 7:30 a.m. 3 Proctors

18 attendees Marovich, PA-C

2 hrs.CME

Videostroboscopy 1 7:30 a.m.

1-2 proctors 10 attendees

J. Lehman MD

2 hrs.CME

ENT Procedures 1 7:30 a.m.


Nabilah Ali, PA-C

2 hrs.CME

Vertigo 2 10 a.m.


2 hrs.CME

Basic Flex Scope 2 10 a.m.


Parnell, PA-C

2 hrs.CME

Advanced Scopes 1 10 a.m.

5 proctors 24 attendees max Marti Evans, PA-C

2 hrs.CME

Basic Otology 1 10 a.m.

1 proctors 20 attendees Fichera, PA-C

2 hrs.CME

Advanced Otology 2 10 a.m.

3 Proctors 18 attendees

Marovich, PA-C

2 hrs.CME

Videostroboscopy 2 10 a.m.


J. Lehman MD

2 hrs.CME

ENT Procedures 2 10a.m.


Nabilah Ali, PA-C

2 hrs.CME

Advanced Airway PEDI 1 10 a.m.

2-4 proctors 20 attendees C. Hart MD

2 hrs.CME LUNCH BREAK

noon to 1 LUNCH BREAK







noon to 1 Vertigo 3 1 p.m.


2 hrs.CME

Basic Flex Scope 3 1 p.m.


Parnell, PA-C

2 hrs.CME

Advanced Scopes 2 1 p.m.

5 proctors 24 attendees max Marti Evans, PA-C

2 hrs.CME

Basic Otology 2 1 p.m.


2 hrs.CME

Advanced Otology 3 1 p.m.

3 Proctors 18 attendees

Marovich, PA-C

2 hrs.CME

ENT Coding 1 1 p.m.

?1 proctor? 10 attendees Gilbert, PA-C

2 hrs CME

ENT Procedures 3 1 p.m.


Nabilah Ali, PA-C

2 hrs.CME

Advanced Airway PEDI 2 1 p.m.


2 hrs. CME

Advanced Scopes 3 3:30 p.m. 5 proctors

24 attendees max Marti Evans, PA-C

2 hrs.CME

Basic Otology 3 3:30 p.m.


2 hrs.CME

Advanced Otology 4 3:30 p.m. 3 Proctors

18 attendees Marovich, PA-C

2 hrs.CME

ENT Coding 2 3:30 p.m.

?1 proctor? 10 attendees Gilbert, PA-C

2 hrs CME

ENT Procedures 4 3:30 p.m.


Nabilah Ali, PA-C

2 hrs.CME

Advanced Airway ADULT 1 3:30 p.m. 4 proctors

20 attendees C. Hart MD

2 hrs.CME

Advanced Scopes 4 6 p.m.

5 proctors 24 attendees max

Felder, PA-C

2 hrs.CME

Advanced Airway ADULT 2 6 p.m.


2 hrs.CME

ENT for the PA‐C

Airway workshop – AdultLearning objectivesDiscuss and practice tracheostomy care techniques.Discuss and practice management for tracheostomy airway obstruction.Discuss and practice management for tracheostomy airway leaks.Discuss and practice management for tracheostomy bleeding.Discuss indications for and practice cricothyrotomy

Presented by: Catherine Hart, MD

3

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 4

Airway ScenariosAttendees will rotate through 4 simulated scenarios where they will be given a patient and asked to perform corrective measures.

• Scenario 1: 47 year old male with respiratory failure status post tracheostomy 8 days ago. Having increased difficulty breathing.

• Scenario 2: 66 year old female with respiratory failure, ventilator dependant has developed a leak.

• Scenario 3: 59 year male with SCCA, left tongue, status post tracheostomy accidentally decanulated during patient transport.

• Scenario 4: 44 year old male in acute respiratory distress in ER unable to intubate.

5

Task: Resolve Blocked Tracheostomy Indications: Blocked or leaking tracheostomy tube, poor

saturation, etc

1. Explain Procedure. Monitor oxygen saturation.

2. Check equipment, ensure cuff functions.

3. Position the patient supine with a shoulder roll to hyperextend the neck and bring tracheal orifice closer to surface.

4. Provide supplemental oxygen prior to procedure.

5. Check inner cannula – most common cause of obstruction – mucous plug.

A. Rinse ‐ inner cannula with warm saline.

B. Suction ‐use saline bullets and suction.

6. Visualize distal end tracheostomy tube with flexible fiberoptic endoscope checking for granulation tissue.

Pearl ‐ If unable to clear obstruction may need to change trachoestomy tube.

6

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Task: Resolve Leaking Tracheostomy Indications: Leaking tracheostomy tube, poor saturation, etc


2. Check cuff pressure. •Defective cuff – ensure cuff has enough air and is working.

3. If cuff is working and still have leak consider

•Tracheomalacia.•Fistula

4. Visualize distal end tracheostomy tube with flexible fiberoptic endoscope checking for granulation tissue, etc.

5. Change tracheostomy tube (regular to extra long tracheostomy tube or vice versa).

7

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Task: Change Tracheostomy

Indications: for tracheostomy change include minimizing risk of postoperative infection and granulation tissue formation, verifying formation of a stable tract for ancillary support staff, and downsizing the tracheostomy tube if the patient is clinically improving.

Contraindications:

Changing a tracheostomy tube too soon after operation (generally < 5 days) before tract has healed adequately, increases the likelihood of entry into a false passage.

Performer inexperience and unavailability of staff versed in airway management.

Extremely high ventilator settings, which increases the risk of decannulation.

Patient noncooperation without ancillary support.

Complications: Although tracheostomy tube changes are routinely performed, the procedure is not without complications.

Minimize complications by understanding and practicing procedure as well as anticipating potential problems. In addition to oxygen, pulse oximeter and suction, have basic emergency equipment at bedside, such as a manual ventilator bag, 2 extra tracheostomy tubes (same size as the trach and one smaller) and an endotracheal tube with stylet. 8

Task: Change Tracheostomy


2. Check equipment, ensure cuff functions.

3. Position the patient supine with a shoulder roll to hyperextend the neck and bring tracheal orifice closer to surface.

