ENT for the PA-C 2014 Workshops

Co Sponsored by

ENT for the PA-C 2016 Workshops

March 30, 2016 Orlando, Florida

Stacey Ishman, MD, MPH Program Co-Director (AAOA-HNSF)

Marie Gilbert, PA-C, DFAAPA Program Co Director (SPAO-HNS)

Jose C. Mercado, PA-C, MMS, DFAAPA Workshop Director (SPAO-HNS) Introduction

There are multiple methods and techniques available to successfully complete all the topics presented in these workshops. Some are based on patient request, available equipment or supervising physician’s preference.

The goal of these workshop is to correctly demonstrate the most common methods and give participants time for hands on training.

Workshop topics have been selected based on relevancy, practice need and audience requests from over seven years of lecture series. This entire program has been reviewed and is approved for a maximum of 28 earnable hours of AAPA clinical Category I CME credit by the Physician Assistant Review Panel. The activity was planned in accordance with AAPA’s CME Standards for Live Programs and for Commercial Support of Live Programs.

Table of Contents Workshop Schedule…………………………………………… 1

Airway Workshop –Advanced……………………………. 3

Audiology workshop………………………………………….. 11

ENT Procedures Workshop………………………………… 12

Flexible Fiberoptic Workshop –Basic…………………. 20

Flexible Fiberoptic Workshop – Advanced…………. 25

Otology Workshop – Basic…………………………………. 31

Otology Workshop – Advanced…………………………. 37

Vertigo Workshop……………………………………………… 42

Recommended Reading…………………………………….. 46

Workshop Schedule Time Workshop Instructor Proctors 7:30 a.m. -9:30 a.m. Advanced Otology Ryan Marovich Carol Seago Andrew Clark Colby Crawford Basic Flex Scope Cheryl Pernell Carrlene Donald Deb Munsell Trina Sheedy Catherine Hart Brigitte Narvarte Vertigo Mike Valdez Jennifer Brooks Audiologist 10:00 a.m. to 12:00 p.m. Audiology Robinson Cummings Basic Flex Scope Cheryl Pernell Carrlene Donald Deb Munsell Trina Sheedy Catherine Hart Brigitte Narvarte Basic Otology Jeff Fichera Kelly Richards Bibi Farida Hussain Kathy Shelly Amy Myer Advanced Otology Ryan Marovich Carol Seago Andrew Clark Colby Crawford Advanced Flex Scope Marti Felder Amanda Lawrence Kim Lakhan Marie Gilbert Stacey Ishman Linda Smith ENT Procedures Jose Mercado Jason Fowler Nabiliah Ali Erin Reynolds Kevin Prater Vertigo Mike Valdez Jennifer Brooks Audiologist 1:00 p.m. – 3:00 p.m. Audiology Robinson Cummings Basic Flex Scope Cheryl Pernell Deb Munsell Trina Sheedy Brigitte Narvarte Amy Myer Linda Smith Basic Otology Jeff Fichera Kelly Richards Bibi Farida Hussain Advanced Otology Ryan Marovich Carol Seago Andrew Clark Colby Crawford Advanced Flex Scope Marti Felder Amanda Lawrence Kim Lakhan Kathy Shelly Marie Gilbert Stacey Ishman ENT Procedures Jose Mercado Jason Fowler Nabiliah Ali Erin Reynolds Carrlene Donald Kevin Prater Vertigo Mike Valdez Jennifer Brooks Audiologist

