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BackTable / ENT / Podcast / Transcript #100
Podcast Transcript: Tympanic Membrane Perforation in Children
with Dr. Daniel Choo and Dr. Walter Kutz
In this episode of BackTable ENT, Dr. Gopi Shah, Dr. Walter Kutz (UT Southwestern), and Dr. Daniel Choo (Cincinnati Children’s Hospital) discuss indications and repair techniques for tympanic membrane perforation in children. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Children with Tympanic Membrane Perforations
(2) Medical Conditions Associated with Tympanic Membrane Perforations
(3) Bilateral Tympanic Membrane Perforations
(4) Deciding When Tympanoplasty is Needed
(5) Guidelines for Choosing a Tympanoplasty Graft
(6) Harvesting the Tympanoplasty Graft
(7) Dealing with Otorrhea on “Game Day”
(8) Deciding Between The Microscope & The Endoscope
(9) Post-Operative Management of Tympanoplasty
(10) When Tympanoplasty Isn’t Enough
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[Dr. Gopi Shah]
This week on the BackTable Podcast.
[Dr. Daniel Choo]
I do think some of our kids with pretty severe clefts and skull base malformations, they're just always going to need a tube or some type of ventilation drainage place, but if they've got a subtotal perforation and a near-maximal conductive hearing loss so you've got to do something, sometimes I'll graft those drums and I'll probably use tragus for that, but then also put in-- I did my ear fellowship with Herb Silverstein and he put in these subannular tubes that actually go underneath. If you've got the drum already lifted up to do your tympanoplasty, it's actually a pretty easy thing to slide one under there.
[Dr. Gopi Shah]
Hello everyone and welcome to the BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. Now a quick word from our sponsor. Cook Medical's Otolaryngology-Head and Neck Surgery Clinical Specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs. Areas of focus include head and neck otology, and laryngology with products ranging from a full suite of interventional sialendoscopy products and the doppler blood flow monitoring system to the Biodesign Otologic Repair Graft and the Hercules 100 Transnasal Esophageal Balloon. For more information, visit cookmedical.com/otolaryngology.
Now back to the show. My name is Gopi Shah and I'm a pediatric ENT. We have an awesome topic today on tympanic membrane perforations in children. I have two returning guests, let me introduce them. I have first Dr. Walter Kutz. He's a neurotologist and professor at the University of Texas Southwestern Medical Center. You all may know him. He's been a guest and host on previous Backtable ENT episodes on topics including otologic manifestations of migraine, hearing loss, and cognitive decline, eustachian tube disorders, and congenital hearing loss. Also returning today, we have Dr. Daniel Choo. He's a neurotologist whose practice is now almost entirely pediatric-focused and he's the chief of pediatric ENT at Cincinnati Children's Hospital. He was also recently a guest on Backtable ENT episode 78, Leadership in Pediatric Otolaryngology with Dr. Dana Thompson and Dr. Shoham Roy.
It is my pleasure to have you both back on the show today to talk about tympanic membrane perforations in children. Welcome back, guys.
[Dr. Daniel Choo]
Thanks, Gopi.
[Dr. Walter Kutz]
Thanks, Gopi.
[Dr. Gopi Shah]
Before we get into it, you all want to just first tell us a little bit about yourselves and your practice for any of our listeners who might be new to BackTable or who may not know you guys.
[Dr. Walter Kutz]
Yes. My name is Walter Kutz and I've had the pleasure of being on Backtable before. I always enjoyed the episodes and especially listening to the other episodes. I'm an otologist and neurotologist at UT Southwestern. I finished my fellowship in 2007 at the House Ear Clinic and joined UT Southwestern and I've been there ever since. I would say about 70% of my practice is adult, 30% is children. I usually operate about three to four days a month and then I have two clinics and I see a lot of pediatric patients through my UT Southwestern clinic as well.
[Dr. Gopi Shah]
What about you, Dan?
[Dr. Daniel Choo]
It's striking that I've been in Cincinnati now for 24 years and I'll confess that during my residency in Syracuse, the hardest and most onerous part of our rotations were the peds rotations. I came out of residency thinking, "I'm going to have a height line on my office door and if you don't come up to that line, you can't come in my ride." To be practicing in Cincinnati Children's is really strange for me. My background is like Walter's also in otology, and neurotology. Training in Florida as well as in Washington DC at NIH before I came out here. It's a great, very gratifying practice to work on kids. Probably about a third of my work is implant-related stuff, hearing loss. Another third is congenital ears and then another third is revision chronic ear stuff like we're talking about today.
[Dr. Gopi Shah]
Obviously I love children as well. My practice is all pediatric ENT, but I do not have the height marker at the door because I need to make sure that I pass that marker. For those of you who do not know me, I clear five foot and that's about it. All right. Let's get into it. The reason I wanted to have this podcast topic on tympanic membrane perforations in children is because, one, I think that sometimes diagnosing them can be difficult to make that decision-making about how to manage, when to watch, when to consider surgery, and then the surgery itself and post-op can be difficult. Let's just first talk about how some of these kids present to you. How old are they usually? What are some of the symptoms and go from there?
(1) Children with Tympanic Membrane Perforations
[Dr. Daniel Choo]
They seem to come in different phases. I'll get my three, four, five-year-old kids who've had one or multiple sets of tubes in their earlier lives and then as the tubes fell out, they're left with a residual perforation mixed in there but overlapping in that Venn diagram. Then you got these kids who just developed these chronic suppurative ears that just drain and they always have a perforation and seem to manage those with and without tubes and you end up at this place where they've got holes in their eardrums. Then a smaller proportion are those kids who come back later either from a traumatic or maybe they had just had a fluke acute otitis episode that perforated and they come in with these clean, dry, very sclerotic-looking perforations. Each of those you manage obviously just a little bit differently.
[Dr. Walter Kutz]
Yes, it's pretty similar in my practice. Sometimes a child may not have any early symptoms and they get their first hearing screening in school. They notice they have a little hearing loss, you come to see them, they have a dry perforation which I think a lot of times is probably from a tympanostomy tube that extruded and they have a persistent perforation.
[Dr. Gopi Shah]
I usually will ask any history of drainage, how's their speech, how are they doing in school. What other things on the history are you all asking or do you always have on your checklist of questions?
