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BackTable / ENT / Podcast / Transcript #183
Podcast Transcript: Office-Based Ear Tubes in Children
with Dr. Shelagh Cofer
Given that recurrent otitis media can expose children to hearing loss, delayed speech development, and repeated antibiotic use, it is not at all surprising that ear tube insertion is the most common ambulatory procedure performed in the United States. But what if there was a way to insert ear tubes in children without going to the operating room? In this episode, host Dr. Ashley Agan speaks with Dr. Shelagh Cofer, pediatric otolaryngologist at the Mayo Clinic, about the Hummingbird Tympanostomy Tube insertion system. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Impact of Ear Infections
(2) The Development of In-Office Ear Tubes
(3) Who is a Good Candidate for In-Office Ear Tubes?
(4) What to Expect the Day of Ear Tube Placement
(5) Surgeon Technicalities for In-Office Ear Tubes
(6) Benefits & Drawbacks of In-Office Ear Tubes
(7) Tips & Tricks for Smooth Application of In-Office Ear Tubes
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[Dr. Ashley Agan]
My name is Ashley again, and I'll be your host today. I am joined by Dr. Shelagh Cofer, and I'm very excited to dive into an exciting conversation about in-office ear tubes in kids. Dr. Cofer is an associate professor of otorhinolaryngology at the Mayo Clinic in Rochester, Minnesota. She's passionate about caring for children with simple and complex disorders in ENT and very interested in new technologies that can enhance the care of children with ENT disorders like in-office ear tubes.
Welcome to the show, Shelagh.
[Dr. Shelagh Cofer]
Thank you. Thanks for having me.
[Dr. Ashley Agan]
Before we get into it, maybe tell our listeners a little bit more about you and your background.
[Dr. Shelagh Cofer]
Sure. Yes. I did a training with medical school and residency at University of Illinois in Chicago, and then I went on and did some other additional training just in pediatric otolaryngology, and that was in Minnesota. I did a year there, and then I joined the staff at the Mayo Clinic in 2008 and have been there since.
(1) The Impact of Ear Infections
[Dr. Ashley Agan]
Awesome. Let's talk about, before we get into office ear tubes, maybe we can set the stage with just speaking about the background of ear tubes in kids in general because it's basically, as ENTs, it's probably the most common case we've ever done. Because we do so many in residency when we're training, and when we get out, it's part of the bread and butter. Most people could probably do a tube in their sleep.
[Dr. Shelagh Cofer]
Right. Exactly. I know. It's not brain surgery, but it is a common problem. You're so right, Ashley. More than 80% of children will have an ear infection by the age of three, and when we think about the most common reason that a parent would take a child in to primary care, it's for an ear infection. Annually, it's estimated that $2.8 billion is spent just to care for children with ear infections. That's a lot of impact there.
On an individual level, ear infections can impact a child's hearing, their speech, and language development, things like their balance development, not to mention taking all those antibiotics and then losing sleep by the parent and the child and suffering that happens from ear infections. When we talk about surgery to treat ear infections, specifically tympanostomy tube placement, as you mentioned, it is the most common procedure that's done in an ambulatory setting, and nearly three-quarters of a million cases are done a year. This is a very common problem.
[Dr. Ashley Agan]
Yes, it's pretty amazing. I experienced some of that myself when my daughter was younger, so I got to be on the patient side of it for a little bit, which was good for me. It's good to walk in those shoes. Take me back to when the idea for in-office ear tubes was coming up and how you were-- because I know you were involved in some of those early studies. Talk to me about that.
[Dr. Shelagh Cofer]
Yes, I was. I just want to take you back a little bit further even, historically, just to give some perspective on where we are today, but two prior developments have really impacted surgical care of patients with ear infections. The first of these was the arrival of the operating microscope, and that was in the 1950s. They became commonly available, allowing the ear to be seen and visualized magnified and in great detail. That was a huge leap forward.
Around the same time, anesthesia gases were developed, and so we now had this tool where we could have rapid onset of sleep or general anesthesia and rapid offset or awakening. For years and years, the most common way for a child to get ear tubes was in the operating room with general anesthesia. If we fast forward to a few years ago, just by happenstance, I became connected with a company that was developing a device to try to do these ear tubes in a single pass, so eliminate some of the steps, make things more efficient and streamlined, and could we potentially do this even in the office?
I was really lucky to be a principal investigator on a lot of those studies and just followed the research, and it's now a real thing. It's been great.
