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Sharif K, Cofer SA. In-office Tympanostomy Tube Placement in Children. Otolaryngol Clin North Am 2025:S0030-6665(25)00052-0. [PMID: 40382229 DOI: 10.1016/j.otc.2025.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2025]
Abstract
Tympanostomy tube placement is routinely performed in adults in the office setting without sedation and with only topical or locally applied anesthetic. Innovative tools are now available to facilitate placement of tympanostomy tubes in children in the office, rather than under general anesthesia. We discuss the current state of an in-office approach to tympanostomy tube placement in children. An experienced team and a well-defined workflow are key to the successful placement of tympanostomy tubes in children without sedation. Shared decision-making between clinicians and caregivers will help determine the most appropriate setting for their child's ear tube placement.
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Affiliation(s)
- Kayvon Sharif
- Division of Pediatric Otolaryngology, Department of Otorhinolaryngology-Head & Neck Surgery, Mayo Clinic Children's, 200 First Street SW, Rochester, MN 55905, USA
| | - Shelagh A Cofer
- Division of Pediatric Otolaryngology, Department of Otorhinolaryngology-Head & Neck Surgery, Mayo Clinic Children's, 200 First Street SW, Rochester, MN 55905, USA.
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Giroux K, McColl LF, Harter C, Seitz E, Kistler I, Chiang T, Jatana K, Elmaraghy C. Protocol implementation for in-office manual tympanostomy tube insertion. Int J Pediatr Otorhinolaryngol 2025; 192:112326. [PMID: 40184856 DOI: 10.1016/j.ijporl.2025.112326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Revised: 03/20/2025] [Accepted: 03/24/2025] [Indexed: 04/07/2025]
Abstract
Bilateral myringotomy/tympanostomy tube insertion (BTI) can decrease the frequency, severity, and quality of life burden of acute otitis media and chronic otitis media with effusion for pediatric patients and their caregivers. Implementing a practice protocol for in-office BTI (IO-BTI) can benefit patients by eliminating the risks associated with general anesthesia, pre-procedure fasting, and post-anesthetic effects such as emergence delirium. However, adaptation of IO-BTI has largely relied on proprietary devices that may limit cost savings and access to care. The goal of this study was to develop a protocol for manual IO-BTI without single use device to yield the aforementioned benefits, as well as lower health care costs to families and improve access to and timeliness of care. Described is a protocol for manual IO-BTI in an ambulatory clinic setting. The caregivers of 178 pediatric patients who underwent IO-BTI between 04/01/2023-07/31/2024 were administered a binary satisfaction survey. Surgical outcomes such as post-operative pain, early tympanostomy tube extrusion, and tympanostomy tube plugging were examined via retrospective chart review. The cost of BTI with general anesthesia in the operating room (OR) setting, device manual IO-BTI, and IO-BTI with single use devices were also examined. Survey responses demonstrated a 99 % post-procedure satisfaction rate among patient caregivers. There were low frequencies of post-operative pain (0.7 %), premature tympanostomy tube extrusion (0.8 %), and plugging of tympanostomy tubes (1.5 %). Gross cost analysis of device manual IO-BTI compared to IO-BTI with single use devices and BTI with general anesthesia in the OR revealed a 1.5x and 6x cost increase, respectively. The presented study demonstrates that manual IO-BTI is safe, feasible, cost effective, and yields high caregiver satisfaction and positive surgical outcomes for pediatric patients.