[Dr. Walter Kutz]
I like to ask about have they had a history with tympanostomy tubes. I think it's very important. A lot of these kids, if they don't have a cholesteatoma, they don't really have drainage, they have a mild hearing loss, we're going to follow them for a while. If they're really struggling in school, perhaps that may be more incentive to repair the perforation or at least consider a hearing aid. I think asking about cleft palate, does the child have other craniofacial abnormalities, allergy problems, these sort of things are really important. Also, I think asking about the contralateral ear is important. Are they continuing to get infections in their contralateral ear? I'd be less likely to offer a tympanoplasty in that situation.
[Dr. Gopi Shah]
Then the physical exam, sometimes I find it can be difficult. Sometimes there can be a history of the perf and documented it on my last visit. Sometimes, maybe it's the four-year-old or the six-year-old that just doesn't want me in their ear that day. Are you always using just standard otoscopy? Do you use a microscope every time? How do you get the exam and how do you follow it? Do you ever put a scope in, flex or rigid?
[Dr. Daniel Choo]
I'd love using an endoscope in the ear, but in the clinic, it's a little bit onerous for us. I'm not sure what your guys' experiences are, but it's a little bit of work to hook it up. It's so much easier to just walk them down to our room where we have the microscope. It's pretty rare that we've got to get into a formal wrestling match with a nurse or an MA, mom and dad, and as well as myself to get a good look. If the parents are comfortable, I'll also try and work into it. Maybe it won't be a 100% exam on this visit today, but you'll come back in a month or so and we'll take another look and I'll gradually ease the kids into it. The standard otoscopes, I think we can probably get by with that, a majority of the time. The kids will let you get a decent look and you'll get a good enough idea as to the scope of the perforation.
Boy, just like we've seen in the operating room, the endoscopes give you so much better view. It's pretty sensitive though, to put that in a squirmy four-year-old kid, that would be tough.
[Dr. Walter Kutz]
Yes. I'm the same way. I enjoy using endoscopes in the operating room and I use them frequently like Dan. In the clinic, it's challenging. If you bump that exterior canal with an endoscope, it really hurts. Even with adults, you have to be much more gentle and thoughtful than if you're using a speculum and/or a microscope. I think like you said, if you talk to the child and you try to gently look in the ear, you don't necessarily have to remove all the cerumen the first time. If you can get an idea of what's going on, just like Dan said, I think you just get to know the child, know that, "Hey, I'm not going to hurt you." Then you can even come back and take a look later.
[Dr. Gopi Shah]
Yes. If I have a chronic perf that I'll watch, and the child is older, maybe like six to, depending on the six-year-old, maybe eight, it just depends, once a year, I might try to put a camera in just so that the family can see it. We can all see it. Then when I see him back in three to six months, depending on their symptoms, I'll use just the regular otoscopy, or if I still can't get a great look with otoscopy, if it's super interior, I just need to get a better view, then I'll use the microscope. Then I agree, putting a scope in the ear, though I know a couple of times, it's like, "Let me try the flexible. It's softer and I can still get a good look," but it's so long and big that even trying to, "Oh my God, you're going to stick this big old thing in my ear," and they sometimes aren't having it either.
I agree sometimes, with an endoscope, it is very nice, but the heat on the light has got to be turned down, because even that, just having the heat can be painful or scary and just make them jerk. A ding there is not necessarily what we want. I think the families, if they can see it, like it too. If we can see it better, it's nice.
[Dr. Daniel Choo]
I think that's been great. When we renovated our clinics several years ago, we put video monitors on each side of the wall in the microscope room so that whatever ear you're looking at, the kid can also see, which I found has been very helpful. They'll let me do a ton more if they can see what I'm doing to them. Then when it comes to discussing surgery, it's been so much easier to talk off the screen with the family.
(2) Medical Conditions Associated with Tympanic Membrane Perforations
[Dr. Gopi Shah]
You had mentioned some of the risk factors underlying eustachian tube dysfunction from craniofacial like cleft palate. We do have a special group of whether it's syndromic, non-syndromic, cleft palate, or children with trisomy 21, eustachian tube dysfunction that can end up with residual perfs or get a perf that doesn't heal, and so forth. How do you think about those kids? How does that underlying risk factor play a role into your decision-making of how to manage?
[Dr. Walter Kutz]
Yes, I think I'm more likely to follow those perforations, especially if they're not causing really any issues. If they're a small perforation, and they're dry, there's no cholesteatoma, hearing's still good, it's basically acting like a tympanostomy tube, which a lot of these kids are going to need anyway. Now, saying that, my overall big three criteria to fix a perforation would be if there is evidence of a cholesteatoma, if they have chronic otorrhea that they're on multiple sets of ototopical drops, and maybe sometimes they get a lot of oral antibiotics from their pediatrician, and then if they have really significant hearing loss. Those are the kids I would typically address, but a kid with a cleft palate, other syndromic issues, higher risk of eustachian dysfunction, oftentimes I'll try to follow them as long as I can, and a lot of times, even if it's some hearing loss, they can wear a hearing aid pretty successfully.
[Dr. Daniel Choo]
I'm on the same page. There's different points in my career where I felt like, "oh, I can close that one, that'll be all right," and you get burned a few times and say, "All right, I need to dial that back a little bit." It's rare that I've been disappointed that I waited longer. There's extremely rare instances where a very benign-looking perf ends up developing some squame growing into the middle ear, and I said, "oh, I should have gone back in before that developed," but that's a pretty rare exception, I think. I'm more sensitized, and I don't know if it's from living in the Ohio River Valley, but the environmental allergy stuff, rhinosinusitis with associated eustachian tube dysfunction, it was a real bugaboo for me. There's kids where we patched them up successfully, but then they come back with recurrent fluid, and you end up poking a hole back through with a tube in a drum that you just repaired, and you feel like, "Ugh, why did I do that?" We're cautious about those for sure these days.
[Dr. Gopi Shah]
Do you try to get them evaluated for allergy, put them on medication? How do you manage that part of it or consult?
[Dr. Daniel Choo]
If I'm suspicious about that, certainly starting on history and physical, we'll try and probe it and see if there's a family history of environmental allergies, which I think is a risk factor, take a quick look in their nose, see if their turbs are really swollen, chronically congested. I'll usually start putting them on an antihistamine and some Flonase-type stuff, but if they still have symptoms after that, then that's when I'll usually refer them on for a formal allergy testing. The frustrating one is where it comes back all negative, and you and the family are saying, "I know my kid has allergies." I wish it had shown positive, and we'd figure out what to treat more targeted fashion.