1 3:30 p.m. – 5:30 p.m. Audiology Robinson Cummings Basic Flex Scope Cheryl Pernell Deb Munsell Trina Sheedy Brigitte Narvarte Jennifer Brooks Linda Smith Advanced Otology Ryan Marovich Carol Seago Andrew Clark Colby Crawford Advanced Flex Scope Marti Felder Amanda Lawrence Mike Valdez Marie Gilbert Kathy Shelly Amy Myer ENT Procedures Jason Fowler Jeff Fichera Carrlene Donald Kevin Prater Nabiliah Ali Stacey Ishman Advanced Airway Jose Mercado Kim Lakhan Erin Reynolds Nabiliah Ali Catherine Hart 6:00 p.m. – 8:00 p.m. Advanced Scopes Marti Felder Amanda Lawrence Susan Kepes Linda Smith Brigitte Narvarte ENT Procedures Jason Fowler Ryan Marovich Andrew Clark Jeff Fichera Kevin Prater Advanced Airway Jose Mercado Kim Lakhan Erin Reynolds Kathy Shelly Nabiliah Ali

2 ENT for the PA-C

Presented by: Jose Mercado, PA-C

Airway workshop – Advanced Learning objectives Discuss and practice tracheostomy care techniques. Discuss and practice management for tracheostomy airway obstruction. Discuss and practice management for tracheostomy airway leaks. Discuss and practice management for tracheostomy bleeding. Discuss indications for and practice cricothyrotomy

3 Notes______

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Airway Scenarios Attendees will rotate through 4 simulated scenarios where they will be given a patient and asked to perform corrective measures. • Scenario 1: 47 year old male with respiratory failure status post tracheostomy 8 days ago. Having increased difficulty breathing. • Scenario 2: 66 year old female with respiratory failure, ventilator dependant has developed a leak. • Scenario 3: 59 year male with SCCA, left tongue, status post tracheostomy accidentally decanulated during patient transport. • Scenario 4: 44 year old male in acute respiratory distress in ER unable to intubate.

5 Task: Resolve Blocked Tracheostomy Indications: Blocked or leaking tracheostomy tube, poor saturation, etc 1. Explain Procedure. Monitor oxygen saturation.

2. Check equipment, ensure cuff functions.

Mercado 2013 © 3. Position the patient supine with a shoulder roll to hyperextend the neck and bring tracheal orifice closer to surface.

4. Provide supplemental oxygen prior to Mercado 2013 © procedure.

5. Check inner cannula – most common cause of obstruction – mucous plug. Mercado 2013 © A. Rinse - inner cannula with warm saline. B. Suction -use saline bullets and suction. 6. Visualize distal end tracheostomy tube Mercado 2013 © with flexible fiberoptic endoscope checking for granulation tissue. Pearl - If unable to clear obstruction may need to change trachoestomy tube. Mercado 2013 © 6 Task: Resolve Leaking Tracheostomy Indications: Leaking tracheostomy tube, poor saturation, etc

1. Explain Procedure. Monitor oxygen saturation.

2. Check cuff pressure. •Defective cuff – ensure cuff has enough air and is working.

Mercado 2013 © 3. If cuff is working and still have leak consider •Tracheomalacia. •Fistula

4. Visualize distal end tracheostomy Mercado 2013 © tube with flexible fiberoptic endoscope checking for granulation tissue, etc.

5. Change tracheostomy tube (regular to extra long tracheostomy tube or Mercado 2013 © vice versa).

7 Task: Change Tracheostomy

Indications: for tracheostomy change include minimizing risk of postoperative infection and granulation tissue formation, verifying formation of a stable tract for ancillary support staff, and downsizing the tracheostomy tube if the patient is clinically improving. Contraindications: Changing a tracheostomy tube too soon after operation (generally < 5 days) before tract has healed adequately, increases the likelihood of entry into a false passage. Performer inexperience and unavailability of staff versed in airway management. Extremely high ventilator settings, which increases the risk of decannulation. Patient noncooperation without ancillary support. Complications: Although tracheostomy tube changes are routinely performed, the procedure is not without complications. Minimize complications by understanding and practicing procedure as well as anticipating potential problems. In addition to oxygen, pulse oximeter and suction, have basic emergency equipment at bedside, such as a manual ventilator bag, 2 extra tracheostomy tubes (same size as the trach and one smaller) and an endotracheal tube with stylet. 8

Task: Change Tracheostomy

1. Explain Procedure. Monitor oxygen saturation.

2. Check equipment, ensure cuff functions.

3. Position the patient supine with a shoulder roll to hyperextend the neck and bring tracheal Mercado 2013 © orifice closer to surface.

