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BackTable / ENT / Article
Hummingbird Ear Tubes: Tips & Tricks for Efficient Application
Megan Saltsgaver • Updated Oct 26, 2024 • 51 hits
More than 80% of children will experience an ear infection by the age of three, making ear tube placement one of the most common pediatric procedures. With the increasing use of medical devices for in-office ear tube placement, it’s essential for surgeons to stay current on the latest technologies and techniques. Pediatric otolaryngologist Dr. Shelagh Cofer shares her expertise and offers valuable tips for successfully using the Hummingbird ear tube device in the office setting.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• In-office ear tube placement is becoming a popular procedure due to the convenience, efficiency, and cost effectiveness for patients.
• Setting up for the procedure is simple. On a Mayo stand tray, one Hummingbird device is opened for each ear. Phenol is needed to numb the eardrum. Other essentials include a 3 mm ear speculum, an alligator forceps for tube removal (if necessary), and a curette for cleaning earwax.
• For patients with a recent acute ear infection and bulging eardrum, Dr. Cofer suggests waiting 48–72 hours to allow pressure to subside, preventing fluid from obstructing the view during the procedure.
• The Hummingbird TTS device has a small black line near the tip to help gauge depth, ensuring accurate incision and tube placement. Dr. Cofer likes to think of the procedure in three steps: insert, slide, withdraw.
• With all new medical devices, proper training and practice is needed for operator proficiency.
Table of Contents
(1) The Growing Demand for In-Office Ear Tubes
(2) In-Office Setup for Hummingbird Ear Tube Placement
(3) Tips & Tricks for Smooth Application of Hummingbird Ear Tubes
The Growing Demand for In-Office Ear Tubes
Each year, an estimated $2.8 billion is spent on caring for children with ear infections, making ear tubes (also known as tympanostomy tubes) an in-demand treatment. To reduce costs and increase efficiency, a new method of ear tube placement is gaining popularity: in-office ear tube placement.
Initially, the idea of performing the procedure in the operating room with less sedation was considered. However, challenges arose due to children moving during the procedure and the complexity of the equipment, making this approach less practical. From these early attempts came the realization that in-office ear tube placement could be faster, more efficient, and safer.
In-office ear tube placement offers several advantages for both parents and children. There’s no need for fasting, avoiding the irritability and discomfort that often come with preparation for surgery. Parents also benefit from the convenience of having the consultation and procedure done on the same day, all while dramatically reducing medical costs.
Dr. Shelagh Cofer, a pioneer of this approach, has successfully performed over 225 in-office procedures since the FDA approval of the Hummingbird ear tube device for children six months and older. With several medical device companies now manufacturing these tools to meet the growing demand, in-office ear tube placement is quickly becoming a preferred option for many families.
[Dr. Ashley Agan]
When you were first approached, it's like, "Hey, let's put ear tubes in the office in small children." When I first heard about this concept, there was a little bit of a cringe. I was like, I don't know if I want to do that. Do people, do parents want that? I think I was like, I don't know about this. Tell me what your reaction was.
[Dr. Shelagh Cofer]
There is a little bit of a historical angle to the device development as well, and initially, we thought, "Oh, well, we can just use less sedation. We'll do it in the operating room, we'll just give them a little bit of nitrous oxide," just like you would get in a dentist's office, "And we'll pop tubes in, it'll be less sedation, it's good for patients." It turned out that really having motion and localization in the operating room setting just didn't turn out to be a good fit.
That experience of learning that, we really realized that the most benefit you're going to get out of doing these, using a tool to do ear tubes faster is in the office setting. Now, most ENT offices don't have the ability to give sedation. We don't have a nitrous oxide machine in our clinic. When we do ear tubes in the office on young children, we do not use sedation. Because we're not using anesthesia, patients don't have to come in fasting. They eat and drink normally as usual, and then they come in. We see them for an appointment, and we're able to do the tubes all on the same visit.
It is very efficient. It's not like you have to be scheduled for another procedure and do the fasting and have all of that hassle of another day off from work. It's just been great. I've been so excited to see how this came to be and to be involved in it and to be able to offer it to patients. It's just an amazing thing.
[Dr. Ashley Agan]
How many do you think you've done now, or how long have you been doing it? It's a while.