4. Provide supplemental oxygen prior to procedure.

5. Deflate cuff, suction and release ties. Ensure tracheostomy is stabilized.

6. Remove tracheostomy as patient coughs.

7. Insert new tracheostomy with obturator within lumen. (Rotate 90º from itscorrect position, to engage the stoma. Then turn the obturator back 90º to its correct position.)

8. Remove obturator and replace with inner cannula. Inflate cuff if needed and secure tracheostomy.

9

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

1. Explain Procedure. Locate landmarks

2. Make 1 inch vertical incision.

3. Introduce catheter at 45° angle and aspirate bubbles to verify location.

4. Insert flexible guide wire (Seldinger Technique).

5. Anchor guide wire and remove catheter.

6. Insert cricothyrotomy catheter.

10

Task: Perform CricothyrotomyIndications: Temporary emergency airway when tracheal intubation, face mask or laryngeal mask is not possible or

unsuccessful.

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

11

ENT for the PA‐C

Airway workshop – PediatricLearning objectives• Discuss and practice pediatric tracheostomy care techniques• Discuss and recognize differences in pediatric versus adult tracheostomy tubes• Discuss and practice management for pediatric tracheostomy airway leaks• Discuss and practice management for obstructed pediatric tracheostomy tubes• Discuss indications for and practice tracheoscopy of pediatric tracheostomy tubes

Presented by: Catherine Hart, MD

Leaks/Inadequate Ventilation

A low‐pressure, high volume cuff is preferred to avoid unnecessary injury to the tracheal mucosa such as tracheal malacia.

1. Check cuff pressure first.

2. Consider changing to a longer or wider tracheostomy tube.

3. Monitor cuff pressure on a regular basis.

12

Shiley® Tube Size

Leak Test Volume

10 20cc

8 17cc

6 14cc

4 11cc

Task: Resolve Leaking Tracheostomy Tube/Inadequate ventilation

Indications: Leaking tracheostomy tube, poor saturation, etc

13


2. Check cuff pressure. •Defective cuff – ensure cuff has enough air and is working.

3. If cuff is working and still have leak or inadequate ventilation consider:

•Tracheomalacia.•Fistula•Tube obstruction

4. Visualize distal end tracheostomy tube with flexible fiberoptic endoscope checking for granulation tissue, etc.

5. Change tracheostomy tube (larger diameter, longer tube).

Task: TracheoscopyIndications: Poor ventilation, poor saturation, suspected

obstruction

14


2. Check equipment

3. Lubricate scope

4. Visualize distal end tracheostomy tube with flexible fiberoptic endoscope checking for granulation tissue, secretions, appropriate position.

5. Address any obstruction encountered.

Airway Scenarios• Scenario 1: 4 month old, s/p tracheostomy 4

weeks ago. Tachypnea, increased work of breathing, oxygen desaturation.

• Scenario 2: 12 month old female with respiratory failure, ventilator dependant. Unable to adequately ventilate on current vent settings.

• Scenario 3: 14 month old male, tracheostomy tube and ventilator dependent. Has had 3 episodes of accidental decannulation at home in the last month.

• Scenario 4: 2 year old male with tracheostomy. Accidental decannulation at home. Family couldn’t replace trach. Shows up in ED in moderate distress.

15

Pediatric Airway Workshop Evaluation

6

Name Session 1 2

On scale of 1 through 5 with 5 being most likely Scale 1‐5

1. Were learning objectives met?

2. Was instruction free of commercial bias?

3. Was there adequate instruction before practice?

4. Was there adequate supervision during practice?

5. Were training aids useful/realistic in learning skill?

6. How likely are you to perform these skills in future

7. Did this training improve your skills?

Comments:

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

17

ENT for the PA‐C

ENT Coding WorkshopLearning ObjectivesRecognize the required components for ENT Specialty Evaluation and Management coding.Document appropriately to support medically necessary levels of E&M coding.Employ correct codes for ENT office procedures.

Presented by: Marie Gilbert, PA‐C

Procedures Coding Question Cerumen

A new patient is seen for chief complaint of vertigo. To examine the TMs, the provider must disimpact wax from both sides, using alligator, suction, and irrigation. How do you code appropriately to get paid for the wax?

A. Just the wax, 69209 x2

B. Just the E&M, because it includes disimpaction for examination or audio.

C. E&M with a ‐25 modifier, plus 69210

D. E&M with a ‐25 modifier, plus 69210 x2

The correct answer is _____

18

ICD‐10 QuestionCoding Sinusitis

A 35 year old female presents with 2 weeks of symptoms and findings consistent with bilateral maxillary and left ethmoid sinusitis. How do you code this?

A. J01.01Acute recurrent maxillary sinusitis

B. J01.00 Acute maxillary sinusitis plus

J01.20 Acute ethmoid sinusitis, unspecified

C. J01.80 Other acute sinusitis

D. J01.40 Acute pansinusitis, unspecified

19

ICD‐10 QuestionStill Coding Sinusitis

This same 35 year old female presents four months later having had 2 other “sinus episodes,” and continued nasal obstruction despite nasal steroids. CT confirms maxillary, ethmoid and sphenoid disease. How do you code this?

A. J01.81 Other acute recurrent sinusitis

B. J01.41 Acute recurrent pansinusitis

C. J32.4 Chronic pansinusitis

D. J32.8 Other chronic sinusitis

20

ICD‐10 QuestionStill Coding Sinusitis. Really.

IDC‐10 coding for chronic sinusitis requires additional coding. What for?

A. To identify alcohol use

B. To identify tobacco use/exposure

C. To identify immunocompromise

D. To identify the causative organism

The correct answer is _______

21

Procedures Coding QuestionAssisting in the O.R.

What is the correct way to bill for an NPP assisting on a total thyroid?

A. 60240 –AS, under surgeon’s NPI

B. 60240 –AS, under NPP’s NPI

C. 60240 ‐80, under surgeon’s NPI

D. 60240 ‐80, under NPP’s NPI

The correct answer is ___.

22

Procedures Coding Question Discussion: Assisting in the

O.R.

• Use the modifier "AS" for assistant at surgery services provided by a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS).

• Bill under the NPP’s NPI.

