Six Sigma tympanostomy tube insertion: Achieving the highest safety levels during residency training

Elective Tympanostomy Tube Removal at 2.5 Years: Results of a Protocol for Retained Tubes

OBJECTIVES

In 2001, we instituted a protocol for the removal of retained tympanostomy tubes, delaying elective removal until 2.5 years after placement. It was hoped that this would decrease the number of surgeries without increasing the rate of permanent tympanic perforations compared to removal at 2 years.

METHODS

Protocol: Fluoroplastic Armstrong beveled grommet tympanostomy tubes were placed by a single surgeon supervising the residents. The children were seen at 6-month intervals after placement. Children with a retained tympanostomy tube(s) at 2 years were seen again at 2.5 years, and the retained tubes were removed under general anesthesia with patch application. All were evaluated 4 weeks after surgery by otoscopy, otomicroscopy, behavioral audiometry, and tympanometry.

STUDY

A computerized collection of patient letters and operative reports was queried to identify children treated according to the protocol between 2001 and 2022. Those with examinations at 2 years ± 1 month and 2.5 years ± 1 month and complete follow-up were included.

RESULTS

Of the 3552 children with tympanostomy tubes, 497 (14%) underwent tube removal. One-hundred and forty seven children fit the strict inclusion criteria. Among those with retained tubes at 2 years, 67/147 (46%) had lost any remaining tube or tubes at 2.5 years and did not need surgery, 80/147 (54%) required unilateral or bilateral tube removal, 9/147 (6%) had a persistent perforation at 1-year follow-up, and 4/147 children (3%) required tympanic re-intubation after either spontaneous extrusion or removal and patching at 2.5 years.

CONCLUSIONS

Delaying tympanostomy tube removal until 2.5 years can cut the need for surgery in half with, an acceptable (6%) incidence of persistent perforations.

LEVEL OF EVIDENCE

Four case series-historical control Laryngoscope, 134:439-442, 2024.

Traumatic perforations are associated with previous tympanostomy tube placement

INTRODUCTION

Recognized late complications of tympanostomy tube placement include persistent tympanic perforation, tympanosclerosis, and focal atrophy. Based on clinical experience, we suspected that atrophy at healed tympanostomy tube sites might predispose to re-perforation following trauma.

METHODS

Computerized record review of children seen in an academic pediatric otolaryngology practice from January 2001 to December 2020.

RESULTS

33 children with confirmed traumatic tympanic perforations and complete follow-up were identified. All perforations were unilateral. 19 of 33 (58%) perforations were in children with tympanostomy tube placement in the past and 14/33 (42%) had never had tubes. 17/19 (90%) traumatic perforations in the tube group were due to blunt or barotrauma rather than penetrating trauma as compared with 6/13 (46%) in the non-tube group (p = 0.0147 by Fisher's exact test). One patient in the non-tube group had an unknown mechanism of injury. 15/19 perforations in the tube groups were in the antero-inferior or antero-superior quadrants (old tube sites) compared to 4/14 in the non-tube group (p = 0.0152). Perforations tended to be larger in the non-tube group (non-tube mean perforation size = 27%/tube group mean = 18%) The median time to re-perforation was 8 years (range 3-15 years). Boys predominated in both perforation groups.

CONCLUSION

Traumatic perforations in this series occurred more often in the antero-inferior quadrant (old tube site) in children with previous tympanostomy tube placement. These perforations tended to be smaller and less often resulted from penetrating injuries than in children who had never undergone tube placement.

LEVEL OF EVIDENCE

3B - individual case-control study.

Laceration of Aberrant Internal Carotid Artery Following Myringotomy: A Case Report and Review of Literature

INTRODUCTION

The presence of an aberrant internal carotid artery (ICA) in the middle ear is rare. Patients may be asymptomatic or complain of conductive hearing loss, otalgia, pulsatile tinnitus, or aural fullness. Otoscopic exam findings can include a pulsating erythematous lesion on the tympanic membrane (TM). It may be misdiagnosed as a glomus tumor, hemangioma, or serous otitis media, or go unrecognized until surgical exploration. Early recognition is important as intraoperative discovery carries risk of iatrogenic injury, hemorrhage and subsequent neurologic sequelae. Prevention requires adequate preoperative suspicion and can be confirmed with radiologic examination via computed tomography (CT) scan or magnetic resonance angiography (MRA). Management of iatrogenic injury of an aberrant ICA can include packing, vessel embolization and/or surgical ligation.

PATIENT CASE

We report the case of an aberrant ICA injury in a pediatric patient undergoing a myringotomy with tube placement, who sustained neurologic deficits that eventually resolved following treatment with packing and coil embolization.

