Behavioral Strategies to Minimize Procedural Distress During In-Office Pediatric Tympanostomy Tube Placement Without Sedation or Restraint

AbstractThe purpose of this study was to evaluate behavioral strategies to minimize procedural distress associated with in-office tympanostomy tube placement for children without general anesthesia, sedation, or papoose-board restraints. 120 6-month- to 4-year-olds and 102 5- to 12-year-olds were treated at 16 otolaryngology practices. Mean age of children was 4.7 years old (SD = 3.18 years), with more boys (58.1%) than girls (41.9%). The cohort included 14% Hispanic or Latinx, 84.2% White, 12.6% Black, 1.8% Asian and 4.1% ‘Other’ race and ethnicity classifications. The in-office tube placement procedure included local anesthesia via lidocaine/epinephrine iontophoresis and tube placement using an integrated and automated myringotomy and tube delivery system. Behavioral strategies were used to minimize procedural distress. Anxiolytics, sedation, or papoose board were not used. Pain was measured via the faces pain scale-revised (FPS-R) self-reported by the children ages 5 through 12 years. Independent coders supervised by a psychologist completed the face, legs, activity, cry, consolability (FLACC) behavior observational rating scale to quantify children’s distress. Mean FPS-R score for tube placement was 3.30, in the “mild’ pain range, and decreased to 1.69 at 5-min post-procedure. Mean tube placement FLACC score was 4.0 (out of a maximum score of 10) for children ages 6 months to 4 years and was 0.4 for children age 5–12 years. Mean FLACC score 3-min post-tube placement was 1.3 for children ages 6 months to 4 years and was 0.2 for children age 5–12 years. FLACC scores were inversely correlated with age, with older children displaying lower distress. The iontophoresis, tube delivery system and behavioral program were associated with generally low behavioral distress. These data suggest that pediatric tympanostomy and tube placement can be achieved in the outpatient setting without anxiolytics, sedatives, or mechanical restraints.

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The Neverending Ouch

Pediatric Traumatic Emergencies ◽

10.1093/med/9780190946623.003.0020 ◽

2020 ◽

pp. 171-180

Author(s):

Julianne Hughes ◽

Isabel A. Barata

Keyword(s):

Chronic Pain ◽

Rating Scale ◽

Pain Scale ◽

Pain Medication ◽

Sociocultural Factors ◽

Evidence Based ◽

Pain Rating ◽

Older Children ◽

Children's Pain ◽

Pain Rating Scale

Chronic pain is defined as pain that is either persistent (ongoing) or recurrent (episodic) and is thought to be multifactorial, involving biological, psychological, and sociocultural factors. Generally, pain is considered chronic when the pain itself or recurrent episodes of pain persist greater than 3 to 6 months. Assessing children’s pain can be challenging, and validated tools should be used such as the Wong-Baker FACES Pain Rating Scale or the OUCHER Pain Scale (younger children) and verbal numerical scales (older children). Following assessment, treatment can be initiated based on the severity, nature, and presumed etiology of the pain. Management of acute or chronic pain episodes should follow evidence-based recommendations, which include both pharmacological and nonpharmacological principle. A stepwise escalation in pain medication may be required to adequately control the patient’s pain.

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In-Office Tympanostomy Tube Placement Using Iontophoresis and Automated Tube Delivery Systems

OTO Open ◽

10.1177/2473974x20903125 ◽

2020 ◽

Vol 4 (1) ◽

pp. 2473974X2090312 ◽

Cited By ~ 3

Author(s):

David M. Yen ◽

Michael T. Murray ◽

Robert Puchalski ◽

Andrew R. Gould ◽

John Ansley ◽

...

Keyword(s):

Tympanic Membrane ◽

Pain Score ◽

Delivery System ◽

The United States ◽

New Drugs ◽

Tube Placement ◽

Tympanostomy Tube ◽

Technical Success ◽

Performance Goal ◽

Patient Reported

Objectives (1) To evaluate safety, tolerability, and technical success of lidocaine iontophoresis and a tympanostomy tube placement system for adults in an office setting and (2) to meet regulatory evidence requirements for new drugs and devices. Study Design Prospective, multicenter, single arm. Setting Patients were recruited in 8 community-based practices in the United States between June and September 2017. Subjects and Methods This study evaluated tympanic membrane anesthesia and tube placement in 30 adults. Anesthesia was achieved via iontophoresis of a lidocaine/epinephrine solution. Tube placement was conducted using an integrated myringotomy and tube delivery system. Tolerability of tube placement was measured using a patient-reported visual analog scale from 0 mm ( no pain) to 100 mm ( worst possible pain). Mean pain score was compared to a performance goal of 45 mm, where statistical superiority represents mild pain or less. Technical success and safety through 3 weeks postprocedure were evaluated. Results Twenty-nine (29/30, 96.7%) patients had tube(s) successfully placed in all indicated ears. One patient demonstrated inadequate tympanic membrane anesthesia, and no tube placement was attempted. The mean (SD) pain score of 9.4 (15.7) mm was statistically superior to the performance goal. There were no serious adverse events. Seven nonserious events were related to device, procedure, or drug: inadequate anesthesia (1), vertigo (1), and dizziness (1) at the time of procedure and ear discomfort (1), tube occlusion (2), and medial tube migration (1) postprocedure. Conclusion Lidocaine iontophoresis provides acceptable tympanic membrane anesthesia for safe, tolerable, and successful in-office tube placement using an integrated myringotomy and tube delivery system.