• The provider must accept assignment. Medicare allows 85% of the 16% for the assistant at surgery services provided by a PA, NP, or CNS.

• ‐80 modifier is usually reserved for MD 1st assist. There are very few local carrier exceptions.

23

Coding Workshop Score Card

24

Name Session 1 2

Task Go No Go

• Describe 3 key elements of E&M

• Demonstrate how to determine type of service

• Demonstrate how to determine level of code

• Demonstrate understanding of procedure code selection

• Choose appropriately between ‘95 and ‘97 Guidelines

• Demonstrate coding E&M based on time

Comments

Proctor Name Marie Gilbert, PA‐C, CPMA

Proctor SignatureNotes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

ENT for the PA‐C

ENT Procedures WorkshopLearning ObjectivesDiscuss indications for and practice removal nasal foreign body.Discuss indications for and practice control anterior epistaxis.Discuss indications for and practice control posterior epistaxis.Discuss indications for and practice fine needle aspiration.Discuss indications for and practice peritonsillar abscess drainage.Discuss indications for drainage auricular hematoma and practice splinting.

Presented by: Nabilah Ali, PA‐C

25

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 26

1. Explain Procedure. Apply topicalanesthetic & decongestant BILATERALLY.

2. Good visualization with use of bright headlight & nasal speculum.

3. Alligator forceps should be used to remove cloth, cotton, or paper. Other hard FB are more easily grasped using bayonet forceps, Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook

4. Perform flexible fiberoptic endoscopy to check for infection, bleeding and additional foreign bodies.

27

Task: Removal Foreign Body NoseIndications: Unilateral purulent nasal discharge

Mercado 2013 ©

Mercado 2013 ©

Mercado 2011 ©

Mercado 2013 ©

1. Apply direct manual pressure for at least 10 minutes.

2. Spray or apply topical anesthetic with decongestant. Reapply direct manual pressure an additional 10 minutes

3. Once bleeding has subsided, identify site of nosebleed

4. Control bleeding with silver nitrate cauterization. (start from outside in)

5. Lubricate naris with Vaseline or Neosporin ointment. Keep cotton in nares for at least 1 hour to prevent staining

6. Let sit for 10‐15 minutes to ensure hemostasis is achieved.

• Avoid sneezing, forceful nose blowing, nose picking, etc. • Follow up 2 weeks as re‐cauterization may be necessary.

28

Task: Control Anterior EpistaxisIndications: Anterior persistent nosebleed in office

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

1. Thoroughly soak in sterile water for 30 seconds.

2. Insert nasal pack into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril.

3. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloonfirst with air only inside the patient’s nose.

4. Inflate second balloon with air.

5. Allow the patient to sit for 15‐20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics!

6. To remove packing, deflate balloons 48‐72 hours later.

29

Task: Control EpistaxisIndications: Persistent anterior or posterior nosebleed

despite cauterization

1. Explain Procedure. Preparesupplies

2. Palpate and identify mass or lesion.

3. Clean topically with alcohol.

4. Stabilize the mass with non‐dominant hand. Insert needle through the skin with a quick motion.

5. Transfer specimen to slides and either fix or immediately submerge in alcohol.

30

Task: Fine Needle AspirationIndications: Obtain histopathologic diagnosis of suspected

neoplasms

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

1. Explain Procedure. Prepare supplies and locate landmarks

2. Apply topical anesthetic, inject local anesthetic.

3. Insert large bore needle with guard (optional) over area of greatest fluctuance (imaging).

4. Aspirate pus (release pressure when with drawing).

5. Perform incision at the point of maximum protrusion, usually between the uvula and the second upper molar tooth.

6. Perform blunt dissection with curved hemostat.

Treat with PCN based antibiotics and oral steroids. 31

Task: Drainage Peritonsillar AbscessIndications: Drainage peritonsillar abscess >1cm.

Johnson RF, Stewart MG, Wright CG. An evidence‐based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128(3):332–343

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

1. Explain Procedure. Prepare supplies

2. Prepare 1/16inch thick Aquaplast by making pattern on OPPOSITE ear.

3. Inject anesthesia (ring block).

4. Drain hematoma.

5. Immerse Aquaplast in hot water (160°F) until it becomes transparent. Then mold over site.

6. Prepare non‐adherent gauze pad or petroleum gauze the shape of the Aquaplast so they project 1‐2 mm BEYOND margins

7. After placement of gauze pads between the splints and the skin surface secure with two or three through and through 0 silk on a straight needle to snuggly compress splint dressing to hematoma in sandwich fashion.

32

Task: Drain Auricular HematomaIndications: Drainage hematoma within 5‐10 days to prevent

irreversible cartilage thickening.

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©Mercado 2013 ©

ENT for the PA‐C

Flexible Fiberoptic Workshop – BasicLearning objectivesDiscuss normal anatomy visible via flexible fiberoptic nasopharyngoscopyPractice the use of the flexible fiberoptic nasopharyngoscope on mannequins.Practice the use of the flexible fiberoptic nasopharyngoscope on simulated patientUnderstand and practice proper endoscope use and care.Normal variants and abnormal findings will be discussed in Advanced Course.

Presented by: Cheryl Pernell, PA‐C

33

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 34


2. Position patient

3. Apply topical anesthetic soft palate.

4. Stabilize tongue with non‐dominant hand.

5. Place warm dental mirror in the back of the throat and angle it down towards the larynx. Light can be reflected downward and the larynx can be seen in the mirror.

6. Indirect laryngoscopy can be quick and gives a good three dimensional view of the larynx in true color.

35

Task: Practice indirect laryngoscopy Indications: Asses vocal cords on mannequin and simulated

patient.

Mirror Laryngoscopy, image is inverted.

Mercado 2013 ©

Task: Practice flexible endoscopy

Indications: Flexible endoscopy is done when there may be a condition or disease in the nose, sinuses or throat that is not adequately visualized on routine examination.