[Dr. Shelagh Cofer]
I've been doing it a while since we had full FDA clearance for the device. It's FDA-approved for use in children age six months and older. Since we've had that full approval, which was in 2022, I believe, and I've done 225 cases plus in-the-clinic since having it commercially available. I'd probably do three or four a week, maybe three to five.
[Dr. Ashley Agan]
Wow. You're at the point now where you could probably do these in your sleep now because you've probably done so many.
[Dr. Shelagh Cofer]
Yes.
[Dr. Ashley Agan]
As far as devices go, so the Hummingbird by, the company is Perceptis, they're the single pass device. There's Tula, which is made by Smith & Nephew. We did a podcast related to Tula because it's slightly different in that they have the iontophoresis numbing part of their procedure. Then KARL STORZ has got a new device coming probably later this summer or later this year called Solo+ that's, I think, it's similar to Hummingbird. I think it's going to be like a single-pass device, maybe some nuance to it.
New devices coming to the market. I think that's in response to the demand for it and that it's growing and patients want it and it's successful. It'll be interesting to see how things evolve. When you are seeing patients in clinic and talking about potentially doing in-office ear tubes, do you think about your patient selection differently depending on the age? Your little kids that are under two versus your two to five range versus the over five? The reason I'm asking, I'm just thinking about smaller kids being easier to swaddle and hold still, and then older kids having enough maturity to potentially talk them through it. Then with the kids in the middle, just potentially being impossible. I don't know. Tell me more about how you think about the age.
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In-Office Setup for Hummingbird Ear Tube Placement
Dr. Shelagh Cofer shares her office setup for in-office ear tube procedures. Before entering the room, her staff has prepared a Mayo stand with all necessary equipment. While size 3 suction is plugged in and ready if needed, it is rarely used due to the single-pass nature of the Hummingbird device.
On the Mayo stand tray, one Hummingbird device is opened for each ear. Dr. Cofer uses 89% phenol to numb the eardrum, which is applied with a small sponge from an open container. Other essentials include a 3 mm ear speculum, an alligator forceps for tube removal (if necessary), and a curette for cleaning earwax.
After numbing the eardrum, the Hummingbird device is used to make the incision. An assistant removes a pin from the device, and once inserted to the correct depth, the slider is retracted, placing the tube in the eardrum. While occasional bleeding may occur, Dr. Cofer rarely suctions to avoid dislodging the tube.
Some surgeons worry that not suctioning could lead to clogging or early extrusion of the tube, but research has shown no significant difference between suctioning and not suctioning in terms of these outcomes. Although many otolaryngologists are trained to clean the ear thoroughly, this practice is proving less necessary with the new device.
[Dr. Ashley Agan]
As far as your setup, do you have a little Mayo stand that has what you need all at the ready?
[Dr. Shelagh Cofer]
We do. We make sure all of our equipment is set up and ready before we even go into the room. That means our little tools are open. Our suction is plugged in, although we rarely use a suction, and everything's ready to go when we walk into that room.
[Dr. Ashley Agan]
On your tray, you've got your-- do you have a size-3 suction, a little suction, just ready just in case?
[Dr. Shelagh Cofer]
We have a 3 suction open. It's plugged into the tubing. It's not on. It's off our field. It's there available if needed. On our actual Mayo stand tray, we have one device open for each ear. We have a small individual container of phenol. I think Apdyne.
[Dr. Ashley Agan]
Is that 89% phenol?
[Dr. Shelagh Cofer]
It is. That comes with a little small micro sponge that you dip and then dab it onto the eardrum. It makes a very precise blanched area of the eardrum so you know exactly where to go. We have a speculum which is typically a 3-millimeter speculum, which will fit the vast majority of children. We have a couple other things available that we really rarely use, which is an alligator to grasp and remove a tube if we needed to. We have a curette for cleaning wax, and that's basically it.
[Dr. Ashley Agan]
If you encounter bleeding, do you ever have to put a little Afrin in there or do you just gently suction if that happens?
[Dr. Shelagh Cofer]
Fortunately, that hasn't occurred often. If we have to suction, it's typically, once we put the tube in, as soon as you touch the eardrum with the device, it makes the incision. There's a pin on the device, which my assistant has removed, which helps prevent the slider from moving until you're ready for it to. Once you insert to the depth, you slide back the slider and you come out. Now, you're going to already have deposited the tube, but you might have fluid that's coming out from the middle ear. Very often, that could be bloody because of all the inflammation and the time that effusion has been in the middle ear has created a lot of inflammation. It can bleed.
