Basic Format Myringotomy & Tympanostomy Procedures Basic Format Myringotomy & Tympanostomy Ch 17 STST MAVCC Unit 7

ENT FACT QUIZ: AAO-NHS* Test your knowledge of common ear, nose and throat disorders and their treatment. Cotton swabs are a safe and easy way to clean wax from inside your ears. Fact or Fiction 2. Reading in a moving car can cause motion sickness (make you "car sick"). Fact or Fiction 3. Hay fever is not caused by hay and does not cause a fever. Fact or Fiction 4. Tonsils and adenoids filter bacteria out of what we swallow and breathe. Fact or Fiction 1. Fiction! Remember, never stick anything smaller than your elbow in your ear! When you insert cotton-tipped applicators or tissues in your ear, the wax is just pushed deeper into the ear canal. When wax begins to block your ears (and hearing), seek medical advice. Your doctor may remove the wax, or suggest special wax-softening ear drops. 2. Fact! Motion sickness relates to your sense of balance and equilibrium. Your sense of balance is maintained by a complex interaction of your inner ears, eyes, skin pressure receptors, muscle and joint sensory receptors, and the brain and spinal cord. Motion sickness can appear when the central nervous system receives conflicting messages from these four key bodily systems. When you read a book in a moving car, your inner ears and skin receptors detect the motion of travel, but your eyes see only the pages of your book. 3. Fact! "Hay fever" is a commonly used term for seasonal allergic rhinitis, which can produce such symptoms as runny nose, itchy eyes and throat, uncontrollable sneezing, and sometimes itching of the skin. Some people have an over-active immune system which identifies normally harmless particles, such as pollens or animal dander, as dangerous. This causes an excessive reaction that actually causes inflammation -- an allergy. The substances causing it are allergens. Fiction! Any filter that could strain out microscopic material would not allow the passage of any food particles and would make eating impossible. Tonsils and adenoids are strategically located near the entrance to the breathing passages where they catch incoming infections. They "sample" bacteria and viruses and can become infected themselves. It is thought that they then help form antibodies to those "germs" as a part of the body's immune system to resist and fight future infections. * American Academy of Otolaryngology-Head & Neck Surgery

ENT FACT QUIZ 5. A person can be trained or conditioned not to snore. Fact or Fiction 6. You can "toughen up" your ears by continued exposure to loud noise. Fact or Fiction 7. You should avoid speaking or singing when your voice is hoarse. Fact or Fiction You don't have to go swimming to get "swimmer's ear." Fact or Fiction Fiction! Unfortunately, you have no conscious control over snoring. More than 300 devices are registered in the U.S. Patent and Trademark Office as cures for snoring, including head straps, neck collars and mouth pieces. If these devices work, it is probably because they keep the snorer awake. Snoring is often a sign of obstructed breathing, and this obstruction can be serious. However, the majority of snorers can be helped through lifestyle changes and medical treatment. Contact an otolaryngologist-head and neck surgeon for a complete evaluation. If you think you have grown used to a loud noise, it has already damaged your ears. When noise is too loud, it begins to kill the sensitive nerve endings in your inner ear. Remember, there is no way to restore life to dead nerve endings; the damage is permanent. Consult an otolaryngologist for appropriate hearing protectors if you work in an excessively noisy environment, or use power tools, noisy yard equipment, or firearms. Fact! When your voice is injured or hoarse, you should "rest" your vocal folds, just as you would avoid walking on a sprained ankle. And remember, whispering (instead of speaking) does not rest your vocal folds. If you are hoarse longer than 2-3 weeks, or have a complete loss or severe change in voice lasting longer than a few days, consult an otolaryngologist. Prolonged hoarseness may be a sign of a serious health problem requring medical treatment. Whenever water gets into the ear-from swimming, showering, or hair washing-it can bring in bacterial or fungal particles. Usually, the water runs back out of your ear. But sometimes water is trapped in your ear canal, allowing bacteria and fungi to grow and infect the outer ear. You may have "swimmer's ear" (otitis externa) if you experience the following symptoms: your ear feels blocked and itches; your ear canal is swollen; your ear drains a runny, milky liquid; or your ear is very painful and tender to touch. If you experence these symptoms, or if your glands become swollen, see your doctor

Objectives Assess the anatomy, physiology, and pathophysiology of the myringotomy, tympanostomy. Analyze the diagnostic and surgical interventions for a patient undergoing a _______________. Plan the intraoperative course for a patient undergoing_____________. Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for_____________. Describe the care of the specimen Discuss the postoperative considerations for a patient undergoing _______________ .