4. Provide supplemental oxygen prior to procedure.

Mercado 2013 © 5. Deflate cuff, suction and release ties. Ensure tracheostomy is stabilized.

6. Remove tracheostomy as patient coughs.

Mercado 2013 ©

7. Insert new tracheostomy with obturator within lumen. (Rotate 90º from its correct position, to engage the stoma. Then turn the obturator back 90º to its correct position.) Mercado 2013 ©

8. Remove obturator and replace with inner cannula. Inflate cuff if needed and secure tracheostomy. Mercado 2013 ©

9 Task: Perform Cricothyrotomy Indications: Temporary emergency airway when tracheal intubation, face mask or laryngeal mask is not possible or unsuccessful.

1. Explain Procedure. Locate landmarks Mercado 2013 ©

2. Make 1 inch vertical incision.

Mercado 2013 ©

3. Introduce catheter at 45° angle and aspirate bubbles to verify

location. Mercado 2013 ©

4. Insert flexible guide wire

(Seldinger Technique). Mercado 2013 ©

5. Anchor guide wire and remove catheter. Mercado 2013 © 6. Insert cricothyrotomy catheter.

10 Mercado 2013 © ENT for the PA-C

Presented by: Robinson Cummings, AuD, PA-C

Audiology - Recognize methodology of audiometric evaluation - Recognize methodology of testing otoacoustic emissions (OAE) - Perform audiometry, tympanometry and OAE testing on a simulated patient

11 ENT for the PA-C

Presented by: Jose Mercado, PA-C and Jason Fowler, PA-C

ENT Procedures Workshop Learning Objectives Discuss indications for and practice removal nasal foreign body. Discuss indications for and practice control anterior epistaxis. Discuss indications for and practice control posterior epistaxis. Discuss indications for and practice fine needle aspiration. Discuss indications for and practice peritonsillar abscess drainage. Discuss indications for drainage auricular hematoma and practice splinting. 12 Notes______

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Task: Removal Foreign Body Nose Indications: Unilateral purulent nasal discharge

1. Explain Procedure. Apply topical anesthetic & decongestant BILATERALLY.

Mercado 2013 © 2. Good visualization with use of bright headlight & nasal speculum.

Mercado 2013 ©

3. Alligator forceps should be used to remove cloth, cotton, or paper. Other hard FB are more easily grasped using bayonet forceps, Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin Mercado 2011 © hook, or right angle ear hook

4. Perform flexible fiberoptic endoscopy to check for infection, bleeding and additional foreign bodies. Mercado 2013 © 14 Task: Control Anterior Epistaxis Indications: Anterior persistent nosebleed in office 1. Apply direct manual pressure for at least 10 minutes.

2. Spray or apply topical anesthetic with decongestant. Reapply direct manual pressure an additional 10 minutes Mercado 2011 ©

3. Once bleeding has subsided, identify site of nosebleed

4. Control bleeding with silver nitrate cauterization. (start from outside in) Mercado 2011 ©

5. Lubricate naris with Vaseline or Neosporin ointment. Keep cotton in nares for at least 1 hour to prevent staining

Mercado 2011 © 6. Let sit for 10-15 minutes to ensure hemostasis is achieved.

• Avoid sneezing, forceful nose blowing, nose picking, etc. • Follow up 2 weeks as re-cauterization may be necessary. Mercado 2011 © 15 Task: Control Epistaxis Indications: Persistent anterior or posterior nosebleed despite cauterization 1. Thoroughly soak in sterile water for 30 seconds.

2. Insert nasal pack into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril. 3. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.