(3) Bilateral Tympanic Membrane Perforations
[Dr. Gopi Shah]
Those are definitely harder. Those are usually the slightly older kids, otherwise healthy, and it's hard to know, like you said, which way do you go with that underlying eustachian tube dysfunction. Walt, you had mentioned the contralateral ear. What about in an otherwise child with no other medical comorbidities, but they have bilateral perfs? How do you determine the contralateral ear?
[Dr. Walter Kutz]
Yes, that's a great question. You Look at the literature, and some people have cutoffs, five years old, seven years old, eight years old. Again, I've been in this situation, and in Texas, it's really hot in the summer. Kids want to swim. They get that you're wet, and it's miserable for them. I probably do maybe a few tympanoplasties at a little younger age than maybe that I'd prefer, and usually get away with it. I don't really have a strict age cutoff. I think every kid's different. Some people may have their guideline of seven or eight years old if it's just a dry perforation not causing trouble, but if they don't have the risk factors, then I'd have a careful conversation with the parents. Usually, I try to maybe get them a little older, out of that eustachian dysfunction stage. I don't know if that's six, seven, eight years old, something like that. Oftentimes, I think their parents appreciate that you're not just wanting to operate right away. You're building a relationship. Once you do the surgery, hopefully, it's successful, but if it's not successful, you've had this conversation a few times, and I think you've been thoughtful about your decision-making. Again, I don't really have a strict age cutoff, but even a five or six-year-old, even with bilateral dry perforations, the parents understand that there's a chance the child may need another tube, they may not heal properly, very low-risk of retraction of cholesteatoma, then I think proceeding carefully is reasonable.
[Dr. Daniel Choo]
Yes. I would say the interesting part about the relationship with our patients and our families, a lot of times when I've been waiting on these kids for a while, it's actually the parents who say, "Hey, is it about time? Can we talk about fixing this thing yet?" I'll say, "Oh yes, that's right. We're going to do that now about this age." It's much more comfortable. I think that shared decision-making at that point inspires a lot more confidence for them.
(4) Deciding When Tympanoplasty is Needed
[Dr. Gopi Shah]
Absolutely. Like you said, if the hearing's good, the speech is good, we're not getting drainage and it's dry, what's our goal here? Having to split that up, functionally, how are they doing and what's our audio show, and are we having problems from it? A tympanoplasty surgery, the post-op care isn't-- sometimes if you have dissection or if they have drainage, it's not an easy recovery, or that dry ear if you're going to do drops. If you have to take a look and suction anything out, there's more to it than sometimes just, "Okay, we're going to go ahead and start tympanoplasty," because the why I think is important. Every once in a while, I've seen kids maybe between the ages of five to seven and we've been watching a dry perf and the hearing test is still good, but the size looks bigger. Do you watch that? What do you do if you notice, "Is this getting bigger?"
[Dr. Walter Kutz]
That's not that common of a problem, but I've seen that. I think I would do the same criteria if their hearing is still reasonable. If they're five or six and their parents want to wait another year or two, that's fine. You do worry about things like secondary acquired cholesteatoma and they can sometimes be difficult on the exam. Things like persistent or recurrent otorrhea, that may be a higher instance of a secondary acquired cholesteatoma or just chronic suppurative otitis media that's just not going to get better without surgery, but I think I follow the same sort of decision-making. I wouldn't be as concerned about a larger perforation, although typically that's going to cause more hearing loss. You'd probably be more tempted to repair it anyway, but I think I'd follow along as I would regardless.
[Dr. Daniel Choo]
Yes. Same for me, Gopi. I don't know. Does it change your thinking or your approach?
[Dr. Gopi Shah]
If the hearing is good, I don't feel like a rush, but I just worry, I'm like, "Is it just going to make the repair harder or the chances of closure harder if that hole is bigger if we're starting with 40% and now it's 70?" Every once in a while the audio looks pretty good, the kid's doing well in kindergarten and language is good, and it's always hard to know. Maybe I'll see them as opposed to, usually for my staple kids, I'd see them about every six months to get an audio and an ear check, but maybe I'd see them a little bit sooner at three to six months and really talk to the family about-- see how they're doing in school. If they're getting in trouble more, if the teacher's calling you. It could be that we have a change in the hearing or when they're swimming, we may want to be a little bit more particular about plugs and things like that.
[Dr. Walter Kutz]
Yes, I think on the size of perforation, I still like doing lateral graft tympanoplasty and I feel kids heal really well from this. Even a subtotal perforation, in some ways that operation is very standardized for me. Gopi, we work together. It's the same operation every time. It looks the same at the end. I actually enjoy that operation. I guess in my hands, the size of perforation may not matter as much. Saying that, if it's what I'm going to do, a medial graft and use an endoscope and it's more of that anterior superior, those are more challenging, and I think, heal less commonly, but it's something to consider for sure.
[Dr. Daniel Choo]
I think the size, that probably hits on it well, is the location of the perforation and what you got to repair is probably the more significant driver of, should you fix that before it gets worse up in that anterior superior corner or not. You're such a House guy. Who does lateral grafts these days?
[Dr. Walter Kutz]
They work.
[Dr. Gopi Shah]
In terms of the location, the anterior perfs or the anterior superior, do you follow those more carefully? What's your decision-making on those for a child that's between that three to five years old, the tube fell out and they ended up with a 25% anterior superior perf?
[Dr. Daniel Choo]
I don't think it changes too much. I'm still following, does it get infected a lot? Does it drain, and is there hearing loss? Those are the things that the parents seem to bring the kids in and get worried about. Even if it's a pretty decent-sized anterior superior perforation in a three-year-old kid, we'd probably say, "You know what, let's watch it for a little while longer. We'll stack the deck and when we actually do repair this, we'll be at a point where it's probably going to be one and done.
[Dr. Walter Kutz]
Yes, I agree with that. I think just talking about a little technique, it's nice having partners from different training. Jake Hunter was with our group for about six years and he did a lot of over-under type technique where you'll de-glove up the malleus completely and I think it gives you really good access to those superior anterior perforations. That's something that I've been cautious about in the past because I always thought the drum may lateralize off the manubrium, but in reality, if you don't overpack the middle ear space, it's a very good technique and I'll use an endoscopic approach typically. I'm not just the House guy. I am also willing to learn different techniques that seem to work very well. I think over time, you learn what works for you and I think it's okay to change and try some different techniques.