Terms and Definitions Otitis Media Pressure Equilization Tubes (PE Tubes) Also called polyethylene ventilation tubes

Definition/Purpose of Procedure Incision into the tympanic membrane under direct vision to remove accumulated fluid—often to treat otitis media in the middle ear; PE tubes are frequently inserted through the tympanic membrane during this procedure

Relevant A & P External ear: 1. Pinna (auricle) 2. External auditory canal (meatus). Auricle is attached to head by muscles and ligaments. It consists of flexible cartilage covered with thick skin. The superior rim is called the helix. The earlobe is called lobule and lacks cartilage. The cartilaginous projection located anterior to the opening of the canal is called the tragus. The external auditory canal starts at the pinna and ends at the TM. It is about 2.5 cm in length and is S-Shaped. It passes thru the auditory meatus of the temporal bone. The canal is covered with epithelium, is lined with fine hairs, and there the ceruminous glands are, which secrete cerumen (wax). Tympanic Membrane (eardrum) : separates the outer and middle ear. It consists of an outer layer of epithelium, a central layer of fibrous connective tissue, and an inner mucous membrane lining. It is disk shaped, should be concave, and about 1 cm diameter. Normally pearly grey, shiny, translucent. It is in an oblique position. A branch of the facial nerve (the 7th cranial nerve) that carries taste impulses from the tongue passes along the inner surface of the TM. Landmarks of the TM: 1. annulus: the fibrous ring surrounding the TM 2. Par flaccida: small superior portion (less tense) because it lacks the central fibrous connective tissue 3. Umbo: point of maximum concavity where the malleous is attached

Relevant A & P When soundwaves reach the tympanic membrane they cause it to vibrate. The vibrations are then transferred to the tiny bones in the middle ear. The middle ear bones then transfer the vibrating signals to the inner ear. The tympanic membrane is made up of a thin connective tissue membrane covered by skin on the outside and mucosa on the internal surface. The eustachian tube is the tube that runs between the middle ear and pharynx and regulates the ear pressure around the ear drum. Eustachian tube patency refers to the degree to which the eustachian tube is open. The eustachian tube runs between the middle ear and pharynx (throat) and regulates the pressure around the ear drum. Ear infections are more common in children because their eustachian tubes are shorter, narrower, and more horizontal than in adults, making the movement of air and fluid difficult. Bacteria can become trapped when the tissue of the eustachian tube becomes swollen from colds or allergies. Bacteria trapped in the eustachian tube may produce an ear infection that pushes on the eardrum causing it to become red, swollen, and sore.

Pathophysiology Pathology of the Outer ear: The external auditory canal can be obstructed easily—esp with children. What are 2 common causes of obstruction? 1. Excess earwax 2. Foreign body. Pt complaints may include: loss of hearing, feeling of fullness, dizziness, tinnitus (ringing in the ear). Growths such such as soft tissue growths –polyps and bony growths (called exotoses) may also impair hearing. There may be infections and abcesses of the pinna and canal. What is otitis externa? Any general inflammation of the external auditory canal. One common example: swimmer’s ear (may be bacterial or fungal). Usually diagnosed with otoscope. Of the TM: Easily ruptured. Performation may be caused by either external trauma or excess pressure from within the middle ear. Pt C/O may include: pain, hearing loss, drainage, and dizziness. Defect confirmed with otoscope. Damage may be permanent or surgically repairable (M & T).

Pathophysiology Otitis media is an inflammation and/or infection of the middle ear. Acute otitis media (acute ear infection) occurs when there is bacterial or viral infection of the fluid of the middle ear, which causes production of fluid or pus. Chronic otitis media occurs when the eustachian tube becomes blocked repeatedly due to allergies, multiple infections, ear trauma, or swelling of the adenoids. Serous otitis media is the most commonly diagnosed bacterial isllness in children in the US and accounted for 14, 568 visits to see a physician in 2001. Hearing loss is the main concern when fluid is present in the middle ear. If left untreated, hearing loss could affect language development and IQ level. PIC above: Fungal Otitis Externa OtomycosisJungle Ear

Pathophysiology: Deafness Conduction-type Sensorineural Central deafness Mixed-type Functional Congenital Neonatal STST p. 589

Diagnostics Exams Preoperative Testing Otoscope Handheld lighted instrument for viewing the external auditory canal. A speculum is placed in the pt’s ear by placing gentle traction on the pinna to straighten the canal. Many conditions of the middle ear can be diagnosed by observing alterations in the color, position, and integrity of the TM. Indications : Acute Otitiis Media in the presence of an exudate that has not responded to antibiotic therapy. The only symptom may be conductive hearing loss. Effusion of fluids into the middle ear occurs because of negative pressure caused by blocked eustachian tubes. Serous otitis media which persists more than 8-12 weeks and accompanied by hearing loss also indicates the need for fluid removal by ventilating tubes. (Allrefer.com) Ear tube insertion may be recommended for the foillowing: Long-term (chronic) or recurrent (more than 3 in one year) ear infections Hearing loss in children Patients undergoing hyperbaric oxygen therapy Symptoms indicasting the need for tubes may include the following: Persistent ear pain Ear drainage Hearing loss (over a 3-month period) Recurrent trauma (barotrauma) from flying or deep sea diving

Surgical Intervention: Special Considerations Patient Factors Peds: may warm room, toy or other distraction Room Set-up ENT microscope positioned near head of OR table –ready to be move once pt anesthetized OR Table in reverse position to make room for microscope and sitting surgeon Set up on Mayo stand

Surgical Intervention: Anesthesia Method: Local, General inhalation for children (typical); can be performed under local in office for adults Equipment