4. Inflate second balloon with air. 5. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics!

6. To remove packing, deflate balloons 48- 72 hours later. 16 Task: Fine Needle Aspiration Indications: Obtain histopathologic diagnosis of suspected neoplasms 1. Explain Procedure. Prepare supplies

Mercado 2011 © 2. Palpate and identify mass or lesion.

3. Clean topically with alcohol. Mercado 2011 ©

4. Stabilize the mass with non- dominant hand. Insert needle through the skin with a quick motion. Mercado 2011 ©

5. Transfer specimen to slides and either fix or immediately submerge in alcohol. Mercado 2011 ©

17 Task: Drainage Peritonsillar Abscess Indications: Drainage peritonsillar abscess >1cm.

1. Explain Procedure. Prepare supplies and locate landmarks

Mercado 2011 © 2. Apply topical anesthetic, inject local anesthetic.

Mercado 2011 © 3. Insert large bore needle with guard (optional) over area of greatest fluctuance (imaging).

4. Aspirate pus (release pressure when with drawing).

Mercado 2011 © 5. Perform incision at the point of maximum protrusion, usually between the uvula and the second upper molar tooth. 6. Perform blunt dissection with curved hemostat.

Mercado 2011 © Treat with PCN based antibiotics and oral steroids. 18 Johnson RF, Stewart MG, Wright CG. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128(3):332–343 Task: Drain Auricular Hematoma Indications: Drainage hematoma within 5-10 days to prevent irreversible cartilage thickening. 1. Explain Procedure. Prepare supplies

2. Prepare 1/16inch thick Aquaplast by Mercado 2013 © making pattern on OPPOSITE ear.

3. Inject anesthesia (ring block). Mercado 2013 ©

4. Drain hematoma.

5. Immerse Aquaplast in hot water (160°F)

until it becomes transparent. Then mold Mercado 2013 © over site.

6. Prepare non-adherent gauze pad or Mercado 2013 © petroleum gauze the shape of the Mercado 2013 © Aquaplast so they project 1-2 mm BEYOND margins

7. After placement of gauze pads between Mercado 2013 © the splints and the skin surface secure with two or three through and through 0 silk on a straight needle to snuggly compress splint dressing to hematoma in sandwich fashion. Mercado 2013 © Mercado 2013 © 19 ENT for the PA-C

Presented by: Cheryl Pernell, PA-C

Flexible Fiberoptic Workshop – Basic Learning objectives Discuss normal anatomy visible via flexible fiberoptic nasopharyngoscopy Practice the use of the flexible fiberoptic nasopharyngoscope on mannequins. Practice the use of the flexible fiberoptic nasopharyngoscope on simulated patient Understand and practice proper endoscope use and care. Normal variants and abnormal findings will be discussed in Advanced Course.

20 Notes______

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Task: Practice indirect laryngoscopy Indications: Asses vocal cords on mannequin and simulated patient.

1. Explain Procedure. Prepare supplies

2. Position patient 3. Apply topical anesthetic soft palate. Mercado 2013 © 4. Stabilize tongue with non-dominant hand.

5. Place warm dental mirror in the back of the throat and angle it down towards the larynx. Light can be reflected downward and the larynx can be seen in the mirror.

6. Indirect laryngoscopy can be quick and gives a good three dimensional view of the larynx in true color.

Mirror Laryngoscopy, image is inverted. 22 Task: Practice flexible endoscopy

Indications: Flexible endoscopy is done when there may be a condition or disease in the nose, sinuses or throat that is not adequately visualized on routine examination.