[Dr. Daniel Choo]
Maybe that's a good segue, Gopi, for technique pieces to this because, for those, I always felt it was so, maybe not invasive is not the right word, but to de-glove the malleus and do all that work to get up to that front corner, I've been doing a lot more cartilage grafting for those and if it's small enough, even trying something like a butterfly graft for that, to me, that felt almost wrong because it was too easy and I didn't struggle enough to get a good result, but I'm struck by how often you do get a great result and the hearing is good and it's a really quick healing, quick recovery. As opposed to de-gloving the malleus and going that way. A lot of times I'll skew my tympanomeatal flap a little bit more inferiorly and anteriorly and lift the drum up from bottom-up and that lets you get around the malleus and get the graft up where it needs to be. Packing and supporting the graft up in that top front corner is still really hard though. I think that's one of the failure-prone areas for us still.
[Dr. Walter Kutz]
Yes I agree. That's very similar. I would typically do a medial graft and leave the skin on the malleus and trying to pack that superior anterior is very difficult. One instrument that's been helpful with that is a Thomasin Dissector. It's that right-angled with a little spatula tip. Dan, you know about this. We use it a lot in the endoscopic world but it works great for microscopic world as well but you can turn and place your gel foam around that malleus and it helps but it doesn't seem like it can ever quite get enough packing up that superior interior space. It's challenging. I do agree, if you can do something like a fat graft or I don't do a lot of butterfly grafts but something just simple, you've tried something that's going to probably have a really high likelihood of working, you're not going to really disturb the rest of the anatomy of the tympanum membrane, I think that's definitely worthwhile and a really good point.
(5) Guidelines for Choosing a Tympanoplasty Graft
[Dr. Gopi Shah]
Is there a certain size criteria for a butterfly cartilage graft besides that it's too big that you were like, "no, I think I'm going to have to do a standard tympanoplasty?" For our listeners who may not know this is the cartilage graft where you're making it into a grommet, correct? You're taking some of the epithelium off of the tympanic membrane and making sure so that skin isn't trapped in it and then popping it in like a tube?
[Dr. Daniel Choo]
There's a lot of variables. The location of it definitely makes a difference. In some ways having a little myringosclerosis around the perforation in those actually can be a little bit helpful because it gives your graft something to really butt up against and holds it steady. In very rough terms, I'd say if it's more than three millimeters in size, I'm probably going to do something more formal and lift up the drum and try and graft it.
[Dr. Gopi Shah]
What about a fat, do either of you guys do the little fat plug?
[Dr. Walter Kutz]
I do that. I probably should do that more often. I think if you're going to sleep, I'm an otologist, I think a lot of otologists are like, "well, I'm going to do a formal tympanoplasty. I'm going to have that nice 80% to 90% success rate." Fat graft's probably less than that. I don't know if it's that much less but I do think there's been times where I've looked at a perforation and I probably could have just done a fat graft, give that a good try and I would probably say that's the same. If it's greater than three millimeters I'd consider formal tympanoplasty. Dan, I don't know, do you do fat grafts some here and there?
[Dr. Daniel Choo]
That's pretty rare. I think what's supplanted it more for me lately is I've been using a good bit of the porcine submucosal intestinal grafts and I think it's commercially available, pretty benign, easy to work with stuff and if there was something where I was going to do either a fat graft or even, I don't know, some people do a gel foam plug and a perforation after roughing it up. With some of these synthetic grafts you can just clean up the edges of the perforation, pack some gel foam underneath it to support the graft, and then just work right through the hole. It looks a whole lot prettier and it feels like it's a little bit more intentional than just stuffing some soft tissue into the hole. That's my baggage, I will tell you. If I don't struggle enough then I'm probably not going to get a good enough result.
[Dr. Walter Kutz]
It's in a stuffer where you take your fascia or whatever and you're going to stuff it through the perforation. That's something else I've thought of I probably should have more often. I guess one warning for the audience on that, if the patient has significant conductive loss, one of the disadvantages of-- that actually would be considered a myringoplasty because you're not entering the middle ear space. If they do have a significant conductive hearing loss, you're worried about the ossicles or cholesteatoma. That'd be maybe one argument to do a tympanoplasty but most of the time they don't really have a lot of conductive loss and I think doing something that's pretty straightforward and simple would work well. I've had some healing issues with the porcine submucosal grafts. Have you had any trouble with larger perforations maybe 50-70% perforations or they seem to be healing okay for you?
[Dr. Daniel Choo]
No, I don't like using that on the larger perforations like that. I don't know if it gets a vascular supply fast enough and then it's a race, more distal portions are going to start dissolving away and left with a recurrent perforation again but I have been happy if you've got a subtotal perforation, let's say you decide to use some tragus and some perichondrium and there's still a little gap there, using the submucosal stuff to fill in whatever defects you have there, and it seems to epithelialized pretty quickly from that.
[Dr. Walter Kutz]
Dan, you mentioned use of cartilage. I've actually interestingly probably used less cartilage over time even in kids and it seems like my results have been-- they seem good. I haven't looked at them systematically. If you really don't know your results you'll be humbled if you look at them systematically. You're usually like, "oh, it holds every time." They're like, "oh, well, it only held 70% of the time," but I think one of the challenges, maybe one of the points you brought up is when you use cartilage, cartilage is pretty rigid and the drum's actually a very dynamic almost like a cone-shaped. I think sometimes I put cartilage in there and I think just that the cartilage doesn't really sit under the drum and you have that little gap but I've seen some of these heal up and we have this little crescent-shaped residual perforation. It sounded like you may take some of the porcine submucosal or a little perichondrium and fill in that little gap. Is that right? Is that what you were describing?
[Dr. Daniel Choo]
Yes, exactly. That's a really helpful tip. I'm curious so I'm going in the opposite direction. I'm probably using more cartilage than I did 10 years ago. I'm really happy with the healing outcomes. It has made a little bit of a difference in a positive way and so far I think I'm still seeing good hearing results from it and especially on those anterior superior perforations that we talked about. I think that area really helps me. What's made you shift the other way, Walt?
[Dr. Walter Kutz]
I think it's just that I think the fascia or the perichondrium is just pretty no-nonsense. It's simply placed in there, it's going to really form underneath the drum, you put some packing, and I think some of the cartilage, I think it's a little hard to size. If you're going to do a shield piece of cartilage, you're going to cut out that strip of the malleus. Sometimes it's difficult to make sure that's not contacting the malleus at the right angle but like you said, in reality, all the literature and our experience shows that cartilage doesn't seem to really negatively affect the hearing results which is really surprising but there's been literature upon literature that really shows there's really not much of a difference. I think the fascia and perichondrium are just simple to work with.