(2) The Development of In-Office Ear Tubes
[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.
(3) Who is a Good Candidate for In-Office Ear Tubes?
[Dr. Shelagh Cofer]
That is a really good point. I, in my mind, also break it down into similar age ranges, the very little littles that we use a gentle swaddle technique to help immobilize them, and a nurse or an assistant will help steady their head. Then the older kids, eight and older, I would say, probably, who you can coach through. Then that in-between range where they're really too big to put them into a swaddle. It just doesn't feel right.
We do have ways that we can work with them and different ways to immobilize, primarily the shoulders, and helping to steady the head. Involving the parent a little bit in this process is really helpful. As far as the patient selection, really, you have to meet the same criteria as you would for any child to recommend ear tubes. If you have a very teeny tiny ear canal, or let's say your eardrum is super retracted, it's stuck in and there just isn't a space behind the eardrum or if you have a tendency to bleed easily, these are the reasons that we would consider you not to be a candidate to do tubes in the office. Otherwise, anybody else, no matter what your age, can easily have it done.
[Dr. Ashley Agan]
Once a parent has said, "Okay, we want to do this office procedure thing," what happens next in your office? Are most people getting it done the same day as their consult? Do they already know that they're leaning towards that anyway?
(4) What to Expect the Day of Ear Tube Placement
[Dr. Shelagh Cofer]
We have a great setup and a great system to be successful at doing this. I think if you want to incorporate this into a practice, for example, it's important to start setting up the expectations even before the clinic appointment. We have a half day where we schedule all of our patients who are interested. They've already been sent an educational brochure, which describes the procedure. When they show up already to my office, they know what to expect. They have already thought about it. They've already decided, "Yes, I'd prefer this approach."
Even so, when I see them in the clinic, I do talk to them about, "You can have this set up as a scheduled procedure in the operating room and with fasting," all of that, or we can do it today here in the clinic. We just use that shared decision-making process, which I think is really important to make sure that the right child, the right parent is getting the right procedure in the right location.
It works really well, but it does help to have that expectation. When I see them for consult, I also describe in more detail what will happen during the procedure. We are in a consult room and we have a procedure room that's just a few doors down from us where we go to do the procedure. As soon as we're done, we just pop up and we go back to the other room. It's a very smooth process. I would say it takes about 30 minutes to do a consult, do the ear tubes, and have the patients do their scheduled follow-up.
[Dr. Ashley Agan]
Are your kids usually coming in with audiograms already or do they do it before they see you that day?
[Dr. Shelagh Cofer]
They do. We have appointments scheduled for their hearing tests to be done the same day. These are linked appointments. That's my office staff and how amazing they are and getting this coordinated and supporting this.
[Dr. Ashley Agan]
As far as your audiograms, is it like the classic audiogram or is it just OAEs or just tymps, tympanograms? What kind of information is necessary for you?
[Dr. Shelagh Cofer]
Yes. My preference is to have them complete a full audiogram and a sound booth, including tympanograms. If they're able to wear headphones or inserts, we might be able to obtain your specific hearing information, but sound-filled hearing test results is adequate as well and can reveal mild hearing losses, which is what we would see from a child with an effusion, is a mild conductive hearing loss.
Typically, I have in the past, if there's been a report of parental concern about hearing and there's been a lot of ear infections, they, of course, have to have an effusion on the day that you evaluate them. Just went ahead and done the ear tubes with just tympanograms only and the knowledge that they passed a newborn hearing screen, and then scheduling a follow-up hearing test in six to eight weeks, which is the usual amount of time before we see a patient back. That's just because audiology access can sometimes be a challenge.
[Dr. Ashley Agan]
The child may not be cooperative on the day that they happen to be getting their hearing tests. Little kids are finicky sometimes and aren't always in the mood.
[Dr. Shelagh Cofer]
Yes, sometimes you got to just be flexible.
[Dr. Ashley Agan]
Okay. Moving through the appointment. The patients, they watched their video or they read through their brochure, so they're prepared for it. They know they want it. They get their hearing test. They see you in consultation and you agree, tubes are a good idea, and they want to move forward. Then what happens next?
[Dr. Shelagh Cofer]
What happens next is, sometimes they've already taken a dose of maybe some ibuprofen, some Tylenol at home. If they haven't, we go ahead and administer that in the clinic. They sign their consent form. We reviewed all the risks of the procedure, same risks as with any ear tube placement. You can put a tube in. Typically, we say it stays from 6 to 18 months which is a regular-acting tube durability or duration. All the same potential complications, early extrusion, prolonged retention. After the tube falls out, you can have a perforation or hole.