Indications History (one or more required) 1. Persistent hoarseness. 2. Suspected neoplasm of upper aerodigestive tract. 3. Chronic cough. 4. Chronic postnasal drainage. 5. Recurrent epistaxis. 6. Chronic rhinorrhea. 7. Chronic nasal congestion or obstruction. 8. Hemoptysis. 9. Hemorrhage from throat. 10. Throat pain. 11. Otalgia. 12. Airway obstruction. 13. Dyspnea. 14. Stridor. 15. Dysphagia 16. Head or neck masses—unknown primary tumor. 17. Laryngeal injury—with hoarseness or airway obstruction.18. Chronic aspiration. 19. Velopharyngeal incompetence.20. Suspected foreign body.21. Unilateral middle ear effusion.22. Obstructive sleep apnea or severe snoring.23. Preoperative assessment of vocal cord function, eg, prior to thyroid surgery

36

http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy‐CI_May‐2012.pdf

1. Explain Procedure. Prepare supplies.

2. Position patient.

3. Apply topical anesthetic & decongestant nose.

4. Perform flexible naso/laryngeal endoscopy.

5. Direct laryngoscopy provides detail view of nasal passage and vocal cord function.

6. Remove endosheath and maintain clean technique.

37


Fiberoptic Laryngoscopy, image is true.

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 ©

ENT for the PA‐C

Flexible Fiberoptic Workshop – AdvancedLearning objectivesIdentify normal anatomy, normal variants and abnormal findings visible via flexible fiberoptic

nasopharyngoscopy.Understand indications and perform flexible and rigid scope examination adult.Understand indications and perform flexible scope examination child/infant.Perform intranasal culture and sinus debridement using rigid scope adult.

Presented by: Marti Felder , PA‐C

38

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 39


Indications: Flexible endoscopy is done when there may be a condition or disease in the nose, sinuses or throat that is not adequately visualized on routine examination.

Indications History (one or more required) 1. Persistent hoarseness. 2. Suspected neoplasm of upper aerodigestive tract. 3. Chronic cough. 4. Chronic postnasal drainage. 5. Recurrent epistaxis. 6. Chronic rhinorrhea. 7. Chronic nasal congestion or obstruction. 8. Hemoptysis. 9. Hemorrhage from throat. 10. Throat pain. 11. Otalgia. 12. Airway obstruction. 13. Dyspnea. 14. Stridor. 15. Dysphagia 16. Head or neck masses—unknown primary tumor. 17. Laryngeal injury—with hoarseness or airway obstruction.18. Chronic aspiration. 19. Velopharyngeal incompetence.20. Suspected foreign body.21. Unilateral middle ear effusion.22. Obstructive sleep apnea or severe snoring.23. Preoperative assessment of vocal cord function, eg, prior to thyroid surgery

40

http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy‐CI_May‐2012.pdf


2. Position patient


4. Perform flexible naso/laryngeal endoscopy

5. Direct laryngoscopy provides detail view of nasal passage and vocal cord function.


41


Fiberoptic Laryngoscopy, image is true.

Mercado 2011 ©

Mercado 2011 ©

Mercado 2011 © Mercado 2011 ©

Mercado 2011 ©

1. Explain Procedure. Prepare supplies.

2. Position patient papoose vs. cradle.


4. Perform flexible naso/laryngeal endoscopy

5. Direct laryngoscopy provides detail view of nasal passage (choanal atresia, adenoid hypertrophy, laryngomalecia, subglottic stenosis and vocal cord function.

6. Remove endosheath and maintainclean technique. 42

Task: Practice flexible endoscopy child/infant

Mercado 2013 ©

Mercado 2013 ©

Mercado 2013 ©

Mercado 2011 ©


2. Position patient


4. Perform rigid nasal endoscopy and sinus debridement.

5. Perform rigid nasal endoscopy and obtain culture.


43

Task: Practice rigid nasal endoscopy

Inferior Turbinate

Septum

Dr. Kevin Kavanaugh © www.entusa.com

Inferior Turbinate

Septum

Mannequin Patient

Patient

Mercado 2013 ©

Mercado 2013 ©

ENT for the PA‐C

Otology Workshop – BasicLearning objectives‐ Discuss normal, normal variant and abnormal otologic conditions‐ Demonstrate techniques for cerumen removal‐ Demonstrate techniques for foreign body removal from ear‐ Perform manual pneumatic otoscopy examination

Presented by: Jeff Fichera, PA‐C

44

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 45

Use largest size speculum that fits & place deep enough to clear the hair‐bearing

skin.

Modified semi‐reclined position

allows visualization of attic space.

Hold speculum between first & second finger to

retract the pinna up & backward in an

adult .

Visualize membrane and

identify landmarks.

Suction Curette Alligator Forceps

Warm Irrigation

Mercado 2011 © Mercado 2011 © Mercado 2011 © Mercado 2011 ©

Mercado 2011 © Mercado 2011 ©Mercado 2011 ©Mercado 2011 ©

Task: Removal cerumen impaction

1. Position Patient ‐Explain Procedure

2. Visualize Canal/Landmarks

3. Determine BEST Procedure ‐Remove Cerumen

4. Re‐Inspect Ear

46


2. Position patient

3. Foreign Bodies – eraser heads, beads, cotton tips, bugs, etc… removal requires direct visualization prior to removal either via warm irrigation or instruments like an alligator forceps, curette or suction.

4. Drown insects with mineral oil or lidocaine before attempting removal.

5. Use warm water as cold water may cause dizziness.

47

Task: Removal foreign body ear

Mercado 2011 ©

Mercado 2011 ©

Task: Distinguish OE from OM & AOM from SOMIndication: using OtoSim distinguish types of ear

disease.

48

1. Pull the ear upwards and backwards to straighten the canal before inserting otoscope.

2. Insert the otoscope to a point just beyond the protective hairs in the ear canal. Use the largest speculum that will fit comfortably.

3. Anchor otoscope ‐ hold the otoscope with your thumb and fingers so that your hand makes contact with the patient.

4. Insufflate with non‐dominant hand.

5. Observemovement of tympanic membrane.

Task: Manual Pneumatic OtoscopyIndication: Evaluate middle ear function.

Mercado 2011 ©

Mercado 2014 ©

49

ENT for the PA‐C

Otology Workshop – AdvancedLearning objectivesPractice removing cerumen impaction under microscopePractice myringotomyPractice ventilation tube insertionPractice intra‐tympanic membrane injection

Presented by: Ryan Marovich, PA‐C

50

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 51

Use largest size speculum that fits & place deep enough to clear the hair‐bearing

skin.