Now, a kid with cleft palate, recurrent perforations those sort of things, yes, I'm going to use cartilage just to buy yourself more time and have a better chance of healing results but these kids that maybe it's just a tube that came out that didn't heal well, they had a traumatic perforation, eustachian tubes go in the other side, I just usually use these fascia and perichondrium. I think that more people lean to using more cartilage over time but I've just used a little less recently and it seems to be working okay.
(6) Harvesting the Tympanoplasty Graft
[Dr. Gopi Shah]
What tricks do you have to shaping the cartilage graft because cartilage I agree is difficult to maneuver, to get exactly where you want, sizing it and estimating it? I don't think I appreciated it until actually working with you Walter and Brandon when I was a fellow and being like, "hey, the important stuff is actually--" hate to say it on the back table, "where you're actually harvesting. That's where the attending is harvesting the graft. How do I know what size and what angle and what shape?" Any tricks on that?
[Dr. Walter Kutz]
I was going to let Dan answer because he's the cartilage guru here, but, no, I've used a lot of cartilage. Gopi, I think when we were working together I probably used cartilage in most cases. What I like to do-- I've done it a lot of different ways. I think John Dornhoffer if you want to read some literature, I think he has really good techniques and well-explained if the listeners want to look at some more literature regarding cartilage graft tympanoplasty. I've been shield grafts but what I like to do now is I'll place usually perichondrium or fascia if it's a large perforation and I'll actually place the cartilage separately. I don't really do these composite graphs as much anymore. I'll fix the perforation or have the perforation cover the soft tissue and then I'll put cartilage underneath that and of course, you want to support that cartilage with gel foam. If I'm going to use cartilage that's typically how I'm using it.
[Dr. Daniel Choo]
I think we've been and this is in a period where probably 85% maybe even 90% of my eardrum perforations were fixing endoscopically. I'm hesitant to make a separate incision behind the ear to harvest fascia and so I'm using a lot more-- that may be one of the drivers, Walt, why I'm doing more cartilage, to tell you the truth. Our trainees definitely do struggle with making the graft the right size and shape. When it comes to harvesting we always take as big a tragal graft as you can. I tell people it is physically impossible for you to harvest too big a graft. We leave the tip of the tragus so hopefully it doesn't deform too much and then more recently I've had the trainees take the foil pack from one of our sutures and just create a template, start working with it, and it gives them a much more concrete shape and size that they're going to trim the graft to and especially with an endoscope.
I started out asking them, "take a round knife and measure it out when you're looking in there and tell me how many round knife diameters are we going anterior to posterior, superior to inferior," but one of the pitfalls there is that with the endoscope, they get a bit of this parallax and it can make the round knife look bigger or smaller in relation to the perforation and then when we actually cut it and put it in, you're like, "holy cow, how did we end up so off on this thing?" That's where the foil pack has come in more. I've been much happier with that. It's rare that we put a cartilage graft in there and it's way out of sync with what the hole is like.
[Dr. Walter Kutz]
Those are all good tips. I noticed something just fun about otology is that I think your techniques change a little bit over time probably your whole career. It's very creative in a lot of ways. There's different ways of doing it. I'll go see somebody give a talk and even this conversation and I'm like, "yes, let me try that," and you try that a few times. I agree with all of those and it's as you become really more experienced, you can just eyeball it and cut it pretty accurately every time. That takes many cases to do that. I really like the idea of templates. If you were to use an eight-millimeter speculum, that's a pretty good idea of how large the drum is going to be. You could even just stamp that with a marking pen or something just as a start. Then, that's another way to size things.
[Dr. Gopi Shah]
My first few years out, I would separate it because I liked that technique. I always found the composite, maneuvering it, managing, measuring it, fitting it how I wanted, a lot more difficult. I liked separating it. I like, I think the way you would remove some of the excess cartilage off of-- when you were doing a composite, there was a few times when you did, off of the fascia. You use the small round knife, just so that you wouldn't pop through the fascia. Just gently. I liked those two things that you used to do too. We had mentioned some myringosclerosis. When you're doing formal tympanoplasty, when is it helpful and when do you decide to take that all out? How do you know what you're going to leave in and what you're going to take out?
[Dr. Daniel Choo]
I got a pretty pragmatic, but not consistent approach to it. I really dislike say doing an underlay graft to a bunch of myringosclerosis. I just can't see that healing really well. I'll start peeling away at least till we have a couple of millimeters, if not a few millimeters of healthy drum that we can contact with fascia or perichondrium. Sometimes as you're doing that, the whole thing just peels out like a plaque. You look really slick and say, "oh, this is great." Other times it's so adherent that you just start tearing away more drum. Very pragmatic when it comes to that. I hate to take something that would have had a good healthy margin of native drum and then booger it all up by trying to peel away the plaque. At least a couple of millimeters, if not a few millimeters of drum epithelium that we can graft to makes me feel a lot more comfortable.
[Dr. Walter Kutz]
Yes, I think my approach is very similar. I think myringosclerosis, there's different severity. The really thin, little discolorations, a little whitish, that's probably fine. if it's thick where you take a 5910 beaver blade or a rose and you can't at all poke through the thing, you're afraid you're going to injure the ossicular chain or something, that's probably not going to heal well. Even for a small-medium perforation, one thing I do like about a lateral graft technique, and it could be if you do underlays, I feel comfortable removing the drum. If it is really thick, diseased drum with this really aggressive myringosclerosis, I'll just remove all that and then put a fresh piece of fascia in there, and typically you're going to heal pretty well. It's always a question people ask me that I think it really depends. You want to have a very systematic way of doing it, but all the myringosclerosis is a little different, it's a different location of the perforation. Like Dan said, sometimes you can peel it from the undersurface of the drum, sometimes you can't. A lot of times it's a game-day decision.
(7) Dealing with Otorrhea on “Game Day”
[Dr. Gopi Shah]
Tell me about otorrhea game day. Let's say, two scenarios. One is the patient's in pre-op and they got snot coming out of their ear. Let's say the second scenario is you don't really see anything in pre-op, but you go to the OR and there's drainage and there's some granulation tissue. How do you guys manage that? Also thirdly, do you routinely look with an otoscope before surgery, before the patient goes to the OR?
