1. Otology Workshop; Advanced Ryan Marovich, MPAS, PA-C
March 31, 2016
Orlando, FL
Otology Workshop; Advanced
Ryan Marovich, MPAS, PA-C
J. Andrew Clark, PA-C
Updated 12/03/2015

2. Otology Workshop; Advanced
Clear Instruction
Live Demonstration
Hands-On Practice
Learn by doing
Removal of Cerumen
Ventilation Tube Insertion
Myringotomy
Intratympanic Injection
Perform Paper Patch Myringoplasty

3. 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.

4. Otology Workshop; Advanced
Learning Objectives
Practice removing cerumen impaction under microscope
Practice myringotomy
Practice ventilation tube insertion
Practice intra-tympanic membrane injection
Practice Paper Patch Myringoplasty

5. 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
Mercado 2013 ©
Mercado 2011 ©
Mercado 2011 ©
Reclined position allows visualization of attic space with microscope.
Use largest size speculum that fits & place deep enough to clear the hair-bearing skin.
Hold speculum between first & second finger to retract the pinna up & backward in an adult .
Mercado 2011 ©
Mercado 2011 ©
Mercado 2011 ©
Mercado 2011 ©
Visualize membrane and identify landmarks.
Suction
Curette
Alligator Forceps

6. Myringotomy & Tympanostomy Tube
Practice mannequins available have simulated tympanic membrane to practice removal of cerumen, myringotomy and ventilation tube insertion as well as intratympanic injection.

7. Myringotomy with Ventilation Tube Insertion

8. Discuss 2013 AAO-HNSF guidelines tympanostomy tube insertion children.
Indications Surgery
Discuss 2013 AAO-HNSF guidelines tympanostomy tube insertion children.

9. 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).

10. 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.

11. Negative/Positive Pressure Type “C”
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.

12. Titanium Ventilation Tubes
Types of Tubes
Shepard Grommet
Soileau Tytan®
Titanium Ventilation Tubes
Spoon Bobbins
Goode T-Tubes® 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.
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.

13. 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

14. 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.

15. Topical Anesthetic Phenol is in aqueous form of 20-25% solution
effect of the phenol anesthesia lasts about minutes
Also has bacteriostatic (0.2%), bacteriocidal (1.0%) and fungcidal (1.3%) properties.
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
1. Storrs LA. Topical Anesthesia for Myringotomy. Laryngoscope 1968:78:
2. Weisskopf A. Phenol Anaesthesia for Myringotomy. Laryngoscope 1993; 93:114
3. Plaza G, Herraiz C., De los Santos G. Myringotomy under topical anaesthesia with phenol. Acta Otorhinolaryngol Esp 2000 Aug-Sep;51(6):553-6
4. Schmidt S-H. Anaesthesia of the Tympanic Membrane. Arch Otolaryngol Head NeckSurg 1995, vol 121 Mar
- See more at:
. Hoffman, R. A. and Li, C.-L. J. (2001), Tetracaine Topical Anesthesia for Myringotomy. The Laryngoscope, 111: 1636–1638

16. Procedure
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

17. Myringotomy & Tympanostomy Tube
Myringotomy w/ ventilation tube placement BMT. Incision to drain fluid and tube insertion to maintain patency and ensure future drainage. Tubes last 6 to 24 months.
OK to swim in pool but not beach, avoid submerging head in bathwater.
Mercado 2011 ©
Mercado 2011 ©

18. Myringotomy & Tympanostomy Tube
Demonstration of myringotomy & tympanostomy tube procedure

19. Task: Perform myringotomy & ventilation tube insertion
An operating microscope with a 250-mm lens is brought into the field and focused on the external auditory meatus.
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.
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
Mercado 2011 ©
Mercado 2011 ©

20. 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:
Pribitkin EA, Handler SD, Tom LW, et al. Ventilation Tube Removal, Arch Otolaryngol Head Neck Surg. 1992; 118:

21. 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:
Force RW, Hart MC, Plummer SA, et al. Topical ciprofloxacin for Otorrhea after tympanostomy tube placement. Arch Otolaryngol Head Neck Surg. 1995; 121:

22. Intratympanic Injection

23. Intratympanic Injection

24. Intratympanic Injection
Gentamicin injection into the ear is presently the most common destructive procedure for vertigo (
Intratympanic (IT) methylprednisolone and oral prednisone are equally effective for treatment of idiopathic sudden sensorineural hearing loss. (

25. Intratympanic (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.
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.

26. Intratympanic Injection
Demonstration of intratympanic injection procedure

27. Paper Patch Myringoplasty
Small chronic perforations
Overall closure rate 62.8%, perforations < 5% 78.3%, >5% 45%.
Topical phenol or trichloroacetic acid is applied to the edges of the perforation with a wisp of cotton on an applicator.
A sharp pick is then used to freshen the margins of the tympanic membrane perforation to allow removal of the edges of the perforation.
This technique removes any squamous epithelium that may have migrated under the medial surface of the tympanic membrane at the edge of the perforation and stimulates bleeding and healing from the local vascular supply

28. Task: Perform intratympanic injection
1. Explain Procedure. Prepare supplies. Allow the dexamethasone to warm to room temperature (to avoid dizziness).
Position patient
Apply anesthetic
Make two small incisions - -one for the injection and one for ventilation.
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.
Mercado 2013 ©

29. Paper Patch Myringoplasty
The edge of the perforation is circumferentially freshened to remove epithelium from the medial margin and promote local bleeding.
The inset emphasizes that the medial edge of the perforation must be removed to eliminate squamous epithelium from the middle ear.

30. Paper Patch Myringoplasty
A cigarette paper patch, Steri-Strip, or silk patch is applied to the lateral surface of the tympanic membrane

31. Rotate through stations. Practice mannequins available to practice;
cerumen and ear foreign body removal technique.
myringotomy and ventilation tube insertion
Intratympanic injection
Paper Patch Myringoplasty

32. Otology Workshop; Advanced
Room Set Up
Station 1 Microscopes
Station 4 Microscopes
Screen
Station 1
Station 4
Station 2 Microscopes
Station 3 Microscopes
Projector
Speaker
Station 2
Station 3
Proctors

33. Otology Workshop-Advanced Evaluation
Score cards will be used for admission to workshops and attendance.
Credit will only be awarded for completed score cards.
Name
Session
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:

34. Otology Workshop-Advanced Score Card
Rotate and complete each station.
“Go/No Go” for internal use only.
Completion of workshop is NOT contingent on pass/fail.
Name
Session
Task Go
No Go
Removal of cerumen under microscope
Perform myringotomy
Insert ventilation tube
Perform intratympanic Injection
Perform Paper Patch Myringoplasty
Comments
Proctor Name
Proctor Signature