Lasers in Surgery and Medicine 28:320±323 (2001)

Alternative Indications for Laser-assisted TympanicMembrane Fenestration

Steven P. Cook, MD,* Ellen S. Deutsch, MD, and James S. Reilly, MD

Alfred I. duPont Hospital for Children, Wilmington, Delaware 19899

Background and Objective: To assess the utility of theCO2 Flashscanner laser for treatment of selected middleear diseases other than otitis media with effusion (OME)and acute otitis media (AOM).Study Design/Methods and Materials: A retrospectivereview of the records of 144 patients treated with theOtoLAM1 device, a Flashscanner laser, between July 1,1998, and February 29, 2000. Patients treated for AOM orOME were excluded.Results: Data are presented on 11 patients (17 ears). Fourindications were identi®ed: Elimination of middle ear ¯uidbefore auditory brainstem response with or withoutotoacoustic emission testing (ABR � OAE), barotrauma,eustachian tube obstruction, tympanocentesis when aculture of middle ear ¯uid was deemed necessary. Alltympanic membranes (TM) healed.Conclusion: Fenestration of the TM can be accomplishedfor both diagnostic and therapeutic purposes. Laserassisted tympanic membrane fenestration seems to beeffective in the management of middle ear ¯uid beforeABR � OAE, barotrauma, eustachian tube dysfunction,and for tympanocentesis. Lasers Surg. Med. 28:320±323,2001. ß 2001 Wiley-Liss, Inc.

Key words: ABR; barotrauma; laser assisted tympanicmembrane fenestration; OAE; OtoLAM; tympanocentesis

INTRODUCTION

A variety of clinical situations demand the need foraccess to the middle ear and its contents. Since thenineteenth century, the value of middle ear ventilationand drainage has been recognized as a cornerstone ofmanagement for otitis media with effusion (OME) [1,2].

The exact duration of middle ear ventilation to achieveresolution of OME and in¯ammation is unknown [3,4].Although a myringotomy alone will provide material forculture, it will heal within a day or 2 [3±5]. On the otherhand, the 6 months or more of ventilation provided by atympanostomy tube may not be necessary in all clinicalsituations. Additionally, otorrhea, perforation, and tym-panic membrane scarring are known complications oftympanostomy tubes [2]. It is logical to assume thatanother form of intermediate ventilation would ®ll a largegap in the treatment options for middle ear diseases.Although attempts with heat myringotomy demonstratedthat prolonged ventilation could be achieved when anadequately large opening was created in the tympanic

membrane (TM), for the past 2 decades the medical laserhas been the focus of investigations as a means achievingthis goal [4,6].

Animal studies by and SoÈderberg et al. and Lyons et al.studied the duration and healing of laser treated TMs[2,5]. Goode used the CO2 laser on TMs in human subjectsand achieved intermediate ventilation for several weekswithout evidence of excessive scarring of the TM [7].Recognizing that the CO2 laser aligned with an operatingmicroscope was cumbersome, DeRowe and coworkers thentried to devise a more ef®cient system of laser deliverywith a ®beroptic cable [8]. The newly developed OtoLAM1

device (ESC/Sharplan, Yokneam, Israel), a CO2 Flashs-canner laser, is an ef®cient tool to accomplish TM fene-stration in a clinical setting [3,9,10]. A growing body ofliterature supports the use of tetracaine base in alcohol asan effective topical anesthetic, allowing laser assistedtympanic membrane fenestration (LATMF) to be accom-plished in an of®ce setting [10±12].

Currently, the most common indications for the uses ofLATMF are for the treatment of the acutely infected ear,for drainage and intermediate ventilation for OME with orwithout adenoidectomy and in conjunction with of®cetympanostomy tube insertion [9,10,13]. The purpose ofthis review is to evaluate the versatility of the OtoLAM1

device in the management of additional forms of middleear disease.

MATERIALS AND METHODS

Data were reviewed from all patients who underwenttreatment with the OtoLAM1 device at the Alfred I.duPont Hospital for Children was carried out from July 1,1998, through February 29, 2000. Of 144 patients treated,14 were treated for indications other than AOM or OME.Three patients were excluded. One patient was treated formastoiditis; however, incomplete data excluded him fromthis review. Two children underwent myringoplasty withlaser debridement of the edges of the perforation. They,too, were excluded, because their surgery did not requirefenestration per se. The remaining 11 patients are thefocus of this review.

*Correspondence to: Steven P. Cook, MD, Division of PediatricOtolaryngology, Alfred I. duPont Hospital for Children, P.O. Box269, 1600 Rockland Road, Wilmington, DE 19899.E-mail: scook@nemours.org

Accepted 29 June 2000

ß 2001 Wiley-Liss, Inc.