[Dr. Daniel Choo]
I was just trying to think the last time I canceled a case in pre-op because we were going to fix an eardrum and then the kid had some otorrhea at the time and I really can't remember. For better or worse, we kinda plow ahead. I am one of those believers where I think some of our chronic recurrent otorrhea kids have biofilm disease and cleaning them out at the time of tympanoplasty is probably a good idea. If anything, rather than doing something minimalistic like a butterfly graft, if the kid's draining and the ear looks fairly hot, we'll turn a tympanomeatal flap, clean everything out as good as we can. Up until recently, I was also a big fan of putting in some Otiprio into the middle ear space when we do that. That's that long-acting quinolone. It's in a hydrogel. You squirt it into a liquid and then when it hits a 37-degree environment, it gelatinizes and then it stays in there for about three to four weeks.
In the early healing period, you're giving the ear a fighting chance to stay clear of an acute infection, give that graft a chance to take. Unfortunately, they're going to stop marketing that in the U.S. because they didn't have a great demand for it.
[Dr. Gopi Shah]
Does that have steroid in it too?
[Dr. Daniel Choo]
No, so no steroid component in that one.
[Dr. Walter Kutz]
Yes, I have a similar approach. I can't think of the last time I canceled a case because of otorrhea. Now, if I was intraoperative, I wish I would have canceled the case when it's a total disaster. I think one really good hint for newer surgeons, and I've been in practice a long time, just you keep learning things as you go, but if a child has any history of otorrhea, just tell them to start drops one week before surgery. I usually tell them to start Ciprodex or some drop with a fluoroquinolone and a steroid. I think that can really help prevent some of this. Sometimes I'll forget to tell them or they'll forget to start it, but I'll proceed. There was a good study at House years ago when they looked at patients that had a dry perforation or a draining perforation at the time of surgery and the healing results were really about the same.
It just makes surgery more challenging. The other thing too is sometimes you get such bad meningitis that it's hard to know where do you stop rimming the perforation. It does make it more challenging, but we typically push forward. I think Dan's got a good point. A lot of these kids just have biofilms and if they're going to drain-- you're going to cancel them and they come back three months later and they're draining again.
[Dr. Gopi Shah]
Any tips on-- because when the ear is inflamed, it's going to bleed a little bit more, any tips on hemostasis?
[Dr. Walter Kutz]
I think with the endoscope, I've learned to use 1 to 1,000 epinephrine a lot more often. I didn't really use it that much. I use it the microscope now too, but you can do gel foam with 1 to 1,000 epinephrine or you can use little quarter-inch patties. It'll stop bleeding very quickly within less than a minute. If you get a lot of bleeding, just put some down there, wait a little bit, and then take that out, and you can proceed.
[Dr. Daniel Choo]
I agree. I think it's just patience, which is really hard for us because you got to stop a little bit more frequently, let it dry up, dissect a little bit more. It's really hard when I'm not the primary surgeon just watching that.
(8) Deciding Between The Microscope & The Endoscope
[Dr. Gopi Shah]
Any other tips or tricks about surgery itself because that's going to then lead into some of the post-op care?
[Dr. Daniel Choo]
I'm curious what you guys think why don't you do a ton of endoscopic stuff as well? We're shifting to our fellows who will probably have done more endoscopic ear surgery than they have microscope. Part of me is being old fuddy-duddy otology, neurotology feels like, "man, you got to learn your microscope skills. That's a very different skill set." These days, I actually give the fellows and the residents their preference, like, "all right, how do you want to do this one? Microscope? Endoscope?" Most of them are actually gravitating towards an endoscope. They really like that. What are you guys noticing?
[Dr. Walter Kutz]
That's the same experience. Our probably past three to four fellows, eight, they probably have a little more endoscopic experience. Typically, a lot of these all start endoscopically and then I try to tell them, "hey, we need to make a decision early." If they have a secondary acquired cholesteatoma, they've got a lot of granulation tissue, you've got a lot of bleeding, sometimes it's just quicker, and better for the patient just to go post-auricular, use a microscope. You're not defeated if you convert over to microscope. It's just a tool. We're still ear surgeons. We're doing ear surgery. It doesn't matter if you're doing a microscope or endoscope. No one ever has to use an endoscope and have great results. I like to be able to use both.
Especially the residents, they really like the endoscopes. They get a lot of sinus surgery, and so they really like to use endoscopes. A lot of our fellows, I'll say, "How are you going to do stapes? How are you going to do tympanoplasties?" Most of them are using endoscopes for those operations. I do agree, you worry about losing some microscopic skills. If a case is going to take 50% longer to use an endoscope, it doesn't make a lot of sense to me for a small post-auricular incision. One thing I'll mention about, it's an operative point, is every time you do a tympanoplasty, make sure to look under the remnant tympanic membrane. I think one of the most common cause of failure is actually leaving behind some secondary acquired cholesteatoma. A very common place would be under the manubrium. Always look there.
I had a case recently, had a residual perforation. I knew they had a secondary acquired cholesteatoma. I thought I removed it all and I bet I left a little bit behind and it's just not going to heal well. Then obviously you've left a cholesteatoma behind. I think it's a good pearl to always lift that remnant drum, make sure you don't see that shiny appearance of epithelium because this probably happens more commonly than we think, especially these patients with these draining years.
[Dr. Gopi Shah]
Do you use a 30 for that or does it matter?
[Dr. Walter Kutz]
I think a lot of times you use a zero degree, but I guess if you have a small perforation and you don't have a nice tympanomeatal flap, you could use a 30 to help out.
[Dr. Daniel Choo]
Gopi, I got a question for you.
[Dr. Gopi Shah]
Yes.
[Dr. Daniel Choo]
One of my frustrating things after a pretty straightforward tympanoplasty is every once in a while you get this kid who still has a mild conductive hearing loss. Drum looks great, middle ear space looks nicely aerated, and I just can't get their air-bone gap closed. I've scanned a bunch of those kids saying, "Where did I leave something or where are their adhesions? The scan looks really benign." What do you guys think is going on there?
[Dr. Gopi Shah]
I wonder if there's maybe some sort of scarring between the ossicles, maybe just because of manipulation. There probably are some adhesions that we just don't see in a scan that can be thin and strandy. Maybe the way the eardrum heals doesn't vibrate as well too. Those are the things and I've had those kids and it's just like, "God." Then usually I'll be like, "oh, dang, I'm going to have to send them to Dr. Walter Kutz now for another opinion to see, do we need to do anything or can we watch it? What are we going to do?" It's super frustrating. Then I've had the other kids where, "uh, darn, there's a little hole still left, but the hearing is good, but that's a good result."