DISCUSSION AND CONCLUSIONS

An aberrant ICA can cause life-threatening complications without prior diagnosis in a routine myringotomy. Suspicious exam findings should prompt temporal bone CT to rule out aberrant ICA or other vascular pathology of the middle ear prior to surgery. In the case of iatrogenic injury of an aberrant ICA, there is no consensus in existing literature on optimal management. We reviewed 37 studies to compare therapeutic options and subsequent outcomes. Though complications are rare regardless of management, cases in which solely packing was utilized demonstrated an increased incidence of hemiparesis, aphasia, hearing loss, re-bleeding, and delayed pseudoaneurysm, as compared to an approach coupling packing with embolization or ligation, both of which have comparable outcomes.

Tympanostomy Tubes-A Visual Guide for the Young Otolaryngologist

OBJECTIVES

To illustrate some of the common dilemmas in tympanostomy tube care and describe time-tested ways to address them.

METHODS

Computerized literature review.

RESULTS

Issues including the correct diagnosis of recurrent acute otitis media, tympanostomy tube types and techniques for tube placement, management of tube clogging and otorrhea, and methods for tube removal and patching are illustrated.

CONCLUSIONS

Tympanostomy tube placement is the most common surgery performed in children requiring general anesthesia. While some elements of tympanostomy tube care have been addressed in clinical studies, much of clinical practice is guided by shared experience.

Low cost, easy-to-replicate myringotomy tube insertion simulation model

INTRODUCTION

Simulation is an established part of modern surgical education. Several training centers have proposed different simulation models for myringotomy tube (MT) placement and validated their effectiveness in medical student and resident training. None is widely used. Early models were simple tubes that lacked important microsurgical elements. Newer simulators are more comprehensive, but are difficult and expensive to build. We present a MT placement simulator that is low cost, easy to construct with basic power tools and allows for acquisition of the most necessary MT placement skills.

METHODS

The model incudes a rotating spherical "head", a 4 mm oval speculum, a drilled-out working shaft similar in size to the external auditory canal, and a realistic paper tympanic membrane target, set at an anatomically correct angle. To evaluate the model's efficacy, we assessed the performance of 10 surgically naïve medical student volunteers before training and after 30 min of instruction with the model. Their speed was recorded and operative performance was assessed using a validated Global Rating Scale.

RESULTS

After 30 min of practice on the model, there was significant improvement in MT placement skill scores and significant decrease in time for tube placement (p < 0.05).

CONCLUSION

This MT placement simulation model is inexpensive and easy to build. Unlike existing planar models, it simulates patient head orientation, and requires realistic hand positioning on a 4 mm speculum. Practice with the model for 30 min resulted in statistically significant improvement in MT placement skill scores for inexperienced student surgeons.

Ear, nose and throat surgery: All you need to know about the surgical approach to the management of middle-ear effusions in Australian Indigenous and non-Indigenous children

Otitis media (OM) is a common condition in Australia. It represents a spectrum of diseases from otitis media with effusion (OME) to chronic suppurative otitis media. For all the OM diagnoses, Australian Indigenous children have higher rates of early onset, severe and persistent disease. OME is the most common form of OM and often occurs after an upper respiratory tract infection. It can be difficult to diagnose (and often goes unrecognised). Hearing loss is the most important complication. The middle-ear effusion impedes the movement of the tympanic membrane and causes a conductive hearing loss of around 25 dB. Around 20% will have a hearing loss exceeding 35 dB. Children with early onset, persistent, bilateral OME and hearing loss (or speech delay) are most likely to benefit from interventions. However, the impact of all the effective treatment options is modest. Giving advice about effective communication strategies for young children is always appropriate. The best evidence from randomised trials supports not using antihistamines and/or decongestants, considering a trial of antibiotics and referral for tympanostomy tubes. Despite the availability of evidence-based guidelines, giving advice about treatment is a challenge because recommendations vary according to condition, age, risk of complications and parental preference. While most children with OME can be effectively managed in primary care, we need to get children who meet the criteria for simple ear, nose and throat procedures that improve hearing on to ear, nose and throat surgery waiting lists. Long delays in hearing support may contribute to life-long social and economic disadvantage.

Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction

PURPOSE

Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center.

METHODS

Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis.

RESULTS

Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11.

CONCLUSIONS

A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.

Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis

CONTEXT

Tympanostomy tube placement is the most common ambulatory surgery performed on children in the United States.

OBJECTIVES

The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute otitis media.

DATA SOURCES

Searches were conducted in Medline, the Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews, Embase, and the Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Abstracts and full-text articles were independently screened by 2 investigators.

DATA EXTRACTION

A total of 147 articles were included. When feasible, random effects network meta-analyses were performed.

RESULTS

Children with chronic otitis media with effusion treated with tympanostomy tubes compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB (95% credible interval: -14.0 to -3.4) at 1 to 3 months and 0.0 (95% credible interval: -4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly defined and reported.

LIMITATIONS

Sparse evidence is available, applicable only to otherwise healthy children.

CONCLUSIONS

Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

A systematic review of the effects of residency training on patient outcomes

BACKGROUND

Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.

METHODS

The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.

RESULTS

Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.

CONCLUSIONS

The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.