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Brodsky L, Patrick Brookhauser P, David Chait D et al, The Laryngoscope 1999, 109:2009-14.

Review: This prospective, multisite, clinical cohort trial examined the use of the OtoLam procedure for pressure equalization tube (PET) insertion in an office setting without general anesthesia. The OtoLam is a hand-held otoscope containing a flash-scanner CO2laser coupled to a microchip camera and high-resolution video screen. The laser delivers a single pulse whose wattage and size can be set. A completely still patient is not required for effective use of this device. 54 patients were included in the study. Of these 54 patients, 96 ears were treated. The age ranged between 6 months and 23 years with a mean age of 47.5 months. Children with craniofacial anomalies, emotional disturbances, mental retardation, chronic adenotonsillitis, and difficult to visualize TMs were excluded from the study. Anesthesia was provided by iontophoresis in one patient. All other patients received 8% tetracaine on an Otowick (Xomed product) placed against the eardrum for a minimum of 60 minutes. Adequate local anesthesia was determined by tapping on the tympanic membrane. If the patient appeared to experience pain, 30 more minutes was allowed before proceeding. 79% of all children were restrained (100 % between 24-48 months of age). 64% of TMs were fenestrated on the first attempt. Thicker membranes and mucoid effusions required more wattage to penetrate. Increased pain was associated with multiple firings, As the investigators became more knowledgeable with the OtoLam procedure, less repeat firings were needed. No suctioning was used unless the fenestration could not be visualized (2 patients). PETs were inserted with alligator microforceps. Pain was measured using the objective pain scale for children three or less and the Wong-Baker pain scale for those older than three. At the time of the procedure 40% had absent to mild pain, 30% present but tolerable and 3% severe. At five minutes, 75% had absent to mild pain, 22% tolerable, and 3% severe. The overall physician time for the procedure including anesthetizing the TMs, performing OtoLam and inserting the PETs was 9 minutes. Parent preference for this procedure versus PET placement under general anesthesia was reported at 90%. There was a significant cost saving to the payor but a significant physician investment for equipment that was not covered by current reimbursement for office based PET insertion.

Comments: PET placement is the most common surgical procedure requiring general anesthesia in children. In the US, approximately 1 million children a year undergo PET placement in the operating room. A technique that avoids the need for general anesthesia and the need for an operating room arena is obviously of considerable benefit both in terms of risk and cost. Although laser assisted myringotomy was first described by Goode in 1982, its usefulness has been limited by the need for patient stillness until this device was developed. Improvements in the management of pain in this procedure would make it more likely to be widely adopted. The reported rates for moderate and severe pain in this study seem unnecessarily high. The pre-procedure use of acetaminophen or non-steroidal anti-inflammatory agents might prove useful and should be studied. In addition, the use of a short-acting sedative like intranasal midazalam might also be of benefit. Other agents and concentrations of local anesthetics might also prove more effective. It will be interesting to see if office based PET placement becomes the procedure of the future for all but the most difficult to manage patients.

Reviewed by: Karen Bender, MD
Arnold Palmer Childrens Hospital
Orlando, FL