Anyway, to the question that you asked, it's I think probably just from manipulation scarring, whether it's the ossicles, because we check the ossicles and you're still tucking a graft underneath and you're still doing stuff. It's going to move a little bit to-- could be some straining of adhesions that we don't see, and just in the way the drum vibrates now, it may not be vibrating the same way. I don't know. What do you think, Walter?
[Dr. Walter Kutz]
Yes, there's probably a lot of reasons. I recently published some tympanoplasty results and our mean air-bone gap was 10 or 12. I was like, "what? What is going on?" If you look at the literature, that's about where your mean air-bone gaps, even just simple medial graft tympanoplasties. We always think, "well, we should get total air-bone gap closure," but that doesn't always happen. I was really surprised when I-- I was saying, "well, there's something wrong with the technique," but I looked at the literature, and there's still going to be an air-bone gap in most kids and it's bothersome. Now, when he gets 15, 20, then you're really like, "oh." you're worried about what is really going on. I think it could be many, many different things. It could have some tympanosclerosis that's causing some of the stickler chain, not immobility, but maybe some impaired movement. You're right. It's amazing we get the results to do with replacing a tympanic membrane using all this cartilage, all these sort of things. It's probably multifactorial, and sometimes the parents really focus on that. You can see on the graph, "Wait a second, the hearing in the operated ear is worse than the good ear." I'm like, "Well, the operated ear is not a normal natural ear. We have to repair it." If it's a 10-decibel air-bone gap, it's not going to probably affect the child. That's in reality, a good result, but otology is humbling. That's for sure.
(9) Post-Operative Management of Tympanoplasty
[Dr. Gopi Shah]
In terms of post-op, do you drops a couple of weeks later, for how long, if the kid doesn't do drops, does that change your management? Do you have to suck the packing out week three?
[Dr. Walter Kutz]
I usually have them start drops, I don't know, 10, 14 days after surgery. One trick, if the drops bother the kid, parent can put it in their pocket for 10, 15 minutes. I think warming it up a little bit can help. It's pretty rare that I think drops actually burn, but we do have patients that describe that sometimes. In reality for the young kids, I just put them on drop for a long time because I do like suctioning out the packing, but there comes a point where it is just not good for anybody to keep going after the packing. A lot of times there'll be a little packing anteriorly that you just can't remove on anybody. I just continue drops for a couple of more weeks. It usually takes care of it.
[Dr. Daniel Choo]
Yes. I think that sounds pretty familiar. I'll see my kids back somewhere around three weeks post-op from a typical tympanoplasty and then won't start drops until I see them and then cleaning out the gel foam, whatever is convenient and comes really easily enough so I can get a peek of at least part of the drum to see how it's healing up. Then they come back probably another month after that. That's when we'll do a more formal clean out if there's anything residual as well as an early hearing test to see where they're heading.
[Dr. Gopi Shah]
When do you usually get another audiogram after surgery?
[Dr. Daniel Choo]
It's typically at the second post-op visit, I'll get one and I'll give the parents the caveat. I said, "listen, I just want to know where they're heading and see if we're in a good place early on, but it'll still get better for another few more months." That's typically three weeks from the first visit and then four weeks after that one. Around seven, eight weeks, pretty typical.
[Dr. Walter Kutz]
I do a three-week and then I'll check the hearing in three months after surgery. Now, if there's some concern with healing, I'll see him again four weeks after that initial three-week visit. A lot of times if the thing looks like it's going well, say in about three weeks, I've already started my drops and then I'll just see them back in three months with an audiogram.
[Dr. Gopi Shah]
How long do you all do dry ear precautions for?
[Dr. Daniel Choo]
About four to six weeks. From four weeks. How about sports and weightlifting and all those kinds of things?
[Dr. Gopi Shah]
I was so conservative. I'd be like, "do you mind?" They're like, "I don't know." I was so conservative with water and heavy lifting and sports. I'm like, "these are not our school-based patients. This is okay. This is healing." I would just be super conservative about it.
[Dr. Daniel Choo]
Oh, man. Your patients don't revolt on you?
[Dr. Gopi Shah]
They probably do. They just don't tell me.
[Dr. Walter Kutz]
Especially if they had an ossiculoplasty. I did have one patient that probably said football's big in Texas and played-- I think it was actually two or three months after surgery, and they dislodged their prosthesis, but you're not going to tell them not to play football for two or three months. That's one of those unfortunate occurrences.
[Dr. Gopi Shah]
For any of our craniofacial kids, any nuances or double checks, belt-and-suspender type things that you do for the perforation that you're repairing in the child with Down Syndrome or the cleft palate history that you're doing it, they have the hearing loss or it's otorrhea?
[Dr. Daniel Choo]
I do think some of our kids with pretty severe clefts and skull base malformations, they're just always going to need a tube or some type of ventilation drainage place. If they've got a subtotal perforation and a near-maximal conductive hearing loss so you got to do something, sometimes I'll graft those drums and I'll probably use tragus for that. Then I'll also put in-- I did my ear fellowship with Herb Silverstein and he put in these sub-annular tubes that actually go underneath. If you've got the drum already lifted up to do your tympanoplasty, it's actually a pretty easy thing to slide one under there. You drill almost like a little trough where you're going to recess the tube just a little bit under the annulus area and then lay the drum down on top of that.
You give them much more of an intact drum, hopefully, improve their hearing, but still leave them with a tube. I've never been happy putting a tube through a grafted area of the drum. That just seems to come back with these huge holes for me. This was one way to get around that.
[Dr. Walter Kutz]
I've thought about doing sub-annular tubes. That makes a lot of sense. What I'll do on some of these really tough ears that you need a chronic tube is I'll just punch a hole through the cartilage, use a five suction, push that down through the cartilage, and take a small 5910 beaver blade and make that hole. Then I'll put a T-tube through that. Those patients tend to do really well. I've had a number of patients that have had that tube in for years. I think the tubes are going to stay in. They can get blocked, but it'd be simple enough, I think you go to the OR, pull it out, put a new one back in. I don't recall one being blocked, but that's certainly going to happen one of these days. You're right. You're grafting a drum and you're putting a hole in the drum with a tube. Somebody you just know has poor eustachian tube dysfunction.
[Dr. Gopi Shah]
Do those tubes eventually fall out on their own or do they stay in forever?