Patients were treated in the of®ce or at the bedside hadtopical anesthesia of the tympanic membrane by using 8to 32% tetracaine base dissolved in isopropyl alcohol.A Merocel1 Pope ear wick (Xomed Surgical Products,Jacksonville, FL) was then placed in the external ear canalfor 15 to 45 minutes.

One patient treated at the bedside also had sedation withintravenous midazolam hydrochloride (Roche, Nutley,NJ). One patient was treated in the operating room undergeneral anesthesia.

All patients had LATMF by using the OtoLAM1 device.Laser spot size varied from 1 mm to 2.4 mm, depending onthe clinical situation. Power ranged from 12 to 25 wattswith variation depending on the apparent thickness of theTM. The laser, depending on the power and spot size,automatically adjusted the duration of the laser pulse.

When cultures were indicated, the fenestration in theTM was directly visualized under the microscope and thesample was obtained from the middle ear by using amicroculturette. Most patients were placed on topicaleardrops at the completion of the procedure. Some patientsalso received oral antibiotics. Antibiotic coverage wasmodi®ed when indicated by culture results.

RESULTS

Eleven patients (17 ears) underwent LATMF for indica-tions other than AOM and OME. Ages ranged from 1month to 186 months for children. Two adults were 41 and46 years old. There were eight males and three females. Allfenestrations healed without scarring within 1 to 4 weeks.There were no complications. Table 1 lists the spot size,power, indications for LATMF, anesthetic, patient age andsex, and location where the procedures were performed.

LATMF was used in four different circumstances: (1)before ABR�OAE when OME was delaying auditoryassessment, (2) for the rapid relief of hearing loss anddiscomfort from barotrauma, (3) for the management ofeustachian tube obstruction that mimicked a middle earmass, and (4) for diagnostic tympanocentesis either in theimmunocompromised patient or for symptomatic AOMthat failed to respond to antibiotic therapy.

Nine patients were treated in the of®ce by usingtetracaine in alcohol eardrops. One child was treated inthe operating room under general anesthesia immediatelybefore ABR�OAE. One child underwent bedside LATMFby using tetracaine in alcohol eardrops and midazolamhydrochloride sedation.

Three patients (®ve ears) were treated with LATMFto eliminate middle ear effusion immediately beforeABR�OAE. All had abnormal tympanograms or abnor-mal otoscopic examinations.

Both of the adults were treated for unilateral Grade IIbarotrauma. Both patients had serous effusions. Bothpatients experienced immediate symptomatic relief. TheTMs healed within 2 weeks.

Although there was audiometric and otoscopic improve-ment, one patient took over 2 weeks before he experiencedcomplete subjective improvement. This time frame wasdespite the prior course of antibiotic and the posttreatmentcourse of oral steroids.

One 131-month-old female was referred by her primaryphysician because of an abnormal ear examination, whichsuggested a possible middle ear mass. Her past medicalhistory was remarkable for two sets of tympanostomytubes before age 3 years. Microscopic examination demon-strated a retracted TM. It was dif®cult to determinewhether the TM lying against a middle ear mass or the

TABLE 1. Data for LATMF Patients Treated for Indications Other Than Otitis Media with Effusion and Acute

Otitis Medial*

Patient Indication for Spot size Power

Number Age LATMF Sex (mm) (watts) Location Anesthetic

1 8 mo. OME present prior to ABR M 2 16 Of®ce Tetracaine

2 11 mo. OME present prior to ABR F 2 12 Of®ce Tetracaine

3 7 mo. OME present prior to ABR�OAE M 2 12 OR General

4 41 yr. Barotrauma M 2.4 14 Of®ce Tetracaine

5 46 yr. Barotrauma M 2 Ða Of®ce Tetracaine

6 131 mo Eustachian tube dysfunction F 2.4 14 Of®ce Tetracaine

7b 4 mo. Tympanocentesis M 2 20 Of®ce Tetracaine

8b 1 mo. Tympanocentesis F 2 AD/1 AS 15 Of®ce Tetracaine

9b 9 mo. Tympanocentesis M 2.4 25 Of®ce Tetracaine

10c 21 mo. Tympanocentesis M 1.8 12� 1 AS Bedside Tetracaine

12� 2 AD �midazolam HCl

11c 186 mo. Tympanocentesis M 2.2 14 Of®ce Tetracaine

*LATMF, laser assisted tympanic membrane fenestration; OR, operating room; ABR, auditory brain response; OAE,

otoacoustic emission testing; OME, otitis media with effusion; M, male; F, female; AD, right ear; AS, left ear.aMissing date.bAcute otitis media unresponsive to antibiotics.cImmunocompromised patient.