We review all of that. We have them sign the permission slip, and then we just go down to the end of our hallway where we have a flat table. We've got a medical immobilization board plus a sheet or something soft on the inside of that. We swaddle them up. Our microscope happens to be connected to the ceiling. We're able to just pull it right down. I always do it the same way every time just to make things easy. I start on the left ear. We use speculum, we use a microscope, clean out earwax.
Then what we're going to do is use numbing medicine directly on the eardrum. The Hummingbird device is approved for use with any type of topical anesthetic. I think you were mentioning the Tula device, which has its own proprietary way to numb up the eardrum. We use phenol and we just dab it right onto the eardrum. It's a chemical neurolytic. It works very quickly. Some patients describe that their ear feels full or it stings a little bit or it sounds funny when it hits their eardrum. Then we go right in with the device, makes the incision in the eardrum. It's already got the tube loaded in it, and we deploy the tube and come back out.
It's like, picture earlobe piercing gun, in a way. It's that simple. Then we do-si-do around, switch sides, and I'll do the second ear.
[Dr. Ashley Agan]
Thinking about your team that's in the room, so you have a medical assistant or nurse or someone that's helping hold the head. I assume they're sitting at the head of the bed.
[Dr. Shelagh Cofer]
They sit opposite me. Once the shoulders are immobilized with the sheet, the blanket, the Velcro cross, then they sit opposite me to steady the head. It's a waxing, waning sort of response you're getting from a child. Some kids cry as soon as you lay them down. Some kids cry as soon as you wrap them. Some don't cry until you're done cleaning the ears out, but they start to react and cry when you're putting on the numbing medicine.
What our research has shown is that the response from earwax cleaning is rated exactly the same as the application of the numbing medicine and the tube placement. That tells me that it can be difficult to know why a child is reacting at that age. Some of it is anxiety of something different. It can be pain. It can be, I don't want to be held still. There's a lot of different reasons for that. As soon as we're done, and we are typically done with both ears in three minutes or less, we're releasing the patient and we do what I call R&R, which is we're going to release and retreat.
We leave that area of the procedure room. We go back down to the other room. Most kids, I would say 90%, are no longer crying as soon as we release them and hand them right back to their parent's arm. Then the final 10% might continue to cry, but 100% are done crying by the time we're done with wrapping. up.
[Dr. Ashley Agan]
As far as the personnel that you have helping, so the nurse or medical assistant is helping hold the head, do you have someone that's handing you instruments so that you can put the phenol on really quickly and then go right in with the device right after that so that that moves smoothly?
[Dr. Shelagh Cofer]
I do have the luxury of having somebody who is working in a clinic who can come down for each case that we do and hand me the instruments. They've been trained on how to do that properly. We did a lot of education of the office staff so that it wasn't so dependent on just one person or maybe a couple people who know how to do this, but all the office staff is comfortable with it so they can all jump in and help. I like to be able to just be focused on what I'm doing and try not to have my eyes leave the oculars of the microscope. We were always taught to do that. You should be able to put your hand out, have an instrument put into your hand.
That just helps the flow and it helps us to be quick and efficient.
[Dr. Ashley Agan]
I think that makes sense. Is there anybody else in the room, like is there a child life specialist playing a guitar or dancing, helping distract?
[Dr. Shelagh Cofer]
Yes, it's such a great question. Child life therapists are amazing, and I'm so lucky to be able to have access to them in the outpatient world. I think that that's probably less common than say in a hospital setting. They are so great because if you do have one of those older kids that can be coached through, they spend a lot of time meeting that child. During the consultation, they're in there getting to know that child and talking to them and coming up with a strategy that's going to help them get through the procedure.
When available, I do have that child life therapist in the room with us. If it's a small child, we might have a music therapist on any given day. The music therapist is in there playing the music, which we all love because that makes us all feel comfortable.
[Dr. Ashley Agan]
Yes, anything to help bring down the tension of having a screaming child. Then the parents are there too, right? I'm sure that took some getting used to, to having those extra eyes watching you during your procedure. Whereas in the operating room, you don't have that extra, I don't know, pressure of all the eyes watching the procedure.
