Procedures

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Procedures

• Basic Format
• Myringotomy Tympanostomy

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ENT FACT QUIZ AAO-NHS

• Test your knowledge of common ear, nose and
  throat disorders and their treatment.
• 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
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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
• You don't have to go swimming to get "swimmer's
  ear."Fact or Fiction

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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.

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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 _______________ .

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Terms and Definitions

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

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Definition/Purpose of Procedure

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

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Relevant A P
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Relevant A P
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Pathophysiology
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Pathophysiology
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Pathophysiology Deafness

• Conduction-type
• Sensorineural
• Central deafness
• Mixed-type
• Functional
• Congenital
• Neonatal

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Diagnostics

• Exams
• Otoscope
• Preoperative Testing

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Surgical InterventionSpecial 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

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Surgical Intervention Anesthesia

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

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Surgical Intervention Positioning

• Position during procedure
• Supine with head turned (surgeon will do)
• Supplies and equipment
• Special considerations high risk areas

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Surgical Intervention Skin Prep

• Method of hair removal
• Anatomic perimeters
• Solution options

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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

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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

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Tympanostomy Tubes
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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

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Surgical Intervention Instruments

• General
• Specific
• Myringtomy
• Tray

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Instrumentation
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Instrumentation
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Instrumentation
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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

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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

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Procedure Steps
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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

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PE Tube Inserted
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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
• Patients head is turned, and procedure is
  repeated on other ear (if required)
• Be prepared to switch sides of OR table

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Counts

• Initial usually N/Aper facility policy
• First closing
• Final closing
• Sponges
• Sharps

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Dressing, Casting, Immobilizers, Etc.

• Types sizes
• Cotton ball
• Type of tape or method of securing

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Specimen Care

• Identified as N/A
• Handled routine, etc.

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Postoperative Care

• Destination
• PACU Parent available once initial report give
  and VS stable
• Outpatient Dischargeusually 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

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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.

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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

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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