Otology Workshop Basic

Transcription

1 April 21, 2017 Chicago Otology Basic workshop Jeffrey Fichera, PhD, PA C Updated 2/09/2017 Otology Workshop Basic Clear Instruction Live Demonstration Learn by doing Hands On Practice Identify normal, normal variants and abnormal otologic conditions Remove ear foreign body Remove cerumen Perform manual pneumatic otoscopy 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. 1

2 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 2

3 External Auditory Canal Osteoma Exostosis External Auditory Canal Stenosis EAC Mastoid cavity Michael Hawke Library External Auditory Canal AOE AOE 3

4 External Auditory Canal Fungal otitis externa Fungal otitis externa External Auditory Canal Malignant Otitis Externa Granulation tissue Tympanic Membrane Pars flaccida Lateral process of malleus Pars tensa Promotory Umbo Light reflex 4

5 Normal tympanic membrane Normal tympanic membrane This healthy tympanic membrane is very translucent, which allows visualization of the long process of the incus (1) and the chorda tympani (2). The eustachian tube orifice (3) is seen anteriorly. The translucency of this tympanic membrane allows visualization of the underlying incus (1), eustachian tube orifice (2), and the Round window niche (3). The anterior part of the tympanic annulus, the Anterior sulcus (4), is often hidden from view during routine otoscopy. Normal tympanic membrane Normal tympanic membrane Normal tympanic membrane Normal tympanic membrane 5

6 Acute Bullous Myringitis Granular Myringitis Acute otitis media Acute otitis media Acute otitis media Acute otomastoiditis 6

7 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 hours after antibiotics 4. 2 days later 5. 3 days later 6. 6 days later days later Serous otitis media Serous otitis media Chronic serous otitis media Chronic serous otitis media 7

8 Otitis media with effusion and overinflated retraction pocket. Otitis media with effusion and myringoincudopexy Color Atlas of Ear Disease, 2 nd Edition, Chole RA, Forsen JW, 2002, BC Decker Inc Otitis media with effusion and atelectasis Primary acquired cholesteatoma. Congenital cholesteatoma. Congenital cholesteatoma. 8

9 Tympanosclerosis Myringosclerosis Ventilation tube Pressure equalization tube Grommet T tube 9

10 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 After 6 weeks. Subtotal perforation Large perforation Hemotympanum Barotrauma 10

11 Glomus tympanicum Glomus tympanicum 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 PAs 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. 11

12 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: 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: 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 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: The patient should be semireclined. 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. Positioning Modified semireclined position allows visualization of attic space. 12

13 Positioning Positioning children on parent s lap with legs and arms secured. Head should be stabilized to minimize movement. 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. Visualization 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). Visualization Inspect the ear canal and middle ear structures locating landmarks and noting any redness, drainage, or deformity. Visualize membrane and identify landmarks. 13

14 Instruments Suction Alligator Forceps Ear Speculum Bayonet Forceps Blunt Hook Loop Curette Curved Forceps 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 ;300(13):1506. 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. 14

15 Warm irrigation under direct visualization (cold water stimulates caloric response and 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. Technique [Best Evidence] Burton MJ, Doree C. Ear drops for the removal of ear wax. Cochrane Database Syst Rev. Jan ;CD 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. Adjust to the individual patient s needs. Pearls 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. 15

16 1. Position Patient Explain Procedure 2. Visualize Canal/Landmarks Task: Removal cerumen impaction 3. Determine BEST Procedure Remove Cerumen 4. Re Inspect Ear Modified semi reclined position allows visualization of attic space. 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. Visualize membrane and identify landmarks. Suction Curette Alligator Forceps Warm Irrigation Removal Foreign Bodies Ear 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

17 Removal Foreign Body (Ear) Direct visualization Removal with Alligator Forceps 1. Explain Procedure. Prepare supplies Task: Removal foreign body ear 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 instruments like an alligator forceps, curette or suction. 4. Drown insects with mineral oil or lidocaine before attempting removal. 5. Use warm water as cold water may cause dizziness. Manual Pneumatic Otoscopy 17

18 Manual Pneumatic Otoscopy 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. Manual Pneumatic Otoscopy Practice mannequins available to practice manual pneumatic otoscopy technique. Use of OtoSim Place scope in ear and gently squeeze scope bulb Watch indicator for safe (green) zone of pressure, and witness TM movement. Also use OtoSim slides to see various pathology through otoscope. 18

19 Task: Distinguish OE from OM & AOM from SOM Indication: using OtoSim to distinguish types of ear disease. 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 fingers so that your hand makes contact with the patient. 4. Insufflate with non dominant hand. 5. Observe movement of tympanic membrane. Mercado 2014 Station 1 Otoscopy Screen Station 4 Cerumen Removal FB Removal Station 1 Station 4 Station 2 Oto Sim Station 2 Projector Speaker Station 3 Station 3 Cerumen Removal FB Removal Proctors 19

20 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 On scale of 1 through 5 with 5 being most likely Scale 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 Task Go No Go Removal Ear FB Removal Cerumen Impaction Distinguish OE from OM Distinguish AOM from SOM Perform Manual Pneumatic Otoscopy Comments Proctor Name Proctor Signature 20