Sample dictation

1. GENERAL CONSIDERATIONS
   1.  See AAO-HNS guidelines: https://www.entnet.org/?q=node/340

1. Pediatric
   1. Otitis media with effusion 
   2. Recurrent acute otitis media
   3. Acute otitis media that significantly impacts daily activities including academic performance, school attendance or outdoor activities
   4. Trisomy 21
   5. Cleft palate or any other anatomic abnormalities that compromise soft palate function
   6. Hyperbaric oxygen (to avoid barotrauma)
   7. Systemic infection of unknown etiology with fluid in the mastoid or middle ear space
   8. Chronic eustachian tube dysfunction with atrophic, retracted and flaccid drum
2. Adults
   1. Long standing OME due to chronic eustachian tube dysfunction
   2. Hyperbaric oxygen (to avoid barotrauma)
   3. Systemic infection of unknown etiology with fluid in the mastoid or middle ear space
   4. Chronic eustachian tube dysfunction with atrophic, retracted and flaccid drum
       
3. (Contraindications)
   1. Sub Con
       
4. PREOPERATIVE PREPARATIONS
   1. Consideration 1 (Evaluation)
      1. Sub-Con
         1. Sub-sub-con
   2. Consent should cover the potential complications
      1. A dehiscent high-riding jugular bulb or aberrant carotid artery may be at risk. This can usually be seen on preoperative examination as bluish or salmon-colored effusion. However, this may not be appreciated if the tympanic membrane is opacified
      2. Loss of the tube into the middle ear space AKA dunking the tube
         1. If the tube is visible in the middle ear space, it can often be retrieved through the myringotomy
         2. If the tube drops into the hypotympanum do NOT blindly attempt to retrieve it
         3. A tube in the middle ear space behind an intact TM does not merit retrieval
             
5. NURSING CONSIDERATIONS
   1. Room Setup
      1. Operating microscope and lens with 200mm focal length
          
   2. Instrumentation and Equipment

      1. Myringotomy Tray

         1 Beaver Chuck Handle #3K, 3-7/8''

         1 Devon Drape Clamp, 5-1/4''

         1 Boucheron Speculum, Round

         < >Size #1, 3 mmSize #2, 4 mmSize #3, 5 mmSize #4, 6 mmSize #5, 7 mmSize #6, 8 mmSize #7, 9 mm9.5 cm x 18-Gauge or 1.29.5 cm x 20-Gauge or .99.5 cm x 22-Gauge or .7ANESTHESIA CONSIDERATIONS
         1. General anesthesia with patient masked down
         2. Local anesthesia using phenol
             
      2. OPERATIVE PROCEDURE
         1. Use operating microscope with 250mm focal length
         2. Place appropriately sized speculum in the ear
            1. Use the largest possible oval, beveled speculum and insert it into the canal with the bevel facing anteriorly
            2. For small canals (ie T21), Gruber speculums may be helpful
            3. If there is a large anterior hump, first tilt the speculum posteriorly toward the tympanic membrane and then anteriorly.
         3. Examine the tympanic membrane identify landmarks. It is good practice to predict the presence of fluid in the mesotympanum prior to making an incision
         4. Use a myringotomy knife to make an incision
            1. Radial incisions are parallel to epithelial migration and thus tubes placed in a radial incision are less likely to extrude
            2. Circumferential incisions can be used if there is poor exposure
            3. Anterior/inferior, inferior and posterior/inferior quadrants are all acceptable locations for making a myringotomy
            4. Avoid the posterior/superior quadrant due its proximity to the ossicles
         5. Use a fine suction to remove any fluid. If the contents of the mesotympanum is thick, try irrigating with some normal saline and switcher to a larger bore suction If this does not work, a second smaller radial incision can be made to help equalize pressure white removing the thick secretions
         6. Tube placement
            1. Place the leading edge of the tube into the myringotomy with alligator forceps
            2. Push the posterior or trailing edge of the tube into the myringotomy with empty alligator forceps, Rosen needle or the myringotomy knife
            3. Placement of T-tubes is very similar. Place one flange of the T-tube into the myringotomy and use the forceps or needle to push the "crotch" of the tube into the myringotomy (Dr. Smith's preferred method). Alternatively, both flanges of the T-tube can be simultaneously grasped with the forceps. Both flanges can then be passed through the myringotomy and the forceps opened thereby deploying the T-tube flanges. Be sure to slightly close the alligator forceps before pulling them out through the TM.
         7. Suction and position the tube
            1. Use a fine suction to remove any blood or fluid from the tubes to ensure that they are patent
            2. The suction tip can also be used to orient the tube so that the orifice is visible and easily evaluated on subsequent otoscopic examinations.
         8. Place antibiotic drops into the ear (or water). The idea is to dilute the blood from the myringotomy so it doesn't plug up the tube.
            1. Manaligod - use ofloxacin.
            2. Kacmarynski - use saline only.
            3. Everyone else - use ofloxacin unless there is granulation tissue in which case use ciprodex
            4. Push the tragus medially a few times to pump the drops through the tube and into the mesotympanum
                
         9. Under local anesthesia (Same procedure as above with the following differences)
            1. Put a small amount of phenol on a cotton tip applicator and gently apply it to the tympanic membrane at the site of the planned myringotomy. 
            2. Pope tubes are great for clinic tubes in adults; grasp the back (smaller) flange and put the front flange through the myringotomy. Then push down lightly on the back of the tube to get the back edge through the myringotomy.
                
      3. POSTOPERATIVE CARE< >3-5 drops of Ofloxacin in each ear three times per day for 1 weekFollow up in 3-4 weeks to check tube placement and patency
         
         
         7. SUGGESTED READINGAAO-HNSF guidelines
      4.  Canadian Society of Otolaryngology Guidelines:  https://www.entcanada.org/learning/general-public/public-information-she...
      5.  
      6.  
      7. Hirsch BE. Otitis Media, Myringotomy, and Tympanostomy Tubes. Operative Otolaryngology: Head and Neck Surgery
      8. Lee KJ, Toh EH. Otolaryngology - A Surgical Notebook