Indications History (one or more required) 1. Persistent hoarseness. 2. Suspected neoplasm of upper aerodigestive tract. 3. Chronic cough. 4. Chronic postnasal drainage. 5. Recurrent epistaxis. 6. Chronic rhinorrhea. 7. Chronic nasal congestion or obstruction. 8. Hemoptysis. 9. Hemorrhage from throat. 10. Throat pain. 11. Otalgia. 12. Airway obstruction. 13. Dyspnea. 14. Stridor. 15. Dysphagia 16. Head or neck masses—unknown primary tumor. 17. Laryngeal injury—with hoarseness or airway obstruction. 18. Chronic aspiration. 19. Velopharyngeal incompetence. 20. Suspected foreign body. 21. Unilateral middle ear effusion. 22. Obstructive sleep apnea or severe snoring. 23. Preoperative assessment of vocal cord function, eg, prior to thyroid surgery

http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy-CI_May-2012.pdf

23 Task: Practice flexible endoscopy

1. Explain Procedure. Prepare supplies.

2. Position patient.

3. Apply topical anesthetic & decongestant nose.

Mercado 2011 ©

4. Perform flexible naso/laryngeal endoscopy.

Mercado 2011 © 5. Direct laryngoscopy provides detail view of nasal passage and vocal cord function.

Mercado 2011 © Mercado 2011 ©

6. Remove endosheath and maintain clean technique.

Fiberoptic Laryngoscopy, image is true. Mercado 2011 © 24 ENT for the PA-C

Presented by: Marti Felder , PA-C

Flexible Fiberoptic Workshop – Advanced Learning objectives Identify normal anatomy, normal variants and abnormal findings visible via flexible fiberoptic nasopharyngoscopy. Understand indications and perform flexible and rigid scope examination adult. Understand indications and perform flexible scope examination child/infant. Perform intranasal culture and sinus debridement using rigid scope adult.

25 Notes______

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Task: Practice flexible endoscopy

Indications: Flexible endoscopy is done when there may be a condition or disease in the nose, sinuses or throat that is not adequately visualized on routine examination.

http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy-CI_May-2012.pdf

27 Task: Practice flexible endoscopy

1. Explain Procedure. Prepare supplies

2. Position patient

3. Apply topical anesthetic & decongestant nose.

Mercado 2011 ©

4. Perform flexible naso/laryngeal endoscopy

Mercado 2011 © 5. Direct laryngoscopy provides detail view of nasal passage and vocal cord function.

Mercado 2011 © Mercado 2011 ©

6. Remove endosheath and maintain clean technique.

Fiberoptic Laryngoscopy, image is true. Mercado 2011 © 28 Task: Practice flexible endoscopy child/infant

1. Explain Procedure. Prepare supplies.

2. Position patient papoose vs. cradle.

Mercado 2011 © 3. Apply topical anesthetic & decongestant nose.

Mercado 2013 © 4. Perform flexible naso/laryngeal endoscopy

Mercado 2013 © 5. Direct laryngoscopy provides detail view of nasal passage (choanal atresia, adenoid hypertrophy, laryngomalecia, subglottic stenosis

and vocal cord function. Mercado 2013 ©

6. Remove endosheath and maintain clean technique. 29 Task: Practice rigid nasal endoscopy

1. Explain Procedure. Prepare supplies

2. Position patient

3. Apply topical anesthetic & Mercado 2013 © decongestant nose.

4. Perform rigid nasal endoscopy and sinus debridement. Mercado 2013 ©

Patient

5. Perform rigid nasal endoscopy

and obtain culture. Dr. Kevin Kavanaugh © www.entusa.com

Mannequin Patient Septum Septum

6. Remove endosheath and maintain clean technique. Inferior Inferior Turbinate Turbinate

30 ENT for the PA-C

Presented by: Jeff Fichera, PA-C

Otology Workshop – Basic 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

31 Notes______

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Task: Removal cerumen impaction

1. Position Patient -Explain Procedure

2. Visualize Canal/Landmarks

3. Determine BEST Procedure -Remove Cerumen

4. Re-Inspect Ear

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

Suction Curette Alligator Warm Forceps Irrigation 33 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 Mercado 2011 © visualization prior to removal either via warm irrigation or instruments like an alligator forceps, curette or suction.

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

34 Task: Distinguish OE from OM & AOM from SOM Indication: using OtoSim distinguish types of ear disease.

35 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.