[Dr. Shelagh Cofer]
Right. It is so important, I think, personally, to have a parent there. It doesn't have to be both. Sometimes, it might be a mom, it might be a dad, somebody might be extremely squeamish. I feel that it's really important. I think it sends a message to the child, "You may not like what's happening, but we as your parents and caregivers, we condone what's happening. We support it. We're here for you." I think that's the primary reason.
The secondary reason, I think, is if anything ever did happen or go wrong, which it really never has, and I don't anticipate something happening, but I think it helps in the event that it would for a parent to say, "Well, I saw that. I know what happened. I know what the response was." You don't have to come out of a room and say, "Oh, this tube got a little bit over-inserted." They're going to be wondering in their mind, "What really happened? Was this safe? Am I questioning my decision now?" I think it helps protect them a little bit and protect us, frankly.
[Dr. Ashley Agan]
As far as where the parents are, are they helping hold? Or do you say, "Okay, I want you guys to stay there because we've got our system here and we don't want you bumping or getting in the way?" How do you manage having that extra people in the room who are not your staff and who are not your patient?
[Dr. Shelagh Cofer]
I think there's probably a lot of different ways to set it up, but the way that we set it up is the parent is always opposite side from where I am. They're sitting, picture adjacent to where the nurse is sitting on a stool opposite me. They're sitting on just a little bit more towards the feet of the patient. We encourage them to lean in if they want to. We don't rely on them to do the setting of the head and things because I feel like I just need immobilization and I want to get the job done and do it right and be safe.
I don't rely on the parents to actually immobilize, but I think their presence there, it's just really supportive. When we switch ears, we just switch sides just like the nurse does.
(5) Surgeon Technicalities for In-Office Ear Tubes
[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.
[Dr. Ashley Agan]
When you're done, as far as the decision to use drops afterward, is that any different than when you put tubes in the OR? Is it only if you're seeing otorrhea when you place it, or how do you think about drops afterwards?
[Dr. Shelagh Cofer]
Drops is a really great question. I put all my patients on eardrops when I do them in the office. I do also for in the OR as well. However, in the most recent guidelines, I think, actually, there is a recommendation against the routine use of eardrops after ear tube placement. I think that that's going to be a huge hurdle to have ENTs stop prescribing eardrops after ear tubes. I just think it's going to be really, really difficult uphill challenge.
I get it. I get that it's not shown to improve the outcome in terms of plugging of tubes and things like that. I think that the way I think about it is if you don't prescribe eardrops initially, they all have some ear drainage for a few days, all the patients. If you don't prescribe those eardrops initially when they're having ear drainage, they don't. It doesn't set up for the parents what the paradigm will be going forward. The primary reason that ear tubes are beneficial is that it's easier to treat ear infections. Cold symptoms with ear drainage, get eardrops, right?
I think it helps them to recognize that from here on out, this is what we're going to be doing.
[Dr. Ashley Agan]
Yes. Just go ahead and prescribe, it's like, "Here's your drops. You're going to use them for the next week and then hold onto it. If you see drainage, then you can start using them again." It's ear drainage equals eardrops. Do you like ofloxacin or do you to have the dexamethasone in there too? Do you have a preference of one versus the other?
[Dr. Shelagh Cofer]
I do. I do have a preference to have the dexamethasone. I think that I accept the products that don't have it because with eardrops, the availability has changed over the years. The availability of generic versions has really changed how insurance will view this medication. It's hard to know when a patient what their insurance is going to be covering or not.
I've prescribed eardrops for patients and they go to pick them up, and it's just not right to ask somebody to spend hundreds of dollars to get a small bottle of eardrops. I do, I try to work with what the insurance coverage will be and to make it affordable for patients.
[Dr. Ashley Agan]
I feel similarly. I prefer this one, but I don't know if I prefer it $300 a bottle.
[Dr. Shelagh Cofer]
I know.
(6) Benefits & Drawbacks of In-Office Ear Tubes
[Dr. Ashley Agan]
I don't know if it's actually going to make that big of a difference. When thinking about just benefits and drawbacks, we talked a lot about benefits, with just the convenience of being able to get it done that day. No fasting, no recovery time, really. What else? Cost-effectiveness, I guess, would be one thing to think about when you're doing tubes in the office versus the OR.
[Dr. Shelagh Cofer]
Yes. I think it's very cost-effective because you're not having all those other associated fees. Like a facility fee to have it done in an ambulatory care center or in an operating room. You don't have the recovery room fees, the anesthesiologist fee, all of that, I think. It can be a lot more economical and yet still be viable to offer it to patients in the office. You can't really expect ENTs to be doing this if they're losing money on every single case.