Reclined position allows visualization of attic

space with microscope.

Hold speculum between first & second finger to retract the pinna up & backward in an adult .

Visualize membrane and

identify landmarks.

Suction Curette Alligator Forceps

Task: Removal cerumen impaction under microscope

1. Position Patient/microscope ‐Explain Procedure

2. Visualize Canal/Landmarks

3. Determine BEST Procedure ‐Remove Cerumen

4. Re‐Inspect Ear

52

Mercado 2011 ©Mercado 2013 © Mercado 2011 ©

Mercado 2011 ©Mercado 2011 © Mercado 2011 © Mercado 2011 ©

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.

3. 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.

4. The incision should be slightly smaller than the

diameter of the tube’s inner flange.

5. Microsuction effusion with a 3, 5 or 7 French

Baron suction cannula.

6. A ventilation tube is introduced by holding the

posterior surface of the inner flange with small

alligator forceps.

7. If necessary, insertion is completed with a

curved or straight pick. Most tubes can be

inserted directly with small alligator forceps.

8. Residual effusion or blood is aspirated.

9. Otic antibiotic drops are instilled to reduce

bleeding and loosen any thickened secretions

that were not removed by suction 53

Task: Perform myringotomy & ventilation tube insertion

Mercado 2011 ©

Mercado 2011 ©

1. 1. Explain Procedure. Prepare supplies. Allow the dexamethasone to warm to room temperature (to avoid dizziness).

2. Position patient

3. Apply anesthetic

4. Make two small incisions ‐ ‐one for the injection and one for ventilation.

5. Inject the dexamethasone through the posterior incision.

• 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.

54

Task: Perform intratympanic injection

Mercado 2013 ©

ENT for the PA‐C

Vertigo Workshop Learning ObjectivesDiscuss and demonstrate vertigo examination;

Neurological examinationRhomberg TestFukada Stepping TestDix‐Hallpike

Demonstrate ENG/VNG.Demonstrate and practice canalith repositioning

Presented by: Mike Valdez, PA‐C

55

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________ 56

1. Obtain detailed history

2. Physical examination

a. Neurologicalexamination (CNII‐XII)

b. Rhomberg Test

c. Fukada Stepping Test

d. Dix‐Hallpike

52

Task: Perform Vertigo Physical Examination

57

Patient’s head is systematically rotated so that the loose particles slide out of the semicircular canal

and back into the utricle.

1. If vertigo affects RIGHT ear, the patient is brought to the head hanging position with right ear turned DOWNWARD.

2. Move the head to end of table, rotate head to the left with right ear turned UPWARD.

3. Hold for 30 seconds, then roll patient onto the left side while clinician rotates head LEFTWARD until the nose points down to floor.

4. Hold position for 30 seconds.

5. Then patients returns to sitting position with head facing left.

Task: Perform Canalith repositioning (Modified Eply Maneuver )

Mercado 2013©

Mercado 2013©

Mercado 2013©

Mercado 2013©

Mercado 2013© 58

59

ENT for the PA‐C

Videostroboscopy Workshop Learning ObjectivesRecognize the usage and care of videostroboscopy equipment.Discuss indications for videostroboscopy examination of the adult. Identify normal anatomy, normal variants and abnormal findings visible via videostroboscopyPractice performing and recording a videostroboscopy exam on a simulated adult patient.

Presented by: Jeffrey Lehman, MD

StroboscopyAuthor: Paul C Bryson, MD; Chief Editor: Arlen D Meyers, MD, MBAPublished:Medscape‐ Drugs, Diseases, & ProceduresUpdated: Jul 30, 2015

Overview

Over the past 3 decades, expanding knowledge of vocal fold anatomy and physiology has revolutionized the clinical and surgical practice of laryngology. Since Hirano's original description of the layered microstructure of the human vocal fold in the 1970s,[1] increasingly sophisticated diagnostic and surgical techniques have evolved to more precisely address and preserve vocal production. Innovative diagnostic modalities have grown out of an improved understanding of the critical importance of vocal‐fold pliability to voice production. Videostroboscopy has evolved as the most practical and useful technique for the clinical evaluation of the visco‐elastic properties of the phonatory mucosa.[2]

Video documentation of laryngeal anatomy along with its mechanical function is a painless, office‐based procedure done with topical anesthesia and is essential for state‐of‐the‐art management of human voice disorders. Videolaryngoscopy with stroboscopy is the essential diagnostic procedure for the evaluation of laryngeal mucosa, vocal fold motion biomechanics, and mucosal vibration.[3]

These are the key elements for detecting and assessing pathology as well as determining the impact on voice and airway function.

Stroboscopy is a special method used to visualize vocal fold vibration. It uses a synchronized, flashing light passed through a flexible or rigid telescope. The flashes of light from the stroboscope are synchronized to the vocal fold vibration at a slightly slower speed, allowing the examiner to observe vocal fold vibration during sound production in what appears to be slow motion.

This slow motion picture is an illusion, as the speed of actual vocal fold vibration is not changed by stroboscopy. This special viewing allows the voice care team to evaluate each vocal fold's vibration properties during the different phases of the vocal fold's vibration cycle. Because vocal fold vibration is so fast, the slow motion view is actually derived from many successive vibration cycles. The information acquired from the stroboscopic examination of the vocal folds is essential for planning effective phonomicrosurgery (endoscopic surgery to enhance vocal function). Optimal human voice production is dependent on optimal vocal fold vibration. This requires aerodynamically competent closure of vocal folds along with pliable phonatory mucosa.

Videostroboscopy fulfills several important requirements of a complete office voice examination. It provides useful, real‐time information concerning the nature of vibration, an image to detect vocal pathology, and a permanent video record of the examination. As important as any of these aspects, stroboscopy substantially improves the sensitivity of subtle laryngeal diagnoses over techniques with continuous nonstroboscopic light sources (eg, rigid or flexible transnasal laryngoscopy).