3. Anchor otoscope - hold the otoscope with your thumb and

4. Insufflate with non-dominant hand.

5. Observe movement of tympanic membrane.

Mercado 2014 ©

36 ENT for the PA-C

Presented by: Ryan Marovich, PA-C and Andrew Clark, PA-C

Otology Workshop – Advanced Learning objectives Practice removing cerumen impaction under microscope Practice myringotomy Practice ventilation tube insertion Practice intra-tympanic membrane injection

37 Notes______

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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

Reclined position allows Use largest size Hold speculum between visualization of attic speculum that fits & first & second finger to space with microscope. place deep enough to retract the pinna up & clear the hair-bearing backward in an adult . skin.

Visualize Suction Curette Alligator Forceps membrane and 39 identify landmarks. Task: Perform myringotomy & ventilation tube insertion

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. 3. 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. 4. The incision should be slightly smaller than the diameter of the tube’s inner flange. 5. Microsuction effusion with a 3, 5 or 7 French Baron suction cannula.

6. A ventilation tube is introduced by holding the posterior surface of the inner flange with small alligator forceps.

7. If necessary, insertion is completed with a Mercado 2011 © curved or straight pick. Most tubes can be inserted directly with small alligator forceps.

8. Residual effusion or blood is aspirated.

9. Otic antibiotic drops are instilled to reduce Mercado 2011 © bleeding and loosen any thickened secretions that were not removed by suction 40 Task: Perform intratympanic injection

1. 1. Explain Procedure. Prepare supplies. Allow the dexamethasone to warm to room temperature (to avoid dizziness).

2. Position patient 3. Apply anesthetic

Mercado 2013 ©

4. Make two small incisions - -one for the injection and one for ventilation.

5. 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.

41 ENT for the PA-C

Presented by: Mike Valdez, PA-C

Vertigo Workshop Learning Objectives Discuss and demonstrate vertigo examination; Neurological examination Rhomberg Test Fukada Stepping Test Dix-Hallpike Demonstrate ENG/VNG. Demonstrate and practice canalith repositioning 42 Notes______

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Task: Perform Vertigo Physical Examination

1. Obtain detailed history

2. Physical examination a. Neurological examination (CNII-XII)

b. Rhomberg Test

c. Fukada Stepping Test

d. Dix-Hallpike

52 44 Task: Perform Canalith repositioning (Modified Eply Maneuver ) Patient’s head is systematically rotated so that the loose particles slide out of the semicircular canal and back into the utricle.

Mercado 2013© 1. If vertigo affects RIGHT ear, the patient is brought to the head hanging position with right ear turned DOWNWARD.

3. Hold for 30 seconds, then roll Mercado 2013© patient onto the left side while clinician rotates head LEFTWARD until the nose points down to floor.

5. Then patients returns to sitting position with head facing left.

1. Otolaryngology , A Surgical Notebook Lee / Toh ISBN 9781588903044

2. Color Atlas of ENT Diagnosis, Bull ISBN 9783131293954

3. ENT-Head and Neck Surgery: Essential Procedures, Theissing ISBN 9783131486219

4. Laryngeal Evaluation Indirect Laryngoscopy to High-Speed Digital Imaging, Kendall ISBN 9781604062724

5. Differential Diagnosis in Otolaryngology Head and Neck Surgery, Stewart and Selesnick ISBN 978-1-60406-051-5

6. Basic Otorhinolaryngology A Step-by-Step Learning Guide, Probst ISBN 9781588903372

7. The Audiogram Workbook, Hepfner ISBN 9780865777194

8. Imaging for Otolaryngologists, Dunnebier 9783131463319

Please visit http://www.thieme.com/index.php?option=com_content&view=article&id=633&ca tid=66&Itemid=90 For special discounts.

All workshops written by Jose C. Mercado, PA-C, MMS, DFAAPA except “Audiogram Workshop”