This edition of the Otolaryngologic Clinics of North America covers office-based surgery in ENT. This article discusses procedures in otology that could be performed in the outpatient setting and covers innovations in office-based otologic procedures. The endoscope features prominently in the outpatient setting. The authors recommend the longer 16cm length, 4mm diameter sinus endoscope for any procedures as the shorter otoendoscope often causes hand collision. The value of the endoscope is that it allows for a wider view, especially assessment and documentation of retraction pockets, which in some cases may no longer need surgery compared to previous microscopic assessments. Endoscopic myringoplasty could be performed as well, although the authors’ advice is for this to be limited to perforations smaller than 30%. Generally, grafts used are fat, cartilage and Biodesign, positioned across the perforation without needing to lift a tympanomeatal flap. Local anaesthetic administration for myringoplasty involves injection of lignocaine with adrenaline. Smaller 2.7mm diameter endoscopes are used for narrow ear canals and an even smaller 2mm diameter endoscope could be used for middle ear endoscopy via a myringotomy incision. This allows assessment of the middle ear relatively quickly and could assess for adhesions especially around the round window (in cases of transtympanic treatment), the ossicular chain, cholesteatoma and perilymph fistula. Intratympanic (IT) treatment for sudden sensorineural hearing loss and Meniere’s disease is an ideal office-based procedure. Patients are positioned 300 head up and, following local anaesthesia, a pressure release puncture hole is made before injection of steroid in the posteroinferior quadrant of the tympanic membrane. Patients are then instructed not to swallow and to stay in the same position for 30 minutes. Patients are given four injections in total, performed twice-weekly using 0.4mls of 40mg/ml methylprednisolone each time. For Meniere’s disease, the treatment dose of methyprednisolone and gentamicin remains physician-dependent, as there is no consensus on the optimal dosing protocol. The authors utilise IT steroid injections for patients with intractable Meniere’s disease despite medical treatment for six months using the same protocol as above. For IT gentamicin, the authors use 0.5mls of gentamicin 40mg/ml and, if there are persistent symptoms after a month, another injection is administered.
Office-based otology procedures
Reviewed by Wai Sum Cho
Office based otology procedures.