Relevant Anatomy

The vocal folds, also known as vocal cords, are located within the larynx (also colloquially known as the voice box) at the top of the trachea. They are open during inhalation and come together to close during swallowing and phonation. When closed, the vocal folds may vibrate and modulate the expelled airflow from the lungs to produce speech and singing.

60

Background and Surgical Principle

The concept of stroboscopy is not new. For several centuries, stroboscopic images generated by using a flashing light source have been used to create the illusion of motion for entertainment. From the early 19th century, several examples illustrate the creation of moving‐picture and optical toys, as well as scientific instruments. One device that used rotating disks to observe apparent motion, developed by a Viennese scientist named Stampfer, was called a stroboscope. This term is still used today to connote any pulsatile light‐generating device designed to observe motion.

The history of using a stroboscopic light source to examine the larynx is nearly as long as that of the continuous light source, dating back to the introduction of the laryngeal mirror by Manuel Garcia in 1855. In 1874, Oertel conceived laryngeal stroboscopy, but the feasibility of the device was not realized until 1895, after the introduction of electricity. His device was comprised of a perforated wheel that interrupted the light used to illuminate the vocal folds so that vocal fold vibration could be perceived. The application of the stroboscopic light source allowed the observer to view the vibrating vocal folds in arrested or apparent slow motion, permitting detailed observations of the structure in the open or closed positions. Because of the limitations in illumination, precise control of the flashing frequency, and image quality, members of the scientific community did not embrace this technique.

In the early to mid 1900s, nearly 100 years after Plateau first suggested the use of an intermittent spark to illuminate moving objects to produce a stationary pattern for the purpose of study, H.E. Edgerton and associates developed gas discharge tubes for stroboscopy. They used an oscillator to control the frequency of the discharge and the flashing rate. Many of the principles of modern stroboscopic devices evolved from this early instrumentation.

Pioneers of modern strobolaryngoscopy include Dr. J.W. van den Berg at the University of Groningen, Dr. Rolf Timke at the University of Hamburg, Dr. Hans von Leden at the University of California, and Dr. Elimar Schonharl in Erlanger, who wrote the first definitive book on stroboscopic examination of the larynx in 1960. With the subsequent improvements in audio‐ and video‐recording technology and with the ongoing advancements in optical image resolution and fiberopticlight‐source intensity, the modern videostroboscopic unit can now produce a crisp, brightly illuminated, magnified image.[4, 5]

The Talbot law takes into account the physical reality that images on the human retina linger for 0.2 seconds after exposure (persistence of vision). Therefore, sequential images produced at intervals less than 0.2 seconds produce the illusion of a continuous image. This understanding, along with the concept of correspondence (interpretation of a corresponding portion of sequential images representing an object in motion), allows for the illusion of motion when rapidly produced still images are presented. Finally, a characteristic of the visual system permits interpretation of a series of slightly altered still images by filling in the gaps between frames and completing the illusion of continuous motion.

61

Strobolaryngoscopy takes advantage of these principles by producing intermittent light flashes in close relation to the frequency of the vocal‐fold vibration. A microphone picks up the frequency of the examinee's sustained voice, which triggers the stroboscopic light source. With the provision that the vocal vibrations are periodic, a frequency of light flashes equal to the vocal frequency produces a clear, still image of the same portion of the vibratory cycle.

When the frequency of the flashes is slightly less than the vibration of the vocal fold, it causes a delay in the portion of each vibratory cycle illuminated, and the illusion of slow motion is obtained. However, in all healthy humans, vocal‐fold vibrations are aperiodic to a greater or lesser degree. Therefore, strobolaryngoscopy does not demonstrate fine detail of each individual vibratory cycle; rather, it shows a pattern averaged over many successive nonidentical cycles. In this sense, it is a less‐than‐perfect illustration of the true vibratory nature.

InstrumentationA videostroboscopic unit consists of a stroboscopic light source and microphone, a video camera, an endoscope, and a video recorder. Stroboscopy can be performed by using either rigid or flexible endoscopes; each has its own benefits and drawbacks.

Although flexible endoscopy is ideal for observing unaltered laryngeal behavior from various angles and for viewing the glottis through a narrow supraglottic aperture, it suffers from the low intensity of light carried through the long fiberoptic bundle to the tip of the narrow endoscope. With standard endoscopes, the light bouncing off objects being observed must then travel the length of the endoscope back to a camera or the operator's eye to be detected. The introduction of distal‐chip technology to flexible endoscopes, in which the camera is placed at the distal end of the scope, effectively lessened the drawback profile of flexible laryngoscopes. The enhanced digital picture quality with improved illumination has greatly improved the quality and resolution of transnasal laryngeal stroboscopy.

62

Clinical Application

• Several parameters may be evaluated during the course of the stroboscopic examination.[7]

• Fundamental frequency: The fundamental frequency is measured by using the strobe unit and is used to set the frequency of the light flashes. Strobe light is typically produced at a frequency several hertz slower than the vocal frequency to produce the illusion of a slow‐motion vibratory cycle. An identical frequency is emitted in the locked mode that produces a still image of a single portion of the vibratory cycle.

• Periodicity: Periodicity refers to the regularity of successive vocal vibratory cycles. Normal vibratory activity is regular and periodic.

• Amplitude: Amplitude refers to the lateral excursion of the vocal folds during their displacement away from the midline during oscillation. It is highly dependent on pitch frequency (vocal fold tension) and loudness (subglottal lung pressure). Amplitude is generally graded as normal, less than normal, or greater than normal.

• Symmetry: Normal motion (abduction and adduction) of the arytenoid cartilages is assessed during flexible or rigid telescopic laryngoscopy and vibratory characteristics of phonatorymucosa are assessed during stroboscopy.

• Glottic closure: In a healthy person, the musculomembranous portion of the vocal folds completely closes during the vibratory cycle. The posterior cartilaginous glottis may remain partially open (posterior glottic chink) in some healthy people. [2]

• Mucosal wave: Mucosal wave propagation reflects the rheological properties of phonatorymucosa (epithelium and superficial lamina propria) during a specific vocal task. Most hoarseness is due to diminished phonatory mucosal pliability from disease (acute and chronic), benign and malignant lesions, overuse, and general long‐term use (vocal aging). Focal abnormalities of mucosal wave help to localize pathology in the vocal fold and direct strategies to manage the deficit.