If I'm confident about the tube position, I wouldn't suction at all. It's only when there's a bit of a gusher of fluid and I'm not sure, is this tube seated properly? Is it not seated properly? I feel it's really important to make sure it is. I might suction around the tube, not necessarily down the tube.
[Dr. Ashley Agan]
That's just because you might suck the tube out, or is that the rationale for not suctioning the lumen?
[Dr. Shelagh Cofer]
I am concerned that it could dislodge the tube. I don't think a 3-suction is powerful enough when you have it cranked on to suck the tube right up back out of the eardrum. Just as a precaution, I don't think you need more than 3-suction. We're not suctioning out thick mucoid effusions from the middle ear.
[Dr. Ashley Agan]
Speaking to that, specifically, I think that's one thing when I talk to people about this procedure, it's like, but wait, we have to spend that extra time to suction all that mucoid effusion. If you're not doing that, then what happens? Is the tube going to get clogged or extrude early? Did you have concerns about that, about the lack of suctioning when you first started doing it?
[Dr. Shelagh Cofer]
I absolutely had that concern. In fact, I came in so skeptical, and maybe that's why I come out the other end as such a proponent for this because all of my concerns and questions were addressed in doing the research. The earliest version of the device actually had a channel in it and you could connect the suction tubing right to the device. Then as we were recognizing, you would deploy the tube and then you would have this stringy mucoid effusion that was partially out of the tube. That always made me worried that it would dry, it would desiccate, you'd get increased risk of plugging and then possibly early extrusion.
Yes, that was a big concern of mine. There was a meta-analysis that was done, and there's very few research papers that are published on whether or not the importance of suctioning out the middle ear is vitally important or if it's just something we were all taught to do because you're in the operating room and you can. The studies that are out there did not show any difference in plugging or early extrusion with suctioning versus not suctioning the middle ear at the time of tube placement.
These were patients that were done in the operating room, so they certainly could have been suctioned, which is also borne out by the extrusion and plugging rates that we see, which is very much on par with what's published in the literature, in up-to-date with a 7% plugging and maybe 4% early extrusion rate.
[Dr. Ashley Agan]
It's hard. It's hard to break that habit of wanting to-- it's so satisfying getting that glue ear all cleaned out.
[Dr. Shelagh Cofer]
It is so satisfying. You're right. We love, I think, we like to be tidy and clean it up.
[Dr. Ashley Agan]
Not necessary.
[Dr. Shelagh Cofer]
It's really the release of the vacuum that I think when you release the vacuum by putting the tube in to equalize the pressure, that's why they're called ventilation tubes, right? Pressure equalization tubes. That's the purpose. Once you release that vacuum, the fluid can then either resorb a little bit through the middle ear mucosa as that lining heals, or it can be more likely to drain down the eustachian tube, or it'll just come out the tube.
Tips & Tricks for Smooth Application of Hummingbird Ear Tubes
For phenol application, the sponge should be fully dipped in phenol and then dabbed once on gauze to prevent excess liquid from dripping into the ear canal during insertion. Dr. Cofer prefers to count to four to ensure proper blanching and numbing. In one case, she noticed the phenol wasn’t blanching properly, which she realized was due to improper storage—phenol is highly light-sensitive and loses effectiveness when exposed to light. It's also important to monitor phenol expiration dates.
For children who have recently experienced acute otitis media and have not responded to antibiotics, especially when the eardrum is still bulging, Dr. Cofer recommends waiting 48 to 72 hours before proceeding with ear tube placement. This allows the eardrum to relieve some pressure, reducing the risk of fluid gushing out and obstructing the surgeon's view during the procedure.
Like with any new medical device, practice is essential for proficiency. Understanding how to hold the device, how it works, and how to stabilize your hand on the patient’s head and speculum ensures accuracy and safety. Dr. Cofer explains how to gauge depth with the Hummingbird device. There is a small black line about a millimeter from the tip with the incision point. Once the incision is made, the device is inserted to this depth, the slider is activated, and the device is withdrawn.
Though the Hummingbird device is designed as a single-pass tool, Dr. Cofer prefers to think of it in three distinct steps: insert, slide, and withdraw. This mental breakdown into separate actions helps avoid short-shotting the tube, ensuring that the process is smooth and effective.
