Successful use of either system requires careful patient selection. In-office tube placement isn’t the best choice for many children and families. A child with a retracted eardrum or prominent anterior overhang isn’t a candidate for in-office placement under local anesthesia, Dr. Gavin said.
Explore This IssueSeptember 2020
Doctors must consider the child’s age and personality, as well as the family’s comfort level and motivation. “I’ve found that age plays a big role,” Dr. Gavin said. The new devices are approved for use on children as young as 6 months, but Dr. Gavin said he “found it more difficult to successfully place tubes in children under the age of 2, and even some kids between the ages of 2 and 3 were difficult.” Most children he treated tolerated iontophoresis well, but some of the younger ones were hesitant to lie down under the microscope after the ear was numb.
Dr. Moss would often “test” a child’s potential tolerance during a consultation visit. “I’d take them into the room where the procedure is done and clean wax from the ear canal to see how well they would tolerate it,” he said. A child who could handle wax removal was usually a good candidate for in-office tube placement with local anesthesia.
Assessing the parents’ comfort level is also extremely important. “Children tend to take their lead from the parent, so if they see the parent is comfortable, they tend to do well,” Dr. Gavin said. “On the other hand, if you see a parent is anxious when you’re describing the procedure to them, that anxiety may translate to the child.”
Families who are motivated to avoid general anesthesia and comfortable with the procedure are likely to do well; however, it’s impossible to predict a patient’s response to the procedure.
“I had one child, about 6 years old, who I thought would be a model patient. But once we started the iontophoresis, he became very nervous and apprehensive, and said he wanted to leave,” Dr. Moss said. “His parents reassured him, but he wouldn’t allow us to look into the ear canal.” The in-office procedure was canceled, and ear tubes were later placed in the operating room under general anesthesia.
Why Make Time for In-Office Tube Placement?
Inserting pediatric tympanostomy tubes in an office setting is significantly more time-consuming for the otolaryngologist than placing tubes in the operating room. In the OR, an otolaryngologist can place a set of ear tubes every 10 to 15 minutes. In the clinical setting, without a surgical team to prepare and anesthetize the patient, tympanostomy tube placement takes approximately 30 to 45 minutes per patient.
What physicians sometimes neglect to consider, though, is the time spent completing hospital or ambulatory surgery center paperwork. “People forget about all the effort that’s involved in filling out the history and physical, completing OR paperwork, and writing prescriptions afterward,” said Charles Syms, III, MD, an otolaryngologist in San Antonio, Texas, who was involved in the development of Tula but doesn’t have a relationship with or financial stake in Smith+Nephew, the medical technology company marketing Tula.
Doctors who are considering in-office placement should plan to spend time with the child and family before initiating the procedure, to answer any last-minute questions and help them feel comfortable. During the numbing process, it may be possible to see another patient, if other clinic personnel can supervise the child and family. Children can (and do) resume their usual activity almost as soon as tube placement is complete.
For some physicians, patients, and families, the new tube placement systems are a “game-changer,” said Dr. Syms, adding that in-office tube pediatric tube placement isn’t a good option for everyone.
“Like any new technology that comes along, there will be some who find these devices work well for their clinical practice and some who do not,” Dr. Moss agreed. “There are those who will embrace this new technology and those who may have reservations, and I understand both sides.”