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Affiliation(s)
- Kelly Giroux
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Logan F McColl
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Christian Harter
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, 43614, USA
| | - Emily Seitz
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Isaac Kistler
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA; Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA; Biostatistics Resource, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Tendy Chiang
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Kris Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Charles Elmaraghy
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, 43205, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
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Cofer SA, Badaoui JN, Rimell F, Nimmons G, Raisen J, Tombers N, Truitt TO. Assessment of In-Office Tympanostomy Tube Insertion Tolerability in Children Under 2 Years. EAR, NOSE & THROAT JOURNAL 2024:1455613241300890. [PMID: 39567866 DOI: 10.1177/01455613241300890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2024] Open
Abstract
Objective: In-office tympanostomy tube insertion (TTI) is becoming more available in the practice of pediatric otolaryngology. This study evaluated the tolerability of this procedure in young children. Method: Four methods were used to assess tolerability. (1) Standardized video recordings were collected from 30 patients under 24 months who underwent in-office TTI with a single-pass insertion device with topical anesthesia alone. The videos were then reviewed by 3 independent experts in pediatric care and rated at 5 procedural time points using a defined response scale developed with the U.S. Food and Drug Administration. (2) Separately, overall tolerability was subjectively assessed by the same experts. (3) Patient recovery was assessed by the participating otolaryngologist and support staff. (4) Patient caregivers were surveyed for their impressions of the procedure, including whether they would recommend it to other caregivers. Results: In a total of 90 reviews, 100% of children were successfully treated and were rated as having acceptably tolerated the in-office tympanostomy tube procedure. All patients returned to an acceptable baseline without inappropriate crying and were assessed as fully recovered immediately following the procedure or by the time the child was leaving clinic. For caregivers, 93% agreed or strongly agreed that they would recommend the use of in-office TTI to other caregivers. Conclusions: In-office TTI in young children was determined to be universally well tolerated in young children and is a procedure that patient caregivers would recommend to other caregivers for their children. These results should help reassure otolaryngology specialists and caregivers alike that in-office ear tube placement is a viable option for young children with middle ear disease.
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Affiliation(s)
- Shelagh A Cofer
- Department of Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph N Badaoui
- Department of Surgery, University of Maryland, College Park, MD, USA
| | - Frank Rimell
- Pediatric Otolaryngology, Children's Hospital of Southwest Florida, Fort Myers, FL, USA
| | - Grace Nimmons
- Otolaryngology Head and Neck Surgery, Health Partners Park Nicollet, St. Louis Park, MN, USA
| | - Jay Raisen
- Prairie Sinus Ear Allergy Clinic, Bismarck, ND, USA
| | - Nicole Tombers
- Department of Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Theodore O Truitt
- Otolaryngology Head and Neck Surgery, St. Cloud ENT, St. Cloud, MN, USA
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Rimell FL, Cofer S, Truitt T, Nimmons G, Raisen J. Use of Topical Phenol in Awake Young Children for Tympanostomy Tube Placement. EAR, NOSE & THROAT JOURNAL 2023:1455613231212829. [PMID: 37997671 DOI: 10.1177/01455613231212829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Importance: Phenol kits cleared by the Food and Drug Administration (FDA) are indicated as a topical anesthetic for the tympanic membrane (TM) in adults. However, there is no existing literature that reports outcomes to support the safety and use of phenol on the TM of awake children. Objective: Determine if topical phenol is safe and at low risk for complications and therefore be used effectively in awake children to facilitate office otologic procedures as in adults. Design, Setting, and Participants: Children under 21 years of age whose parents agreed to participate in an awake office setting for tympanostomy tube (TT) placement. All children had TT placement after phenol placement on the TM prior to insertion. Main Outcomes and Measures: TM perforation or other signs of TM complications through a minimum of 6-month clinical follow-up, along with assessment of the tolerability of the procedure by the child. Results: A total of 228 children with an age range of 6 months to 15.9 years and 435 TMs completed TT placement using phenol as a local anesthetic while awake in the office. There were no complications reported in the 204 children at the first follow-up visit post TM placement within 3 to 10 weeks. Of the 93 children followed up at least 6 months, there were no TM complications reported. Conclusions: This is the first study to report the outcomes on the use of phenol in an office setting in children. In this large experience, phenol appears to be tolerable and safe for use in young children in the office and is a potential safe choice of topical anesthesia for surgeons if they choose to perform office procedures such as myringotomies or TT placement on children.
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Affiliation(s)
- Franklin L Rimell
- Division of Otolaryngology Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shelagh Cofer
- Department of Otolaryngology Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Grace Nimmons
- Otolaryngology Head and Neck Surgery, HealthPartners, Minneapolis, MN, USA
| | - Jay Raisen
- Prairie Sinus, Ear & Allergy, Bismarck, ND, USA
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Rosenfeld RM, Tunkel DE, Schwartz SR. Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices. Otolaryngol Head Neck Surg 2022; 166:219-223. [PMID: 35138980 DOI: 10.1177/01945998221074528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice. DATA SOURCES PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity. REVIEW METHODS A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies. CONCLUSIONS The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation. IMPLICATIONS FOR PRACTICE Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Seth R Schwartz
- Ear, Nose and Throat (Otolaryngology) Department, Virginia Mason Medical Center, Seattle, Washington, USA
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