INDICATIONS FOR LASER ASSISTED TYMPANIC MEMBRANE FENESTRATION 321

promontory. Audiometry demonstrated decreased hearingat 2,000 Hz with a Type C tympanogram. LTMF permittedadequate visualization to exclude the presence of middleear ¯uid or mass. Within 1 month, the fenestration wasclosed. The otoscopic examination was normal. Hearingwas normal at all frequencies with a Type A tympano-gram. A computed tomographic scan of the ear wasnormal.

Five children (nine ears) were referred for LATMF tospeci®cally obtain middle ear ¯uid for culture. Agesranged from 4 weeks to 186 months.

Three children (six ears) were less than 1 year of age. Allwere unresponsive to at least 48 hours of antibiotics beforeLATMF. One child was hospitalized with Streptococcuspneumoniae pneumonia.

One 21-month-old child had Stage 4 neuroblastoma. Herequired cultures and middle ear ventilation with auditoryassessment before beginning a chemotherapy protocolthat was to include cisplatin. Although he had a historyof frequent ear infections, his family refused tympanost-omy tubes. This child was treated at the bedside with mida-zolam sedation supplementing his tetracaine in alcoholeardrops. An additional 15-year-old patient who had under-gone a prior renal transplant was referred for cultures of asuspected of middle ear infection.

Cultures obtained from both of the ears of the child withstreptococcal pneumonia were positive for penicillin resis-tant S. pneumoniae. Material from the ears of the childwith neuroblastoma showed Gram-positive cocci on Gram'sstain, but no organism grew on culture. The cultures of¯uids from six ears were negative. One ear, in the 15-year-old renal transplant patient, was dry.

DISCUSSION

LATMF is an extremely versatile procedure. With theprofound topical anesthesia afforded by tetracaine ear-drops, access to the middle ear and its contents can beaccomplished in the of®ce or at the bedside. When indi-cated, the procedure can be performed in the operatingroom. The surgeon has the ability to alter the spot size toaccommodate small ear canals. One can adjust the powerdepending on the thickness and appearance of theTM, further enhancing the range of treatment capability[10].

Because the procedure is reasonably well tolerated inchildren, it can be offered the same day as an of®ceevaluation. Of®ce LATMF may preclude the need fortreatment in the operating room. This advantage avoidsscheduling delays, general anesthesia, and increasedhealth care costs.

As in Goode's investigation, our small series demon-strated that healing was complete within a reasonableperiod of time in all patients [7]. There were no complica-tions. No ear had any visible scarring, even in the ear thathad two previous sets of tympanostomy tubes.

Auditory assessment by ABR�OAE does not have tobe delayed when middle ear ¯uid is present. Ourexperience suggests that reliable results can be obtained,

particularly if all middle ear ¯uid is evacuated at the timeof fenestration. Further evaluation, in a larger series ofpatients, is needed to determine the consistency of thisobservation.

Hearing loss and discomfort from barotrauma is poorlytolerated in adults. LATMF offers rapid relief. This relief isof particular value for someone who may need to ¯y soonafter sustaining barotrauma [4]. Our results showed thateven hemorrhagic or edematous TMs healed well. Com-plete subjective improvement may take some additionaltime.

For the patient with the inconclusive physical examina-tion, LATMF allowed both improvement of her hearingloss and resolution of the physical ®ndings that hadinitially suggested a middle ear mass. Silverstein andcoworkers demonstrated that laser TM ventilation wouldresolve eustachian tube dysfunction. In similar situations,a bloodless and adequate-sized fenestration will permitotoendoscopy [3].

AOM unresponsive to medical management or OME inan immunocompromised patient are circumstances when adiagnostic tympanocentesis might be warranted. LATMFoffers a therapeutic and diagnostic advantage by creatinga large opening to the middle ear. This approach allows adirect culture from this area, microscopic assessment ofthe middle ear mucosa, and relief of pain and fever.Intermediate duration ventilation promotes the resolutionof infection. Modi®cation of antibiotic therapy, based onthese results may permit more precise medical therapy[10].

LATMF has the versatility to offer therapeutic anddiagnostic capability in a wide variety of clinical situationsbeyond the management of AOM and OME. LATMFpromptly improves hearing and resolves the discomfortof barotrauma, eustachian tube dysfunction, and AOMthat had failed medical management. The ability to treatpatients unresponsive to medical management for infec-tion or OME, which delays auditory assessment broadensour management options. Further evaluations of addi-tional patients are needed to verify the consistency of theseresults.

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322 COOK ET AL.

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