The Best Site for Pediatric TT Placement: OR or Office?

A Pioneer’s Approach To In-Office Pediatric TT Insertion

Richard Rosenfeld, MD, MPH, MBA, distinguished professor and past chairman of otolaryngology at SUNY Downstate Health Sciences University in Brooklyn, N.Y., has long known that there is resistance to his approach of performing in-office tympanostomies in children using a manual surgical tube placement method and family/patient support.

Whether it’s the open criticism and incredulity he often gets from attendees at medical conferences where he presents his technique or a practitioner survey he published that documented significant doubts and concerns about performing in-office tympanostomies (Ann Otol Rhinol Laryngol. doi: 10.1177/00034894211008063), “I know this is not for everyone,” he said.

“I am an outlier, probably about eight standard deviations away from the mean on this,” he said. “When I present at meetings, lots of attendees tell me they think I’m a bit crazy to do this.” But for Dr. Rosenfeld, there’s nothing crazy about offering patients and their families a rapid, effective, proven, and repeatable means of alleviating their child’s middle ear symptoms.

The fact that he does it with tubes that have been in use for more than three or four decades and thus have a long-term, documented record of success—as opposed to some of the proprietary tubes used in the automated systems recently approved by the FDA—is a major plus.

A case typically begins with Dr. Rosenfeld explaining the procedure to the family members present and letting them know he’ll be using a technique known as a papoose board to keep the child from moving during the procedure. “I’ve heard this called a restraint, but it’s actually called protective stabilization if you read the practice guidelines from the pediatric dentists who often use it,” he explained. “It’s an extremely safe and ethical technique for pediatric medical procedures. But the goal is to be fast—and I am very fast” (American Academy of Pediatric Dentistry. https://tinyurl.com/ffxphxs9).

Dr. Rosenfeld begins by numbing the eardrum with phenol as a topical anesthetic for children who are two years of age and older. “The problem with phenol is that it stings, and so the second you put it on the eardrum, the younger kids get extremely agitated. So, we give them a double dose of acetaminophen as premedication, which in a randomized trial provided comparable post-procedural pain relief to topical lidocaine solution” (Can J Anaesth. doi: 10.1007/BF03022879).

The actual tube placement is then done with Armstrong beveled fluoroplastic tubes “that have been around for about 50 years,” he said. “I’ll even do these in patients I used to shy away from, at least in the office setting—those with narrow ear canals,” he said. “But now I’ve learned to do those nearly just as fast using softer T tubes, which can fit in those narrow spaces.”

As for how fast a typical procedure is, “my average time is three or four minutes for both ears if it’s an uncomplicated child.”

Dr. Rosenfeld stressed, however, that speed is not the only attribute a surgeon needs when doing in-office tympanostomies. “I’ve learned over the years that you really have to manage the expectations of the family members who are present,” he said. “I tell them, the odds are great that as soon as I lay your child down and we wrap them up, they will start crying. And if I gave you a pain scale to describe your child’s pain level, you’d tell me it was 10 out of 10—but at that point, I am not even touching them!”

His message to them is that their child is not in pain—”They’re just mad, frustrated, and they want to leave,” he explained. “But if you just hang in there with me, nine times out of 10, within 30 to 60 seconds of my letting your child out of the papoose, they’re going to stop crying, and if you give them a pacifier or something to eat, they’re fine; it’s rare to see any persistent post-procedural pain.”

Dr. Rosenfeld stressed that as a surgeon, “you just have to be very efficient; this isn’t a time to be learning how to do tubes. I tell the residents, do a thousand in the operating room, then you can maybe try it in an awake child in front of parents in your office.”