1. Otology Workshop Jeffrey Fichera, PhD, PA-C Ashutosh Kacker, MD, FACS April 26-28, 2013 New York-Presbyterian Hospital/Weill Cornell Medical Center

2. Otology Workshop Basic instruction Clear demonstration Hands-on doing! Removal of CerumenRemoval of Foreign Bodies Manual OtoscopyMyringotomy Ventilation Tube InsertionIntratympanic Injection

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 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

5. Removal of Cerumen

6. 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.

7. Cerumen Removal 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:

8. Complications Though 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.

9. 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. Mercado 2011 © Modified semi- reclined position allows visualization of attic space.

10. Positioning Positioning children on parent’s lap with legs and arms secured. Head should be stabilized to minimize movement. Mercado 2011 ©

11. Visualization The 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). Mercado 2011 ©

12. Visualization Inspect the ear canal and middle ear structures locating landmarks and noting any redness, drainage, or deformity. Visualize membrane and identify landmarks. Mercado 2011 ©

13. Instruments Suction Alligator Forceps Ear Speculum Bayonet Forceps Blunt Hook Loop Currette Curved Forceps Mercado 2011 ©

14. 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. Mercado 2011 ©

15. 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. Mercado 2011 ©

16. 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. Mercado 2011 ©

17. 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.

18. 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.

19. Removal Foreign Bodies Ear

20. 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 1992 Chole RA, Forsen JW, Color Atlas of Ear Disease, 2 nd Edition, BC Decker, 2002 Mercado 2011 ©

21. Removal Foreign Body (Ear) Direct visualization Removal with Alligator Forceps Mercado 2011 ©

22. Manual Pneumatic Otoscopy

23. Pull 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 ©

24. Manual Pneumatic Otoscopy Practice mannequins available to practice manual pneumatic otoscopy technique. Mercado 2011 ©

25. Myringotomy with Ventilation Tube Insertion

26. 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).

27. 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

28. 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.

29. Types of Tubes Shepard Grommet Soileau Tytan® Titanium Ventilation Tubes Spoon Bobbins Goode T-Tubes® Armstrong Beveled Grommets, Modified Paparella-Type Vent Tubes TriuneTubes 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.

30. 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

31. 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.

32. 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.dpufhttp://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

33. 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

34. Myringotomy & Tympanostomy Tube Myringotomy Tympanostomy Tube Mercado 2011 ©

35. 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: 328-329 Pribitkin EA, Handler SD, Tom LW, et al. Ventilation Tube Removal, Arch Otolaryngol Head Neck Surg. 1992; 118: 495-497

36. 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;122:934-940 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

37. Intratympanic Injection

38. http://www.dana.org/news/cerebrum/detail.aspx?id=758

39. 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.ht ml

40. 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