63

Technique

Rigid strobolaryngoscopy

See the list below:

1. Videostrobolaryngoscopy begins by seating the patient in the examination chair at a height comfortable for the examiner. The patient leans forward with the neck flexed and the head extended at the atlo‐occipital joint (Kirstein position).

2. Once in the appropriate position, it is often helpful to apply topical anesthesia (typically, Cetacaine spray) to the posterior aspect of the anterior tongue as well as the posterior oropharynx. The examiner should ensure that the microphone is calibrated properly and have the patient hold the laryngeal diaphragm against the thyroid lamina.

3. With mouth open and tongue protruded, the examiner retracts the tongue anteriorly and carefully inserts the rigid telescope. Optimal examination hinges on the examiner’s attention to achieving proper focus of the vocal folds. Proper focus demonstrates clear visualization of the subepithelial vasculature of the vocal fold. To avoid condensation on the scope, the tip of the telescope is dipped in hot water just prior to beginning the examination.

4. With the vocal folds in clear focus, the examiner can take the patient through a number of vocal tasks using the “ee” sound. This should be done at low, mid‐range, and high frequency pitches as well as different volumes. Soft glottal onset and offset (low subglottal pressure), especially in high‐pitch frequencies, may also be of use to help define some smaller lesions. The examiner is also able to comment on arytenoid and vocal fold mobility, glottic closure pattern, mucosal wave, and pliability. Ulcerative lesions or masses can also be observed.

Flexible strobolaryngoscopy

See the list below:

1. The patient is positioned as above. The nose and nasopharynx are typically anesthetized and decongested with a mixture of 0.25% phenylephrine and 2‐3% lidocaine using an atomizer.

2. After allowing adequate time for decongestion, the flexible scope is inserted through the nose and passed in to position above the larynx. The examination described above can then be performed.

64

Diagnostic Findings

By increasing the illumination and evaluation of vibratory patterns, videostroboscopy has vastly increased the sensitivity of laryngologic diagnoses. Despite the variations attributable to lesion size, concurrent vocal pathologies, and compensatory phonatory behaviors, generalizations can be made about stroboscopic findings accompanying specific true vocal‐fold pathology. The most common benign laryngeal lesions and their typical stroboscopic findings are described below.

Vocal fold cysts

Vocal fold cysts are encapsulated, spheroid lesions containing either mucus or keratin located in the superficial lamina propria of the vocal fold. Keratin cysts are likely congenital and mucous cysts are likely acquired. They are generally unilateral, though several may be present at the time of diagnosis. On stroboscopy, the region of the cyst demonstrates diminished pliability, since the mucosal wave does not propagate normally through the region of the cyst. The exact characteristics of the mucosal‐wave deficit depend on the size and location of the cyst. This is illustrated by the fact that small superior‐surface cysts minimally affect vocal function.

Vocal fold polyps

Vocal fold polyps may be unilateral or bilateral. These lesions represent phonotraumatic pathology due to collision forces and shearing stresses in the superficial lamina propria. They may be of any consistency, ranging from gelatinous to fibrotic. Glottic closure may be compromised, leaving gaps anterior and posterior to the lesion in maximal closure. The vibratory patterns of the 2 vocal folds are asymmetric, with diminution of vibration near the lesion. A medial‐surface polyp also typically disturbs the vibratory pattern of the contralateral vocal fold during closure.

Vocal fold nodules

Vocal fold nodules are bilateral fibrovascular lesions that are roughly symmetric sessile masses, approximately 2‐7 mm in size, that occur in the center of the musculomembranous region at the basement‐membrane zone between the overlying epithelium and the underlying superficial lamina propria. Glottic closure is compromised, especially in high pitch frequencies. Mucosal wave is usually preserved bilaterally, though the pliability and amplitude of excursion are decreased in the region of the nodule.

Sulcus vocalis

Sulcus vocalis refers to a spectrum of phonatory mucosal vibratory deficits in which the stroboscopic findings demonstrate zones of diminished mucosal pliability. This surface observation during stroboscopy reflects the diminished visco‐elastic properties of the superficial lamina propria in that region.

65

Future Applications

Although videostroboscopy greatly expands the diagnostic sensitivity of some aspects (phonatorymucosal wave vibration) of office‐based laryngoscopy, its interpretation depends on the skill and experience of the clinician performing the study (eg, requested vocal tasks), and, specifically, the skill and experience of the diagnostic interpreter. The quality of the images collected is directly related to the skill of the operator performing the procedure. In addition, research suggests that stroboscopic interpretation is a poorly generalizable research metric.[3] Even among the most experienced interpreters, inter‐rater correlations for judging specific parameters is moderate (kappa = 0.61‐0.81) at best. Although increased experience in reviewing stroboscopic results appears to have a modest positive effect on a clinician's intra‐rater reliability, it does not necessarily improve inter‐rater correlation in a group of similarly experienced examiners.

Several technologies have been developed to improve objective measurements of the amplitude of vibration and mucosal wave. Software was developed to measure the glottic‐area waveform (GAW), a plot of the glottic area against the time of opening and closing of the glottis during a representative vibratory cycle (taken from the stroboscopic image). From this information, glottal opening and closing rates are calculated. These measurements are purported to be correlates of vocal‐fold pliability and differ statistically in preoperative and postoperative states for benign vocal‐fold lesions.[8, 9]

An admitted limitation of the stroboscopic image is that vocal‐fold vibration must be relatively periodic to visualize a slow‐motion representation of the phonatory cycle. Efforts to extend the sensitivity of laryngoscopy to incorporate variations of wave characteristic across the glottis and in aperiodic patterns of vibration have yielded new techniques.[10]

The limitations that stroboscopy has in only being able to reveal a highly averaged composite view of vocal fold vibratory behavior during relatively periodic phonation is overcome by high speed imaging.[10] Systems for doing laryngeal high speed digital videoendoscopic recordings have been available for about a decade, but these have been limited, until recently, to black‐and‐white imaging at rates that were only adequate for relatively low‐pitched phonation (2000 images per second). Recent advances in digital high‐speed video (HSV) camera technology have resulted in clinical systems that can produce color images at higher rates (4000 images per second).