There are a lot of nuances to the economics of it. It depends a little bit on the region of country you're in. It depends on the patient's insurance status, what kind of population you see. It's hard, but it does make sense that overall, it has to be less expensive. That's number one. In really listening to parents, I think if you really listened to them, you hear how concerned they are about having their child undergo general anesthesia. I think because there really wasn't an option in the past, they just toughed it out and went ahead and did it because they thought their child really needed ear tubes and they wanted them to be better.
In talking to parents and now that we have this option, it's just so exciting, so great because that is probably the number one thing that we hear from the parents who choose to have this done is, "Wow." Yes, we were able to get it done in one single visit, their child's feeling better sooner, and they got to be with their child. They want to be there and support them. Then I think they really do appreciate the fact that they avoided that risk of general anesthesia and things that can happen with it.
General anesthesia is very safe and it's not something-- some procedures can't be done without it. In those circumstances, when you don't have an option, you just go forward and you do what has to be done. I think now that there's an option, a lot of parents really would like to choose that so that they can follow what they feel is best for their child and certainly not having exposure to medications that they've never had before, potentially any other complication from general anesthesia. I think they appreciate it, a lot.
[Dr. Ashley Agan]
Yes. I think I significantly underestimated how parents feel about general anesthesia and how many people are more concerned about that than the actual ear tube procedure. Then the other thing, emergence delirium, like I've had some families where the older child had ear tubes in the operating room setting, but had horrible emergence delirium that was traumatic for the whole family. I think as an ENT, when we're in the operating room, we're going, right? We're in pre-op or in the OR, we're in PACU, we're back to pre-op and we're just circling. I don't think I appreciated the prevalence of emergence delirium and what that was and how common it was. I think I read that in younger kids, it can be as common as 40%. I don't know. What can you comment on that aspect of it?
[Dr. Shelagh Cofer]
Yes. That's one of the things that I prepare. I make sure I go through what the experience of going to the OR to have ear tubes in your child is like. Your child might cry because they're starving and they're a little bit later in the morning, and you can't predict the OR time. It goes on its own time. They could be hungry or they might cry when they separate from the parent. They might cry as the mask is going on. Now the parent won't be there for that part typically. Although in some situations, they are.
Emergence delirium, so they can certainly cry in the PACU. To me, in my mind, if you have a child that has emergence delirium, and I think there was one study that talked about complications in ear tubes and under general anesthesia and had a 2% major complication rate, which was emergence delirium. It can be seen in 50% or more of patients, and it can last for up to 30 minutes, and things like laryngospasm. If you want to see people move fast, have a child in the OR who's having laryngospasm from ear tubes with just a mask and no IV. People will run into that room so fast now.
It can be treated. It's okay. It doesn't usually result in any kind of sequelae from that, but it's a scary event. I can imagine being a parent, especially if you're not in the medical field, of really being nervous about your child going under anesthesia.
[Dr. Ashley Agan]
Yes. Emergence delirium, what does it look like? It's basically just like the child is crying and delirious and not consolable for more than a certain amount of time. More than a matter of minutes, I guess, or having to be restrained to keep them from hurting themselves.
[Dr. Shelagh Cofer]
Yes. Not being an anesthesiologist, I don't diagnose it, but when you see a patient and you're told that that's what they're having, you see them being just crying, and it's not pain. It's not hunger. It's not they want their parent, they might be sitting in their parent's lap, but nothing that the parent can do or offer can treat this because it is the effect of anesthesia on the brain and this dysphoric state that happens. It's very difficult. You just have to sit and wait it out.
Whereas, in the clinic, as soon as we're done, that parent is consoling. We know that their pain is already subsided because we use the numbing medicine. We've released them from their swaddle. They're handed right back. There are things that the parent can do to try to console. They can give a snack, they can breastfeed, they can try to distract the child. They can do other things, all the things that parents do to try to console their children and they feel more involved. I think they feel more effective.
[Dr. Ashley Agan]
Have parents ever asked for a little bit of sedation or some "silly juice" to take the edge off a little bit? The idea is that it's no sedation. It's just topical, but I've had families ask about just giving a little something. I don't know if you've thought about that or if that's come up.