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Pediatrics

Acute Pain Medicine ◽

10.1093/med/9780190856649.003.0022 ◽

2019 ◽

pp. 312-322

Author(s):

Michale Sofer ◽

Francis Wickham Kraemer

Keyword(s):

Abdominal Surgery ◽

Rating Scale ◽

Numerical Rating Scale ◽

Pain Scale ◽

Older Children ◽

Interventional Techniques ◽

Neonatal Pain ◽

Open Abdominal Surgery ◽

Numerical Rating ◽

The Individual

Following surgery, pediatric patients suffering from pain warrant consistent and frequent pain assessments. This chapter describes a variety of scales that can be used and that must be tailored to the developmental stage of the child. Examples of commonly used pediatric scales include the Neonatal Pain, Agitation and Sedation Scale (N-PASS); Face, Legs, Activity, Cry, Consolability (FLACC); Numerical Rating Scale (NRS); and the Wong Baker FACES Pain Scale. In the setting of open abdominal surgery, certain interventional techniques (continuous epidural, peripheral truncal blockade) can be used to significantly decrease pain and must be tailored to the individual patient and specific surgical subtype. Separate from interventional techniques, older children may also use patient-controlled analgesia (PCA) devices to deliver systemic opioids. For patients who are too young or are unable to press a PCA device, a variety of nurse-controlled analgesic protocols exist to deliver such systemic analgesic therapies.

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Are water precautions necessary after tympanostomy tube placement? A cadaver study

International Journal of Pediatric Otorhinolaryngology ◽

10.1016/j.ijporl.2021.110632 ◽

2021 ◽

Vol 143 ◽

pp. 110632

Author(s):

Anthony Sanchez ◽

Gabriel Arom ◽

Hector A. Perez ◽

Laura Royal ◽

TJ O-Lee

Keyword(s):

Cadaver Study ◽

Tube Placement ◽

Tympanostomy Tube

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Helping Children with Special Needs: Who Receives Tympanostomy Tubes?

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489420987425 ◽

2021 ◽

pp. 000348942098742

Author(s):

David W. Wassef ◽

Nehal Dhaduk ◽

Savannah C. Roy ◽

Gregory L. Barinsky ◽

Evelyne Kalyoussef

Keyword(s):

Developmental Disorders ◽

Developmental Disorder ◽

Private Insurance ◽

Insurance Coverage ◽

Tube Placement ◽

Hospital Charges ◽

Tympanostomy Tube ◽

Tube Insertion ◽

Tympanostomy Tubes

Objectives: Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion. Methods: A retrospective review using the Kids’ Inpatient Database (KID) was conducted, with codes from International Classification of Diseases, Ninth Revision used to query data from the years 2003 to 2012 to determine a study group of children with a diagnosis of a developmental disorder undergoing myringotomy and tympanostomy insertion. This group was compared statistically to patients undergoing these procedures who did not have a diagnosed developmental disorder. Results: In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, P = .002) and higher mean hospital charges ($43 704.77 vs $32 764.22, P = .003). This cohort also had higher proportions of black (17.6% vs 12.3%, P < .001) and Hispanic (23.9% vs 20.6%, P = .014) patients, and had lower rates of private insurance coverage (39.6% vs 49%, P < .001). Conclusion: The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

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The Effect of the COVID-19 Pandemic on Pediatric Tympanostomy Tube Placement

Otolaryngology ◽

10.1177/01945998211008916 ◽

2021 ◽

pp. 019459982110089

Author(s):

Gillian R. Diercks ◽

Michael S. Cohen

Keyword(s):

Tertiary Care ◽

Chronic Otitis Media ◽

Community Setting ◽

Tube Placement ◽

Tympanostomy Tube ◽

Care Providers ◽

Billing Data ◽

Patient Age ◽

Patient Âgé ◽

Tympanostomy Tubes

Objective To evaluate how the coronavirus disease 2019 (COVID-19) pandemic has affected tympanostomy tube placement and practice patterns. Study Design A retrospective review of billing data. Setting A large-volume practice with both community and tertiary care providers. Methods As part of a quality initiative, billing data were queried to identify children <18 years of age who underwent tympanostomy tube placement between January 2019 and December 2020. Patient age, practice location, and case numbers were gathered. Results The study included data from 2652 patients. Prior to state-mandated clinic and operating room restrictions, there were no significant differences in the number of tympanostomy tubes placed ( P = .64), including month-to-month comparisons, the distribution of patients being cared for at community vs tertiary care sites ( P = .63), or patient age at the time of surgery ( P = .97) between 2019 and 2020. After resumption of outpatient clinical and elective surgical activities, the number of tympanostomy tubes placed decreased significantly between 2019 and 2020 (831 vs 303 cases, P = .003), with a persistent month-to-month difference. In addition, patients undergoing tube placement were older (4.5 vs 3.2 years, P < .001). The distribution of cases performed in the community setting decreased during this time period as well ( P < .001). Conclusion During the COVID-19 pandemic, the rate of pediatric tympanostomy tube placement has significantly decreased. The age of patients undergoing surgery has increased, and more children are being cared for in a tertiary setting. These findings may reflect changes in the prevalence of acute and chronic otitis media as the result of the pandemic.