Even though HSV provides much more detailed information about vocal fold phonatory function than stroboscopy, its eventual adoption into standard clinical practice will depend on the extent to which remaining practical, technical, and methodological, challenges can be met. Such challenges include the relatively high cost of HSV systems, management of the large computer files that HSV recordings produce, limitations on the sampling of vocal behaviors obtained during the brief durations of HSV recordings, and a paucity of solid clinical research demonstrating that HSV significantly improves the diagnosis and management of voice disorders[11] (ie, controlled clinical trials).

66

References

1. Hirano M. Morphological structure of the vocal cord as a vibrator and its variations. Folia Phoniatr (Basel). 1974. 26(2):89‐94. [Medline].

2. Kendall KA. High‐speed laryngeal imaging compared with videostroboscopy in healthy subjects. Arch Otolaryngol Head Neck Surg. 2009 Mar. 135(3):274‐81. [Medline].

3. Rosen CA. Stroboscopy as a research instrument: development of a perceptual evaluation tool. Laryngoscope. 2005 Mar. 115(3):423‐8. [Medline].

4. Kluch W, Olszewski J. [Videolaryngostroboscopic examination of treatment effects in patients with chronic hyperthrophic larynges]. Otolaryngol Pol. 2008. 62(6):680‐5. [Medline].

5. Mortensen M, Woo P. High‐speed imaging used to detect vocal fold paresis: a case report. Ann Otol Rhinol Laryngol. 2008 Sep. 117(9):684‐7. [Medline].

6. Low C, Young P, Webb CJ, et al. A simple and reliable predictor for an adequate laryngeal view with rigid endoscopic laryngoscopy. Otolaryngol Head Neck Surg. 2005 Feb. 132(2):244‐6. [Medline].

7. Echternach M, Arndt S, Zander MF, Richter B. [Voice diagnostics in professional sopranos: application of the protocol of the European Laryngological Society (ELS)]. HNO. 2009 Mar. 57(3):266‐72. [Medline].

8. Hanschmann H, Berger R. [Quantification of videostroboscopic vocal cord findings]. Laryngorhinootologie. 2009 Jan. 88(1):6‐8. [Medline].

9. Noordzij JP, Woo P. Glottal area waveform analysis of benign vocal fold lesions before and after surgery. Ann Otol Rhinol Laryngol. 2000 May. 109(5):441‐6. [Medline].

10. Schutte HK, Svec JG, Sram F. First results of clinical application of videokymography. Laryngoscope. 1998 Aug. 108(8 Pt 1):1206‐10. [Medline].

11. Metson R, Rauch SD. Videolaryngoscopy in the office‐‐a critical evaluation. Otolaryngol Head Neck Surg. 1992 Jan. 106(1):56‐9. [Medline].

12. Ferlito A. Diseases of the larynx. New York: Oxford University Press; 2000.

13. Hirano M, Bless DM. Videostroboscopic examination of the larynx. San Diego, Calif: Singular; 1993.

14. Kirstein A. Autoskopie des larynx und der trachea (Laryngoscopia directa, Euthyskopie, Besichtigung ohne Spiegel). Archiv furlaryngologie und rhinologie. 1895. 3:156‐64.

15. Rosen CA, Murry T. Nomenclature of voice disorders and vocal pathology. Otolaryngol Clin North Am. 2000 Oct. 33(5):1035‐46. [Medline].

16. Shohet JA, Courey MS, Scott MA, Ossoff RH. Value of videostroboscopic parameters in differentiating true vocal fold cysts from polyps. Laryngoscope. 1996 Jan. 106(1 Pt 1):19‐26. [Medline].

17. Sung MW, Kim KH, Koh TY, et al. Videostrobokymography: a new method for the quantitative analysis of vocal fold vibration. Laryngoscope. 1999 Nov. 109(11):1859‐63. [Medline].

18. Yanagisawa E, Owens TW, Strothers G, Honda K. Videolaryngoscopy. A comparison of fiberscopicand telescopic documentation. Ann Otol Rhinol Laryngol. 1983 Sep‐Oct. 92(5 Pt 1):430‐6. [Medline].

67

Videostroboscopy Workshop:Score Card

68

Task Go No Go

Understand indications & contraindications to exam.

Properly explain procedure.

Apply topical anesthetic & decongestant.

Perform supervised videostroboscopy on simulated patient.

Identify normal anatomy.

Demonstrate proper equipment handling technique.

Comments

Proctor Name Proctor Signature

Notes___________________________________________

________________________________________________

________________________________________________

________________________________________________

Recommended Reading1. Otolaryngology , A Surgical Notebook Lee / Toh ISBN 9781588903044

2. Color Atlas of ENT Diagnosis, Bull ISBN 9783131293954

3. ENT‐Head and Neck Surgery: Essential Procedures, Theissing ISBN 9783131486219

4. Laryngeal Evaluation Indirect Laryngoscopy to High‐Speed Digital Imaging, Kendall ISBN 9781604062724

5. Differential Diagnosis in Otolaryngology Head and Neck Surgery, Stewart and SelesnickISBN 978‐1‐60406‐051‐5

6. Basic Otorhinolaryngology A Step‐by‐Step Learning Guide, Probst ISBN 9781588903372

7. The Audiogram Workbook, Hepfner ISBN 9780865777194

8. Imaging for Otolaryngologists, Dunnebier 9783131463319

9. Medicare Learning Network, https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNGenInfo/index.html?redirect=/MLNGeninfo

Please visit http://www.thieme.com/index.php?option=com_content&view=article&id=633&ca

tid=66&Itemid=90For special discounts.

Most workshops written by Jose C. Mercado, PA‐C, MMS, DFAAPA, Advanced Airway – Pediatric written by Dr. Catherine Hart, Videostroboscopy written by Dr. Ralph Iannuzzi and ENT

Coding written by Marie Gilbert, PA‐C, DFAAPA, CPMA.

54

ENT for the PA 2017 Workshops - entpa.org ENT for... · 2. Check equipment, ensure cuff functions....

Documents

Transcript of ENT for the PA 2017 Workshops - entpa.org ENT for... · 2. Check equipment, ensure cuff functions....