1. Otology Workshop; Advanced Ryan Marovich, MPAS, PA-C
April 26, 2018
Scottsdale AZ
Otology Workshop; Advanced
Ryan Marovich, MPAS, PA-C
J. Andrew Clark, PA-C
Updated 2018

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. Practice Mannequin(s)
Practice removal of cerumen and FB
Simulated tympanic membrane to practice
Intratympanic steroid injection
Myringotomy and ventilation tube insertion
Paper patch myringoplasty

6. Task: Removal cerumen 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

7. Myringotomy with Ventilation Tube Insertion

8. Myringotomy with Ventilation Tube Insertion
Most common ambulatory surgery performed on children in the US
667,000 < 15 y.o. (>20%)

9. AAO-HNSF Clinical Practice Guideline OME Executive Summary (Update)

10. AAO-HNSF Clinical Practice Guideline OME Executive Summary (Update) cont…

11. Otitis Media Normal Exam Acute Otitis Media (AOM)
Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002

12. Otitis Media Normal Exam Otitis Media with effusion (OME)
Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002

13. 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.

14. Operating Microscope

15. Topical Anesthetics 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 fungicidal (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. Instruments
Myringotomy Tray
Micro Ear Forceps
Fine pick (Rosen)

17. Types of Tubes Armstrong Donaldson Spoon Bobbin Shepard Grommet
Paparella
Triune
T-tube

18. Myringotomy & Tympanostomy Tube
Risks GA
PETTM/ME
Tube Sequelae
Otorrhea
Myringosclerosis
Atrophy
Retraction
Perforation (2%)
Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001; 124:

19. Procedure
An operating microscope with a mm focusing objective 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 or 5 French Baron suction cannula (smallest required)
A ventilation tube is introduced by holding the posterior surface of the inner flange with small alligator forceps.
Insertion can be completed with a curved or straight pick if needed.
Residual effusion or blood is aspirated and/or Otic antibiotic drops can be instilled to clear remaining secretions from middle ear or lumen of tube

20. 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 ©

21. Task: Perform myringotomy & ventilation tube insertion
An operating microscope with a mm focusing objective 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 or 5 French Baron suction cannula (smallest required)
A ventilation tube is introduced by holding the posterior surface of the inner flange with small alligator forceps.
Insertion can be completed with a curved or straight pick if needed.
Residual effusion or blood is aspirated.
Otic antibiotic drops can be instilled to clear secretions/blood that were not removed with suction
Mercado 2011 ©

22. Myringotomy & Tympanostomy Tube
Demonstration

23. Intratympanic Injection

24. Intratympanic Injection
Common Indications
Sudden Sensorineural Hearing Loss
Meniere’s Disease

25. Sudden Hearing Loss: Definition

26. AAO CLINICAL PRACTICE GUIDELINES 2012

27. Allow the dexamethasone to warm to room temperature (to avoid dizziness).
Make one small incision anterior/superior to allow ventilation.
Inject steroid through the posterior inferior quadrant (superficial) – avoid removal and reinsertion of needle if possible
Pt should remain in otologic position and attempt not to swallow
Intratympanic (IT) injections of steroid can be given through the ear drum via a small needle (i.e., 25G or spinal)
Allows for localized treatment when oral corticosteroids may be contraindicated or have proven ineffective
Can begin with a single IT injection of dexamethasone (16-24 mg/mL) or methylprednisolone (30 or 40 mg/mL)
Fresh solution preferable (preservative may burn)
May be repeated for incomplete recovery every 3-7 days for total of 3-4 sessions *

28. Task: Perform Intratympanic injection
Explain Procedure. Prepare supplies. Allow the dexamethasone to warm to room temperature (to limit caloric response).
Position patient
Apply anesthetic
Make ventilation incision- usually anterosuperior
5. Inject the steroid slowly once a very superficial myringotomy site has been established posteriorly with careful attention to avoid contact with the ossicular chain or any middle ear structure
Mercado 2013 ©

29. Intratympanic Injection
Demonstration of intratympanic injection procedure

30. Paper Patch Myringoplasty
Small chronic perforations
Overall closure rate 62.8%, perforations < 5% at 78.3%, >5% at 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

31. 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.

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

33. 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
SPAO Mannequins
Left ear only for procedures
Pictured on left
Pediatric mannequins
Both ears capable for procedures
Pictured on right

34. Otology: Advanced Door Microscopes draw 10 amps each. Door Proctors
Ballroom AB x72
24 learners per session
29 chairs, 2 6 or 8ft tables, AV setup
9 special 8ft tables will be provided by Zeiss to support microscopes
Door
Microscopes draw
10 amps each.
Otology: Advanced
Screen
MICROSCOPE 1
Door
MICROSCOPE 7
Projector
Speaker
MICROSCOPE 2
MICROSCOPE 3
MICROSCOPE 6
MICROSCOPE 8
MICROSCOPE 4
MICROSCOPE 5
MICROSCOPE 9
Proctors
DOOR
DOOR

35. You must complete your workshop cards and turn them in at the end of this session.
Score cards will be used for admission to workshops and attendance.
Credit will only be awarded for completed score cards.
Rotate and complete each station.
Completion of workshop is NOT contingent on pass/fail

36. Otology Workshop-Advanced Session Evaluation
Score cards will be used for admission to workshops and attendance.
Credit will only be awarded for completed score cards.
Name
Session
Scale: 1=NO or LOW, to 5=YES or most likely/most positive
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:
ATTENDEE NAME (print) ______________________________
ATTENDEE SIGNATURE:

37. 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
1. Removal of cerumen under microscope
2. Perform myringotomy
3. Insert ventilation tube
4. Perform intratympanic Injection
5. Perform Paper Patch Myringoplasty
Comments
Proctor Name
Proctor Signature