March 31, 2016 Orlando, FL

Otology – Basic workshop Jeffrey Fichera, PhD, PA-C Updated 12/03/2015 Workshop- Basic

Clear Live Hands-On Instruction Demonstration Practice

Learn by doing

Identify normal, normal variants and Remove cerumen abnormal otologic conditions Remove foreign body Perform manual 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 • Discuss normal, normal variant and abnormal otologic conditions. • Demonstrate techniques for cerumen removal. • Demonstrate techniques for foreign body removal from ear. • Perform manual pneumatic otoscopy examination

Common ear findings Anatomy of the Ear External Auditory Canal

Osteoma Exostosis

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

Stenosis EAC Mastoid cavity

Michael Hawke Library http://www.ghorayeb.com External Auditory Canal

AOE AOE

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

Fungal externa Fungal

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

Malignant Otitis Externa Granulation tissue

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

Pars flaccida Lateral process of malleus

Pars tensa

Promotory

Umbo

Light reflex

Middle Ear

Normal tympanic membrane Normal tympanic membrane

This healthy tympanic membrane is very The translucency of this tympanic membrane allows visualization translucent, which allows visualization of the of the underlying incus (1), eustachian tube orifice (2), and the long process of the incus (1) and the chorda tympani Round window niche (3). The anterior part of the tympanic annulus, the (2). The eustachian tube orifice (3) is seen Anterior sulcus (4), is often hidden from view during routine otoscopy. anteriorly. Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002

Normal tympanic membrane Normal tympanic membrane

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

Normal tympanic membrane Normal tympanic membrane

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

Acute Bullous Myringitis Granular Myringitis

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

Acute Acute otitis media

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

Acute otitis media Acute otomastoiditis

Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002 Progression of AOM Series of photographs of the right tympanic membrane of a 2 1/2-year- old child who experienced an episode of acute otitis media with resolution. Prior to the infection, the tympanic membrane appeared normal, although this patient had had several previous bouts of otitis media.

1. Normal baseline 2. Initial presentation 3. 12 hours after antibiotics 4. 2 days later 5. 3 days later 6. 6 days later 7. 20 days later

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

Serous otitis media Serous otitis media

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

Chronic serous otitis media Chronic serous otitis media

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

Otitis media with effusion and Otitis media with effusion overinflated retraction pocket. and myringoincudopexy

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

Otitis media with effusion and atelectasis Primary acquired .

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

Congenital cholesteatoma. Congenital cholesteatoma.

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

Tympanosclerosis Myringosclerosis

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

Ventilation tube Pressure equalization tube

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

Grommet “T” tube

Chole RA, Forsen JW, Color Atlas of Ear Disease, 2nd Edition, BC Decker, 2002 Traumatic Tympanic Membrane Perforation These right tympanic membrane perforations were caused by an accidental blow to the side of the head. One small perforation is seen just below the umbo and posterior to the light reflection. A larger perforation in the posterior part of the tympanic membrane exposes the round window niche.

1. Day one. 2. Day 14. 3. After 6 weeks.

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

Subtotal perforation Large perforation

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

Hemotympanum Barotrauma

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

Glomus tympanicum Glomus tympanicum

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

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: 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 – laceration – infection of the ear – – pain – dizziness – syncope

Freeman RB. Impacted cerumen: how to safely remove 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 Mercado 2011 © patient experiences Modified semi- during the microsuction, as is reclined often the case after position allows mastoidectomy. visualization of attic space. Mercado 2011 ©

Positioning

Positioning children on parent’s lap with legs and arms secured.

Head should be stabilized to minimize movement.

Mercado 2011 © Visualization

The speculum should be the largest size The speculum should be held with the that fits. It should be placed deep enough first and second fingers. Use the other to clear the hair-bearing skin but not fingers to retract the pinna up and deeper, as unnecessary pain may result. backward in an adult (retract the pinna up and downward in a child).

Mercado 2011 © Mercado 2011 © Visualization

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

Instruments

• Suction • Alligator Forceps • Ear Speculum • Bayonet Forceps • Blunt Hook • Loop Curette • Curved Forceps

Mercado 2011 © 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 and vertigo. Anchor hand on patient in case patient moves Mercado 2011 ©

Mitka M. Cerumen removal guidelines wax practical. JAMA. Oct 1 2008;300(13):1506. Technique

Mercado 2011 © Mercado 2011 © Mercado 2011 ©

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. 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

Mercado 2011 ©

[Best Evidence] Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan 21 2009;CD004326. 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 , 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. Task: Removal cerumen impaction 1. Position Patient -Explain Procedure 2. Visualize Canal/Landmarks

3. Determine BEST Procedure -Remove Cerumen

4. Re-Inspect Ear

Mercado 2011 © Mercado 2011 © Mercado 2011 © Mercado 2011 © Use largest size speculum that Hold speculum between Modified semi-reclined Visualize membrane and position allows fits & place deep enough to first & second finger to identify landmarks. visualization of attic space. clear the hair-bearing skin. retract the pinna up & backward in an adult .

Mercado 2011 © Mercado 2011 © Mercado 2011 © Mercado 2011 © Suction Curette Alligator Forceps Warm Irrigation Removal Foreign Bodies Ear Foreign Bodies

Mercado 2011 © 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, 2nd Edition, BC Decker, 2002 Removal Foreign Body (Ear)

Direct visualization Removal with Alligator Forceps

Mercado 2011 © Mercado 2011 © Task: Removal foreign body ear

1. Explain Procedure. Prepare supplies

2. Position patient

3. Foreign Bodies – eraser heads, beads, cotton tips, bugs, etc… removal requires direct visualization prior to removal either via warm irrigation or Mercado 2011 © instruments like an alligator forceps, curette or suction.

Mercado 2011 © 4. Drown insects with mineral oil or lidocaine before attempting removal.

5. Use warm water as cold water may cause dizziness.

Manual Pneumatic Otoscopy Manual Pneumatic Otoscopy

Pull the ear upwards and backwards to straighten the canal before inserting . 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.

Mercado 2011 © Mercado 2011 © Task: Manual Pneumatic Otoscopy Indication: Evaluate middle ear function.

1. Pull the ear upwards and backwards to straighten the canal before inserting otoscope.

2. Insert the otoscope to a point just beyond the protective hairs in the ear canal. Use the largest speculum that will fit comfortably.

Mercado 2011 © 3. Anchor otoscope - hold the otoscope with your thumb and fingers so that your hand makes contact with the patient.

4. Insufflate with non-dominant hand.

5. Observe movement of tympanic membrane. Mercado 2014 ©

Task: Distinguish OE from OM & AOM from SOM Indication: using OtoSim distinguish types of ear disease. Station 1 Otoscopy Station 4 Cerumen Removal FB Removal Screen

Station 1 Station 4

Station 2 Oto Sim x2

Projector Station 3 Speaker Cerumen Removal Station 2 Station 3 FB Removal

Proctors Otology Workshop-Basic Evaluation

Score cards will be used for admission to workshops and attendance. Credit will only be awarded for completed score cards.

Name Session 1 2 3 4 5 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: Otology Workshop-Basic 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 1 2 3 4 5 Task Go No Go Removal Ear FB Removal Cerumen Impaction Distinguish OE from OM Distinguish AOM from SOM Perform Manual Pneumatic Otoscopy

Comments

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