[Dr. Ashley Agan]
Back to your phenol application, you have that little sponge, do you do a couple of dabs before you go in so that the sponge is not super saturated so that it's just you're doing a tiny little dab on the eardrum? Do you think that matters as far as how much phenol is going on?
[Dr. Shelagh Cofer]
We do. I make sure that they're dipping, and then they do one dab onto a gauze or something like that so that there really isn't a drip that could come off of the tip of that sponge, and it just is very precise application then and it makes a small blanched area that is just about the size of the sponge tip.
Something that I just learned recently, I did a case where the phenol just didn't seem to be blanching, and I usually will count to myself in my head, one, two, three, four seconds, three to four seconds is really all you need, and I wasn't getting the blanching as I was expecting. Then I learned that phenol is very light-sensitive, so the package of phenol has to be stored in the dark, and even though the phenol wasn't expired, we always check that, of course, but it just may have been rendered less effective from light exposure. That's one thing you just want to make sure that the medications you're using are stored properly.
[Dr. Ashley Agan]
Interesting. You're holding the little sponge on the drum for about three or four seconds? Touch it, one, two, three, four, come out, and then go in with the device.
[Dr. Shelagh Cofer]
Sometimes. Another tip that I would say is if the eardrum seems like they had a very recent acute otitis media, and I see a lot of kids who still, they have an ear infection that just hasn't responded to the general course of antibiotics, and then they get down to where they're getting shots, IM shots, and they come in, they still have a bulging eardrum. I try to have them come back in just 48 to 72 hours just so that fluid isn't under quite so much pressure and less likely to get that gusher, which is going to obscure your view. That's something I learned going through this, as many as I've done, and something that I can pass on that knowledge and that information to other people who would like to have this as part of their practice.
[Dr. Ashley Agan]
If it's an acute otitis media and the eardrum is bulging, just let those antibiotics take effect for another couple days and then come back so that it's not shooting out under pressure. Do you do anterior inferior? As far as where you place your tube, is that typically your preference?
[Dr. Shelagh Cofer]
Yes. Historically, that's the way I was trained. I like anterior inferior, especially in small children, because I think it allows me to the placement, the shape of their ear canal, the orientation of the eardrum. I can see down the lumen of the tube and check its patency. If I'm not trusting what I'm seeing on a hearing test or a tympanogram test, I can inspect a little bit easier with my eye, whereas I think when they're more posteriorly, you're looking at the tube maybe more on edge, if you will, instead of straight down the lumen, but anywhere inferior in the usual locations.
[Dr. Ashley Agan]
Got you. As far as other tips for people who are getting started, you talked about counting, when you're placing your phenol, when you're placing the device, do you also do a count to make sure you're not pulling out too soon, or do you stabilize in a certain way? Any tricks that you've picked up along the way?
[Dr. Shelagh Cofer]
Definitely, yes. Practicing with this tool before you actually jump in there and use it is part of the training and part of being successful. You practice with it, you know how to hold it, you know how it works, you balance your hand on the patient's head and the speculum so that, as always, this is what they teach you, if your patient is moving their head and your hand is anchored to their head, your hand will move with them. You're less likely to make a mistake and injure something. We try to do that.
With the Hummingbird, there's two ways that you gauge your depth to make it correct. One is there's a small black line about a millimeter from the tip of the end of the device, and you make the incision, you insert to that depth, and then you slide the slider, and then you come back out. Even though it's a single pass, in my mind, it's got three steps. Insert, slide, come out. That's how I'm thinking about it as I do it. It's not a spring device, it's not mechanical, it doesn't fire into the eardrum. It's very much controlled by the user, the surgeon. I think if you try to rush it, that particular step is you're going to end up with a short shot or something. I sort of think about it as three parts to the one single pass.
[Dr. Ashley Agan]
If you're sliding and coming out at the same time, you're going to short-shot it. You got to make sure that you're stable sliding, okay, now come out so that the tube stays in the eardrum where it's supposed to be.
[Dr. Shelagh Cofer]
Yes. See, you have exactly the same experience.
[Dr. Ashley Agan]
Once you've short-shotted it, then you're like, "Okay, don't do that. Don't do that again."
Podcast Contributors
Dr. Shelagh Cofer
Dr. Shelagh Coffer is a pediatric otolaryngologist at the Mayo Clinic in Rochester, Minnesota.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, July 30). Ep. 183 – Office-Based Ear Tubes in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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