Procedures

Basic Format

Myringotomy & Tympanostomy

ENT FACT QUIZ: AAO-NHS*• Test your knowledge of common ear, nose and

throat disorders and their treatment. 1. Cotton swabs are a safe and easy way to clean wax from inside

your ears.Fact or Fiction

2. Reading in a moving car can cause motion sickness (make you "car sick").Fact or Fiction

3. Hay fever is not caused by hay and does not cause a fever.Fact or Fiction

4. Tonsils and adenoids filter bacteria out of what we swallow and breathe.Fact or Fiction

* American Academy of Otolaryngology-Head & Neck Surgery

ENT FACT QUIZ

5. A person can be trained or conditioned not to snore.Fact or Fiction

6. You can "toughen up" your ears by continued exposure to loud noise.Fact or Fiction

7. You should avoid speaking or singing when your voice is hoarse.Fact or Fiction

8. You don't have to go swimming to get "swimmer's ear."Fact or Fiction

Objectives• Assess the anatomy, physiology, and

pathophysiology of the myringotomy, tympanostomy.

• Analyze the diagnostic and surgical interventions for a patient undergoing a _______________.

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for_____________.• Describe the care of the specimen• Discuss the postoperative considerations for a

patient undergoing _______________ .

Terms and Definitions

• Otitis Media

• Pressure Equilization Tubes (PE Tubes)– Also called polyethylene ventilation tubes

Definition/Purpose of Procedure

• Incision into the tympanic membrane under direct vision to remove accumulated fluid—often to treat otitis media in the middle ear; PE tubes are frequently inserted through the tympanic membrane during this procedure

Relevant A & P

Relevant A & P

Pathophysiology

Pathophysiology

Pathophysiology: Deafness

• Conduction-type

• Sensorineural

• Central deafness

• Mixed-type

• Functional

• Congenital

• Neonatal

Diagnostics

• Exams– Otoscope

• Preoperative Testing

Surgical Intervention:Special Considerations

• Patient Factors– Peds: may warm room, toy or other distraction

• Room Set-up– ENT microscope positioned near head of OR

table –ready to be move once pt anesthetized– OR Table in reverse position to make room for

microscope and sitting surgeon– Set up on Mayo stand

Surgical Intervention: Anesthesia

• Method: Local, General inhalation for children (typical); can be performed under local in office for adults

• Equipment

Surgical Intervention: Positioning

• Position during procedure– Supine with head turned (surgeon will do)

• Supplies and equipment

• Special considerations: high risk areas

Surgical Intervention: Skin Prep

• Method of hair removal

• Anatomic perimeters

• Solution options

Surgical Intervention: Draping/Incision

• Types of drapes– 4 cloth drapes typically or fenestrated drape

• Order of draping

• Special considerations– Clean procedure; use best clean technique

• State/Describe incision– Tympanic membrane

Surgical Intervention: Supplies

• Specific– Suture: N/A– Medications on field (name & purpose)

• Antibiotic gtts (Cortisporin otic often used)

– Catheters & Drains• Pressure equilization tubes specific to surgeon

orders

Tympanostomy Tubes

Surgical Intervention: Supplies

• General– Mayo stand cover

– Suction tubing

– Gloves

– Fenestrated towel drape

– 4 x 4 gauze

– Disposable myringotomy knife

– Small basin w/water

– Pharaceuticals per orders

Surgical Intervention: Instruments

• General

• Specific– Myringtomy

Tray

Instrumentation

Instrumentation

Instrumentation

Surgical Intervention: Equipment

• General: Suction apparatus

• Specific: ENT Microscope with proper lens and ocular adjustment per surgeon specification– Sterile microscope hand grips

• Sitting stool for surgeon

Surgical Intervention: Procedure Steps• Patient is positioned with head turned so that affected head is up• Patient is draped w/fenestrated drape or 4 towels (no prep)• Surgeon places microscope to visualize, and inserts aural speculum in

ear canal• If wax accumulation, surgeon will remove w/curette

– * estimate size of ear canal and present appropriate size speculum– * have gauze available to clean the wax off the curette

• Surgeon makes small curved incision in the posterior-inferior quadrant of the tympanic membrane with a sharp ear (myringotomy) knife– * STSR careful to pass so that surgeon need not look away from operative

site– Be ready for suction; keep tube patent by suctioning water through it or

using stylet (middle ear fluid is thick)

• *culture & sensitivity may be taken at this time from fluid• If fluid or pus is present, it is suctioned using it is suctioned using a

Frazier or Baron suction tip

Procedure Steps

Surgical Intervention: Procedure Steps

• Surgeon positions PE tube, which has been positioned on alligator ear forceps, into the incision (never with gloved hands due to powder)

– * STSR grasps PE tube in the jaws of alligator forceps and carefully pass to surgeon

PE Tube Inserted

Surgical Intervention: Procedure Steps

• Surgeon instills antibiotic drop, then packs with cotton ball– * Have cotton and med ready (circulator may instill gtts

as convenient from med bottle)

• Surgeon removes speculum• Patient’s head is turned, and procedure is repeated

on other ear (if required)– * Be prepared to switch sides of OR table

Counts

• Initial: usually N/A—per facility policy

• First closing

• Final closing– Sponges– Sharps

Dressing, Casting, Immobilizers, Etc.

• Types & sizes– Cotton ball

• Type of tape or method of securing

Specimen & Care

• Identified as N/A

• Handled: routine, etc.

Postoperative Care

• Destination– PACU: Parent available once initial report give

and VS stable– Outpatient Discharge—usually within an hour

• Expected prognosis (Good)– Pt instructed to keep dry until PE tubes fall out

or are removed and TM healed– Hearing expected to return to normal

Postoperative Care

• Potential complications

– Failure to resolve the ear infections. – Persistent perforation after the tube falls out of the

eardrum. – Chronic ear drainage. – Need for further and more aggressive surgery such

as tonsil, adenoid, sinus, or ear surgery. – Hearing loss. – Scarring of the eardrum.

Postoperative Care

– Need to keep the ear dry and to use ear plugs. – Foreign body reaction to the tube itself - for

example, an allergic reaction to the tube material (rare).

– Pt may require second procedure to remove retained tube

• Surgical wound classification: II

Resources

• www.Allrefer.com

• STST pp. 587-596, 601-612, 618-630

• www.nucleusinc.com

• www.pedisurg.com

• Alexanders pp. 733-736

• Fullers pp. 605, 608-609

• Goldman p. 435