[Dr. Walter Kutz]
I haven't been in practice forever, but most of them seem to stay in. Half of the sub-annular tubes, same thing. They'll stay in, but they get blocked and things. That's what I've heard.
[Dr. Daniel Choo]
Yes. You do have to do a little bit of maintenance to keep them open, but I haven't had one fall out. If we've ever wanted to, we had to pull it out.
(10) When Tympanoplasty Isn’t Enough
[Dr. Gopi Shah]
Then quickly, in terms of hearing rehab options for the child that we didn't repair or the child that had the same or worse hearing outcome after surgery, audiology visit, hearing aid, preferential seating. Tell me, FM systems.
[Dr. Walter Kutz]
I think all those. You definitely want to document things and talk to the parents about preferential seating. Let's say they have a unilateral mild, moderate hearing loss, if they're kids in Texas, Medicaid, they're not going to be able to get a hearing aid. It may not be worth that much money just to buy a hearing aid, but, an FM system can really solve those issues in school at least and help learning. One thing, if you don't fix a perforation, most kids can tolerate a hearing aid, but there's a chance the moisture retention that they're going to get chronic otorrhea. I leave that to the parents. If they have bilateral, moderate, severe hearing loss, those kids really probably should be encouraged to wear hearing aids. Also can't forget the bone-anchored hearing devices.
The new transcutaneous devices, we've had really good success. I've converted a number of patients from the percutaneous to the new transcutaneous, and they really like the sound quality better, probably gives a little better high-frequency hearing. Now they don't have this poll sticking out of their scalp. They just put on a magnet and they can use it with their phone and everything else. That's another option that can be considered, but you don't want to forget about the hearing component, obviously. If a kid or a patient has bilateral cholesteatoma, terrible hearing, a lot of times the first surgery, I'll just put in a percutaneous bone-anchored hearing aid, because they may have hearing problems for two or three years. By the time you operate on one ear, do a second look, if you do a second look, so the other ear second look, and you may not get a good hearing result.
I think putting a bone-anchored hearing aid as soon as you can will at least give them-- you're going to solve the hearing issue until you get this all fixed. That's something to think about.
[Dr. Daniel Choo]
Yes, I agree, Walt. The percutaneous ones are so reversible. It's such a benign intervention that you try to talk them into it. It's a hard sell sometimes to tell people, "you're going to have this little post sticking out through your skin," though. Have to get them acclimated to that.
[Dr. Walter Kutz]
For my adult patients and kids, if they don't like it or they don't need it anymore, you just unscrew it in five seconds. I will mention one thing. If you're going to do the transcutaneous, you got to think about, do you need to do a diffusion-weighted MRI in the future. Typically, if somebody has chronic otitis media, unless I just know that ear is safe and very unlikely to have a residual cholesteatoma, I'll just do a percutaneous. That's something to think about because even though it may be MRI compatible, you're going to get so much scatter with that Baha device that it's not going to allow you to do a diffusion-weighted MRI to look for residual cholesteatoma.
[Dr. Gopi Shah]
As we wrap up, do you guys have any final pearls, or maybe something that you do differently now than you did 10 years ago?
[Dr. Daniel Choo]
I think 10 years ago, I wasn't doing a ton of endoscopic ear surgery. I think that is, I hate to say game changer, but I do think there's some real impact that it's had, probably more so in cholesteatoma disease, just the enhanced visualization. I think we're getting better at eradicating disease that way. Then in line with that, with us doing more transcanal endoscopic approaches, I definitely am shifting towards a little bit more cartilage than I did 10 years ago. Just circling back to one of the points we talked about, sometimes you get those really thick cartilages and you hate to put that much mass underneath your eardrum or in your eardrum. The cartilage trimmer is something I'm using more. It's to really shave it down and make it a thin piece of cartilage, and I think still conveys the structural support that you want without imparting such a big mass on the eardrum.
[Dr. Walter Kutz]
Yes, I agree with that. I started using endoscopes in 2014 and like I said, it gives you another way to deal with ear disease. If somebody's cholesteatoma is in the sinus tympani, you just can't see it with a microscope. If you're a skilled endoscopic surgeon, you can put a 30-degree scope, you know what to look for, you know how to prevent all the fogging, you know about hemostasis, you know the right instrument, and there's been a number of times even where it may be a microscopic approach, I'll pull out an endoscope, and I think before I did a lot more endoscopic surgery, it would have been a real challenge. Now, if you use an endoscope frequently, it's not a big deal, and it can really enhance surgery. I do agree, that is something that has certainly changed my practice since I started. I think, as you might have mentioned, Daniel, I think as you get more and more experience, you get more humble, and there's definitely-- early in my career, I was like, "oh, we can fix that. This is going to be great." Now, I think it's more a lot of, "let's watch this perforation." You know where you may get burned because you've been there before. That's just part of your experience as a surgeon, and everybody has to go through a little bit of that. I think that's something that I rarely regretted being a little more conservative initially.
[Dr. Gopi Shah]
Yes, absolutely. I think for the endoscope, I think, Dan, you had mentioned this earlier with the fellows, especially on the PD side, that's what we're used to, right? Endoscopes in the sinuses, endoscopes in the airway. An endoscope in the ear is something, if you're doing PD, you're probably going to gravitate to more. Then in terms of being conservative with a perf in a kid, I've never been burned being conservative with a perf in a kid. Anyways, thank you guys so much. I learned a ton. If our listeners have any questions or want to learn more about you guys, are either of you on any social media?
[Dr. Daniel Choo]
No.
[Dr. Walter Kutz]
Well, I do Twitter, so EarDoc1, and then Instagram, which I don't as much, as Walter Kutz MD.
[Dr. Gopi Shah]
Awesome.
[Dr. Daniel Choo]
You're so hip and fresh. For an old guy, it's shocking.
[Dr. Walter Kutz]
I don't have TikTok. My kids want me to get TikTok. No TikTok here.
[Dr. Gopi Shah]
All right. Dan, if anybody wants to get a hold of you, reach out to us at BackTable, and we'll try to pass a message along. For our listeners, for stopping by, thank you for joining us. If you have any comments, ideas, or ever want to come on the show, please reach out to us. That's a wrap.
Podcast Contributors
Dr. Daniel Choo
Dr. Daniel Choo is the director of Pediatric Otolaryngology - Head and Neck Surgery with Cincinnati Children’s Hospital in Ohio.
Dr. Joe Walter Kutz
Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, March 30). Ep. 100 – Tympanic Membrane Perforation 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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