Description of an office technique for laser ventilation of the ears.

Abstract

The author presents a description of a technique he developed called laser office ventilation of ears (LOVE). LOVE, an office-based procedure performed under local anesthesia, can provide intermediate-term ventilation for middle ear disease. This procedure has potential to change the standard of care for otitis media. Such changes might include a decrease in the need for antibiotics (and thus antibiotic resistance), a decrease in hearing loss associated with otitis media, and a decrease in the overall cost of treatment.

Introduction

The treatment of otitis media has always been a challenge. Although various medications are sometimes successful, there are far too many therapeutic failures. Antihistamines and decongestants occasionally provide relief. [1] Steroids can be helpful, but they are not without potential risks and complications. [2] Their long-term use is certainly inappropriate. Antibiotics, the mainstay of medical therapy, also have their limitations. Their widespread use over the years has led to major bacterial antibiotic resistance. [3] Moreover, hearing loss and acute middle ear effusion frequently persist despite ongoing antibiotic therapy.

Various surgical modalities have been used in the treatment of otitis media. Their common denominator is the establishment of normal middle ear ventilation. These procedures include simple myringotomy with tube insertion, adenoidectomy with or without tube insertion, and the laser ventilation technique. The author, in conjunction with ESC/Sharplan, has developed a technique called laser office ventilation of ears (LOVE), which he presents to the otolaryngology community. [4]

Performing the procedure

One of the most important facets of this procedure is the preoperative explanation to the patient or, when the patient is an infant or child, to the parents. It must be emphasized beforehand that children will almost always cry when they experience the popping noise, sensation of warmth, and sudden release of pressure.

LOVE is performed with the use of topical anesthesia. A solution of tetracaine base ranging from 8 to 32% is mixed by adding 80 to 320 mg of tetracaine base powder to I cc of isopropyl alcohol. The concentration is varied according to the condition of the tympanic membrane (TM). Greater TM inflammation and thickness requires a greater concentration of anesthetic. When premixed and kept in a dark-glass dropper bottle, the solution has a shelf life of 3 months. The solution is applied under direct vision with an otologic microscope. Such visualization is important to guarantee that contact is made with the tympanic membrane. A small piece of cotton is rolled to the appropriate size to fit into the ear canal. The cotton is inserted gently into the ear with an alligator forceps. Cotton is preferred to otowicks because the latter do not offer the same variations in size or ease of manipulation. The cotton is left in place for approximately 1 hour to assure adequate anesthesia. During this time, patients are free to do as they please, including leaving the office to eat.

When appropriate anesthesia has been achieved, the microscope is again used to remove the cotton. In order to ensure that adequate anesthesia has been attained, the tympanic membrane is touched with a suction tip. Any sign of pain necessitates a repeat application. It is necessary to have at least one parent present for adequate control of infants and small children. Once anesthesia has been attained, it will last for at least 1 hour.

The procedure, also known as OTOLAM, is performed with an ESC/Sharplan (Needham, Mass.) [CO.sub.2] laser. This device offers precise control of placement of fenestration and features a scanning beam that limits the amount of thermal damage to surrounding tissue to 50 microns. Adults can be seated comfortably next to the surgeon. Children, of course, must be restrained. Various restraining techniques have been employed, including "papoosing." The author has found that the "love hug" is the most efficacious maneuver. For this technique, the child sits on the lap of one of the parents with its back against the parent's chest. The child's legs are stabilized between the parent's legs. The parent wraps one arm around the child's arms and chest while the opposite hand stabilizes the child's head.

The laser otoscope is inserted into the ear, and the tympanic membrane is visualized on the monitor. The laser fenestration is performed in the anteroinferior quadrant of the tympanic membrane. Laser settings will vary according to the patient's pathology. The average size of the fenestration is 2.4 mm. The size of the fenestration may be created in 0.2 mm increments from 1.0 to 3.0 mm. Power settings are selected in accordance with the thickness of the tympanic membrane and the presence or absence of effusion. The average power setting for otitis media with effusion is 14 to 16 W. A thick tympanic membrane in a patient with acute otitis media might require in excess of 20 W. The laser's computer automatically determines the duration of the single pulse.

Postoperative care is relatively simple. Antibiotic eardrops are administered twice a day for 1 week, and the ears are otherwise kept dry. Followup is recommended every 2 weeks until the tympanic membrane has closed. Thereafter, the patient is usually seen one more time in 30 days.

LOVE can be repeated. In cases of persistent disease, LOVE can be performed with the insertion of tubes (LOVE IT).

Assessing results

The criteria for determining success depends on whether the patient had serous otitis media or acute otitis media. In the author's practice, approximately 76% of patients with serous otitis media experienced closure of the tympanic membrane with no recurrence of effusion for 90 days. Patients with acute otitis media will report an almost immediate relief of pain. In the author's practice, subsequent antibiotic treatment has been significantly decreased, probably as a function of direct topical antibiotic access to the middle ear.

Benefits of treatment

The LOVE procedure presents us with an opportunity to improve the quality of care for otitis media. Early intervention with intermediate ventilation of the middle ear has resulted in a marked decrease in the need for antibiotics. This should result in a decrease in the emergence of antibiotic-resistant bacteria that is currently associated with the treatment of otitis media. Obviously, an overall improvement in hearing would also be realized.

With the LOVE technique, the cost of treating otitis media might be lowered significantly. Obvious savings can be realized with a decrease in the number of office visits, the number of antibiotic prescriptions, and the necessity for myringotomy with tubes in an operating room with anesthesia. Another economic advantage might be realized with the reduction in the amount of time that patients must miss from their workday.

From the Northwestern University Medical School, Chicago.

References

(1.) Haugeto OK, Schroder KE, Mair IW. Secretory otitis media, oral decongestant and antihistamine. J Otolaryngol 1981;10:359-62.

(2.) Rosenfeld RM, Mandel EM, Bluestone CD. Systemic steroids for otitis media with effusion in children. Arch Otolaryngol Head Neck Surg 1991;117:984-9.

(3.) Proceedings of a satellite symposium held at the 8th ECCMID, Lausanne, Switzerland (May 26, 1997). Antibiotic resistance in otitis media: Clinical problem or hypothetical risk? Ear Nose Throat J 1998;77(suppl):1-22.

(4.) Cohen D, Siegel G, Krespi J, et al. Middle ear laser office ventilation (LOV) with a [CO.sub.2], laser flashscanner. J Clia Laser Med Surg 1998;16(2):107-9.