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Advanced Practice Provider Clinics: Expediting Care For Children Undergoing Tympanostomy Tube Placement

The Laryngoscope ◽

10.1002/lary.29477 ◽

2021 ◽

Author(s):

Michael A. Belsky ◽

Anisha Konanur ◽

Edward Sim ◽

Annie Yan ◽

Amber D. Shaffer ◽

...

Keyword(s):

Tube Placement ◽

Advanced Practice ◽

Tympanostomy Tube

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Efficacy of Naproxen Plus Gabapentin Vs Naproxen Alone in Relieving Post-Extraction Pain of Impacted Mandibular 3rd Molar

10.53350/pjmhs2115123264 ◽

2021 ◽

Vol 15 (12) ◽

pp. 3264-3267

Author(s):

Safia Khatoon ◽

Muhammad Ilyas Shaikh ◽

Arslan Mahmood ◽

Priya Rani Harjani ◽

Sarang Suresh ◽

...

Keyword(s):

Combination Therapy ◽

Drug Treatment ◽

Rating Scale ◽

Third Molar ◽

Pain Scale ◽

Combination Drug ◽

Impacted Mandibular Third Molar ◽

Pain Status ◽

Mandibular Third Molar ◽

Combination Drug Treatment

Background: Evaluate the efficacy of using combination drug treatment to relieve post extraction pain of impacted mandibular third molar by using Naproxen plus Gabapentin versus Naproxen alone. Aim: To evaluate the efficacy of using combination drug treatment to relieve post extraction pain of impacted mandibular third molar by using Naproxen plus Gabapentin versus Naproxen alone. Methods: Randomized control study, outcome was evaluated by measuring Pre – Operative and 24-Hour Post – Operative Pain status on Visual Analogue Scale and Wong Baker’s Face Pain Rating Scale. Results: Combination therapy (Naproxen and Gabapentin) was effective in significant pain reduction at 12 Hour and 24-Hour Post Extraction period. With 26 patients out 31 presented with Pain Scale of 0 on combination therapy while only 3 out of 31 for naproxen alone after 24 hours. Conclusion: Enhanced effect of combination therapy of naproxen with gabapentin in reducing post extraction pain of impacted mandibular third molar with respect to naproxen alone. Keywords: Naproxen, Gabapentin, Combination Therapy, Post Extraction Pain, Post Extraction Analgesia, Efficacy.

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Tswana speaking South Africans’ understanding of pain scales

South African Journal of Physiotherapy ◽

10.4102/sajp.v65i1.76 ◽

2009 ◽

Vol 65 (1) ◽

Cited By ~ 1

Author(s):

M. Yazbek ◽

A. Stewart ◽

P. Becker

Keyword(s):

Visual Analogue Scale ◽

Analogue Scale ◽

Rating Scale ◽

Pain Scale ◽

Pain Tolerance ◽

Future Research ◽

Validity And Reliability ◽

Cross Sectional ◽

Pressure Threshold ◽

Pain Scales

Aim: The aim of this study was to establish the validity and reliability of the Tswanatranslations of three pain scales.Design: This was a cross–sectional study to validate and test the reliability of threepain scales.Participants: One hundred subjects participated in the study. They were selectedfrom the back schools of five hospitals in the North -West Province of South A frica andfrom workers in these hospitals who were employed as kitchen workers, laundryworkers and cleaners.Method: Translation of the pain scales and the stages of cross-cultural adaptation were followed as recommended byBeaton et al (2000). Pain tolerance of the subjects was measured using a P.T.M. (pressure threshold meter). The painscales used were the V.A .S. (visual analogue scale) one (nought and ten only), the V.A .S. (visual analogue scale) two(nought through to ten), the W.B.F. (Wong-Baker Faces pain measure) and the V.R.S. (verbal rating scale). The V.R.S.used came in two forms. The first form was written on cue cards which the subjects arranged in order and the second form was the questionnaire version of the V.R.S.The subjects were interviewed and asked five questions relating to their back pain. Upon completion of the interviewthe pressure threshold of the painful area (back) was tested. Subjects then filled in the three pain scales, namely the (V.A .S. one, V.A .S. two, the V.R.S. and lastly the W.B.F. pain scale). Approximately a third of the sample (37) was retested the following day following the same procedure asdescribed above. Results: There was no correlation between the pressure threshold meter readings and the pain scale measurements. Conclusion: From the statistical analysis of the results, it became apparent that the subjects tested did not have anunderstanding of any of the three pain scales. Future research needs to be done in developing entirely different scales for peoples of low literacy and differentlanguage and cultural groups in South Africa.

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