[Dr. Shelagh Cofer]
I haven't had a lot of requests. I think I've had zero, actually, requests for actual sedation. It would be tricky to do it in our clinic. Not that it could be impossible, but I think there's a lot of policies regarding what medications can be given in the outpatient setting and what kind of monitoring is then required. The beauty of this is that in truth, you really don't need any sedation. Just supporting them in other ways is preferred and works really well.
[Dr. Ashley Agan]
Yes. It can be hard to know how different patients respond to medications. It's not always as predictable. Thinking about complications, separate from what we know in the OR, because you have an awake child that's potentially moving or because it's a different type of device and placement, what are other things that you think about that can happen that we don't really think about in the OR?
[Dr. Shelagh Cofer]
I think some people are concerned that maybe the child's moving, we could injure the ear canal, the canal skin. We might have a drip of phenol that gets on the canal skin and causes a burn or something like that. These things could happen, for sure. They haven't. I have had zero cases of any injury to ear canals doing this in the clinic, but I think it's a fair question.
As far as the tube, we have had 98% success rate of inserting ear tubes in the clinic. Once we get going, we really have a very high rate of coming out of that room with an ear tube in each ear. One situation that I would say could happen is slight over-insertion of an ear tube. Now, there's been some changes made to the actual tube and to try to reduce any risk of that.
To be honest, it's only happened once for me, during the trial. I did have to take that patient to the OR, but I think in working through with the parents and talking about the possibility of a malposition or something, they were okay with it. They felt that they were informed, they knew it could happen. Again, it's a very rare event, and it's just not-- I didn't feel it was safe to try to grasp the tube and pull it back out of the incision safely. I think that can happen, but I think in doing this more and more, it becomes really second nature, and practice and having a great team can set you up for success.
[Dr. Ashley Agan]
Yes. Over-Insertion would be the scenario where the tube is dunked and in the middle part of the ear. What about the opposite when you have a short shot or a tube that's deployed and then it's sitting on the eardrum instead of in the eardrum? What's your process for addressing that in the moment?
[Dr. Shelagh Cofer]
That's a great question. In doing this over the years, I would say I've done a short shot more than I've done a dunk, which was only once. In my experience, what I want to do is, usually, I've made the incision, I've deployed, and if the flange just isn't all the way in, it's not sitting properly.
Maybe one instance I've been able to take a pusher instrument and just gently tap it in. If it's really, there's not even one part of the flange, which is seated well in the incision, I just take an alligator, I take that tube out and I just open a new device and we go right in with a new one. That's how we have decided to handle that situation. I think just, overall, I feel more comfortable doing that than taking extra time. I'm not worried about opening another device and the expense associated with that because I think, over time, it just didn't make sense to me to do that. It happens so rarely we just absorb that cost.
[Dr. Ashley Agan]
That makes sense. Do you have to suction typically because you've made the myringotomy and maybe now there's a little bit of bleeding or a little bit of effusion that's covering up your myringotomy now that you go in for the second pass?
[Dr. Shelagh Cofer]
Yes. Under those circumstances, I might need to suction just a little bit, but not every time. Sometimes the incision's there and there's no fluid coming out, even though you know there's fluid there behind the drum, it just isn't coming out. It's quite easy to go back in with another device and just go right through the same incision and deploy.
[Dr. Ashley Agan]
Got you. The least amount of steps as possible. Just get it done. Don't add a suction if you don't need a suction, right?
[Dr. Shelagh Cofer]
Exactly.
[Dr. Ashley Agan]
Anything else that you think about as far as-- we talked about overinsertion, short shot. I think most people, when they're thinking about an awake child or thinking about trauma to the ear canal or the eardrum because of movement. If your assistant is really holding things, holding the head still, and helping, then it should be pretty controlled, right?
[Dr. Shelagh Cofer] ‘
Yes, it's very controlled. Again, this is coming back to the wax and wane sort of thing. As I'm cleaning an ear of wax, I really don't need quite as much immobility as when I'm applying the phenol. I always count down my phenol. I'll say, "Okay, here's the phenol in three, two, one," and I dab. They know, "Okay, this is a time where I'm just going to make sure I really a good steady grip." Then between ears that they're taking their hands off the child's head and they're switching around. That's how that goes.
As far as how these kids react to future, that was something that I was very concerned about when I started doing ear tubes in the office, I was like, "Uh-oh, is there going to be a Facebook page someday with Dr. Cofer's ear tube patients where you traumatized as a child when you were two?" I was worried about it and I paid particular attention to it.
