Otology WorkshopJeffrey Fichera, PhD, PA-C

Ashutosh Kacker, MD, FACS

April 26-28, 2013New York-Presbyterian Hospital/Weill Cornell

Medical Center

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.

CerumenRemoval of cerumen impaction options include;

– 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:

ComplicationsThough 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 – 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 semi-reclined. 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 semi-reclined

position allows visualization of

attic space.

Positioning

Positioning children on parent’s lap with legs and

arms secured.

Head should be stabilized to minimize movement.

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VisualizationThe 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.

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

• 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

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.

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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

[Best Evidence] Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan 21 2009;CD004326.

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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

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 1992Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002

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Removal Foreign Body (Ear)

Direct visualizationRemoval with Alligator

Forceps

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Manual Pneumatic Otoscopy

Manual Pneumatic OtoscopyPull 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. Mercado 2011 ©

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

Otitis media with effusion--fluid in the middle ear without signs or symptoms of ear infection. Note air bubble.

Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002

AAO and AAP recommend the use of tympanometry to confirm tympanic membrane mobility.

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.

Types of Tubes

Shepard Grommet Soileau Tytan® Titanium Ventilation Tubes Spoon Bobbins Goode T-Tubes®

Armstrong Beveled Grommets, Modified

Paparella-Type Vent TubesTriuneTubes

A

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 specula2 sizes of curettes1 myringotomy knife, sickle blade1 suction

Myringotomy BladesSpear BladeLance BladeUpcutting, 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

• A topical solution of 8% tetracaine base in 70% isopropyl alcohol. Five to 10 drops of the solution applied to the tympanic membrane for 10 to 15 minutes and aspirated.

• Lidocaine

• Phenol is in aqueous form of 20-25% solution

• effect of the phenol anesthesia lasts about 15-20 minutes

• Also has bacteriostatic (0.2%), bacteriocidal (1.0%) and fungcidal (1.3%) properties.

1. http://archive.ispub.com/journal/the-internet-journal-of-otorhinolaryngology/volume-4-number-2/use-of-phenol-in-anaesthetizing-the-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

1. 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.

2. The incision should be slightly smaller than the diameter of the tube’s inner flange.

3. Microsuction effusion with a 3, 5 or 7 French Baron suction cannula.

4. A ventilation tube is introduced by holding the posterior surface of the inner flange with small alligator forceps.

5. If necessary, insertion is completed with a curved or straight pick. Most tubes can be inserted directly with small alligator forceps.

6. Residual effusion or blood is aspirated.

7. Otic antibiotic drops are instilled to reduce bleeding and loosen any thickened secretions that were not removed by suction

Myringotomy & Tympanostomy Tube

Myringotomy 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: 328-329Pribitkin 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 AntibioticsAsymptomatic = 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: 16-17Hannley 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://american-hearing.org/disorders/destructive-treatments-of-vertigo/)

• 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.html

• 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.

• 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.

http://www.dizziness-and-balance.com/treatment/it-steroids.htm