Surgical Intervention: Positioning Position during procedure Supine with head turned (surgeon will do) Supplies and equipment Special considerations: high risk areas

Surgical Intervention: Skin Prep Method of hair removal Anatomic perimeters Solution options

Surgical Intervention: Draping/Incision Types of drapes 4 cloth drapes typically or fenestrated drape Order of draping Special considerations Clean procedure; use best clean technique State/Describe incision Tympanic membrane

Surgical Intervention: Supplies Specific Suture: N/A Medications on field (name & purpose) Antibiotic gtts (Cortisporin otic often used) Catheters & Drains Pressure equilization tubes specific to surgeon orders

Tympanostomy Tubes There are many types of drainage tubes available, but the most common is the “bobbin type.” Trade names: Shepard Grommet Why are there different types? There are over 50 different designs...varing in shape, color, and composition.  In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time.  (Longer duration is not always advantageous.) Metal tubes were fashionable some years ago, but probably have an increased complication rate (plugging, certain types of infections). Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

Surgical Intervention: Supplies General Mayo stand cover Suction tubing Gloves Fenestrated towel drape 4 x 4 gauze Disposable myringotomy knife Small basin w/water Pharaceuticals per orders

Surgical Intervention: Instruments General Specific Myringtomy Tray Farrier Ear Specula

Instrumentation Iris Scissors (Straight) Brown Applicator Buck ear curettes (straight and angled)

Instrumentation Adson bayonet forceps Sexton ear knife Frazier Ferguson suction tip Baron Suction tip

Instrumentation Alligator Forceps Top Left—used to insert PE Tubes

Surgical Intervention: Equipment General: Suction apparatus Specific: ENT Microscope with proper lens and ocular adjustment per surgeon specification Sterile microscope hand grips Sitting stool for surgeon

Surgical Intervention: Procedure Steps Patient is positioned with head turned so that affected head is up Patient is draped w/fenestrated drape or 4 towels (no prep) Surgeon places microscope to visualize, and inserts aural speculum in ear canal If wax accumulation, surgeon will remove w/curette * estimate size of ear canal and present appropriate size speculum * have gauze available to clean the wax off the curette Surgeon makes small curved incision in the posterior-inferior quadrant of the tympanic membrane with a sharp ear (myringotomy) knife * STSR careful to pass so that surgeon need not look away from operative site Be ready for suction; keep tube patent by suctioning water through it or using stylet (middle ear fluid is thick) *culture & sensitivity may be taken at this time from fluid If fluid or pus is present, it is suctioned using it is suctioned using a Frazier or Baron suction tip

Procedure Steps

Surgical Intervention: Procedure Steps Surgeon positions PE tube, which has been positioned on alligator ear forceps, into the incision (never with gloved hands due to powder) * STSR grasps PE tube in the jaws of alligator forceps and carefully pass to surgeon

PE Tube Inserted

Surgical Intervention: Procedure Steps Surgeon instills antibiotic drop, then packs with cotton ball * Have cotton and med ready (circulator may instill gtts as convenient from med bottle) Surgeon removes speculum Patient’s head is turned, and procedure is repeated on other ear (if required) * Be prepared to switch sides of OR table The procedure takes less than 30 minutes, and the anesthesia used is temporary and safe. The incision heals without sutures and usually the hole closes spontaneously.

Counts Initial: usually N/A—per facility policy First closing Final closing Sponges Sharps

Dressing, Casting, Immobilizers, Etc. Types & sizes Cotton ball Type of tape or method of securing

Specimen & Care Identified as N/A Handled: routine, etc.

Postoperative Care Destination Expected prognosis (Good) PACU: Parent available once initial report give and VS stable Outpatient Discharge—usually within an hour Expected prognosis (Good) Pt instructed to keep dry until PE tubes fall out or are removed and TM healed Hearing expected to return to normal Ear Tube Insertion: Expectations after Surgery Ear tube insertion relieves pain and restores hearing. The frequency and severity of middle ear infections is significantly reduced. If ear infections recur and the tubes are nonfunctional, the operation can be repeated and another set of ear tubes can be inserted. Ear Tube Insertion: Convalescence & Recovery Patients usually leave the hospital the same day. Swimming is prohibited unless special earplugs are worn. Use of a cap while under a shower is recommended for several days or weeks.

Postoperative Care Potential complications Failure to resolve the ear infections. Persistent perforation after the tube falls out of the eardrum. Chronic ear drainage. Need for further and more aggressive surgery such as tonsil, adenoid, sinus, or ear surgery. Hearing loss. Scarring of the eardrum.

Postoperative Care Surgical wound classification: II Need to keep the ear dry and to use ear plugs. Foreign body reaction to the tube itself - for example, an allergic reaction to the tube material (rare). Pt may require second procedure to remove retained tube Surgical wound classification: II

Resources www.Allrefer.com STST pp. 587-596, 601-612, 618-630 www.nucleusinc.com www.pedisurg.com Alexanders pp. 733-736 Fullers pp. 605, 608-609 Goldman p. 435