When patients were coming back for follow-up, I was watching, are they particularly suspicious or fearful? Do they not even want to come into the the exam room? Do they seem just unusually phobic in a way? It just hasn't been the case. It just doesn't happen. Even for the older kids, they let me examine their ears. They talk to me. They really recover very well, which to me is nice reassurance that it's very tolerable and that we're not traumatizing children.
(7) Tips & Tricks for Smooth Application of In-Office Ear Tubes
[Dr. Ashley Agan]
I feel I've definitely had that concern, too. I feel like I have like older patients who talk about being held down when they were little to have their eardrum punctured and drained or something in their primary pediatrician's office or something that way back in the day. I think that's a really good point.
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."
[Dr. Shelagh Cofer]
Yes. Exactly. How can I avoid that?
[Dr. Ashley Agan]
You've obviously had a very good experience with this, and it's been a part of your-- it developed as part of your practice now, and it's been a good thing for patients. What has been the response from parents? Particularly, I think when I was first thinking about doing these, I was really concerned about, because the child, especially the little kids, like you said, can start crying as soon as you swaddle them. Then, so now you have a crying child and the parents there. I just was like, "Oh my gosh, the parents are going to think that I'm horrible." That hasn't been the case, but what are your parents telling you as far as their satisfaction and their experience with it?
[Dr. Shelagh Cofer]
Yes. I always emphasize it. If you're uncomfortable with anything we're doing that happens in the procedure room, please just speak up and say stop. I would think somebody would have said something along the way, but I've had zero parents say that, really, truly nobody has said that. In fact, when I am done with the procedure, most of them are just surprised, shocked. They're like, "Wow, that was so fast. I had no idea."
When their child is settled down, they're really very happy. They're highly satisfied. We get feedback that, "The fact that I was able to be with my child was huge. The fact that we avoided general anesthesia is huge. The fact that they don't have to take another day off." There's just so many positives.
I've had parents actually say, "Why would anybody do this any other way than how we just did this? Why would you take your child to the OR?" That's oftentimes the response we get. I do talk to parents when they come back. I always try to sort of query them, "Are you still happy that you did this? Do you wish something would have been different? Do you feel like the experience was positive?" Really, it tends to hold up over time.
I think as long as you save that child, that most kids need only one set of ear tubes. One and done. That's just the natural history of ear infections. When they start to hit age three, they're going to be outgrowing it. Their Eustachian tubes are bigger, they're more vertically oriented, and they've built up some immunity. To just really be able to offer parents this option, I think, has been so beneficial.
[Dr. Ashley Agan]
Yes. That's awesome. I think we've had such a good response and a lot of experience with it at this point. As we round this out, any final tips or final thoughts that we haven't covered or that you just want to make sure that you leave our listeners with, maybe for that skeptical listener out there that's like, "Ah, no, this can't be done. It's impossible." What would you say?
[Dr. Shelagh Cofer]
First of all, I would say, first of all, shout out to my team. I have an amazing office staff. If you engage your office staff, this can boost their morale. They really feel like they're contributing to the care of patients, and they enjoy it. We get excited on Hummingbird day. I would say that's number one. Number two, I just think you have to get out of your mindset of this dogmatic thinking and think that there could be possibly a new way of doing something. I absolutely think that this is the future and that the practices, there's many practices that are offering this now. Whether you are using one device versus another device, that's maybe a personal choice of what your comfort level is with different approaches. This is here to stay and parents are seeking it out. They absolutely want to have this as an option. I think it gets patients into your practice. If that's what you're interested in doing is developing a pediatric practice, I think it's a great way to do so.
[Dr. Ashley Agan]
Yes. Awesome. Thank you so much. Thank you for paving the way and taking the time to teach us all about this today. Really, really appreciate it. This has been awesome. If people want to learn more about you and your practice, is there probably a website at Mayo Clinic, or are you on any socials that you want to plug?
[Dr. Shelagh Cofer]
I am on socials. I'm not the most active. You probably are much more so than me, Ashley, but you can reach out to me through email. You can go on the mayoclinic.org website. I'm happy to talk to anybody about this. I've been so excited to have this. It's made ear tubes fun again for me. I've been doing this for 20 years. I would say even an old dog can learn new tricks, right? I'm happy to teach anybody about this who wants to learn.
[Dr. Ashley Agan]
Awesome. That's a wrap for today. Thank you, everybody.
[Dr. Shelagh Cofer]
Thank you.
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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