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BackTable / ENT / Article
How to Integrate In-Office Ear Tube Placement into Your Pediatric ENT Practice
Julia Casazza • Oct 23, 2023 • 40 hits
In-office ear tube placement accomplishes the same result as operative ear tube placement without the risks of the operating room. However, there is a learning curve to for ear tube placements done in office. In this article, BackTable guest Dr. Jordan Schramm of Peak Pediatric ENT in Provo, Utah shares his insights on ear tube placement using the Tula tube system. Successful in-office ear tube placement requires cooperation from patients, families, and office staff. While not all insurance providers pay for the procedure, interest (and thus coverage) is growing.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Families who intend to pursue in-office ear tube placement should be motivated to avoid a trip to the OR. Parents should expect that their children will need to sit and then lie still for about fifteen minutes.
• In Dr. Schramm’s opinion, children who tolerate an in-office otoscopy will tolerate an in-office ear tube placement.
• Defining and sticking to a standard workflow helps in-office ear tube placement occur smoothly. This requires that medical assistants and nurses involved in the procedure understand how the Tula system works.
• Insurance coverage for Tula tubes is limited but growing.
Table of Contents
(1) Patient Selection for In-Office Ear Tube Placement
(2) It’s a Team Effort: Dr. Schramm’s In-Office Ear Tube Placement Technique
(3) Administrative Considerations for In-Office Ear Tube Placement
Patient Selection for In-Office Ear Tube Placement
When planning in-office ear tube placement, selecting the right patient – and, by extension, the right family – is crucial. Based on Dr. Schramm’s experience, children who tolerate otoscopy can likely tolerate an in-office tube placement. While in-office ear tube placement is not painful, it can be uncomfortable. For this reason, parents need to be willing to help calm and distract their child during the procedure. Nevertheless, most of Dr. Schramm’s families find in-office ear tube placement appealing, especially when compared with a trip to the OR.
[Dr. Ashley Agan]
Yes, it's like an adult when you're thinking about doing an office procedure, your gut tells you-- just as you're talking to the patient, as you're doing the nasal endoscopy, if they're holding on to the chair, super stressed out, you're like, "No, this is not going to be a good office candidate." I'm sure if you're able to look in the kid's ear under the microscope, depending on can you look and clean out wax, what's the vibe? Very similar thing as far as deciding who's good for clinic and who's not.
[Dr. Jordan Schramm]
Absolutely. I think the word vibe is perfect. You walk in the room, the kid's screaming at you just by you walking in the room. I'm not thinking tula necessarily, although occasionally the families are like, "Yes, I want to do that and I'll hold my kid down." It's rare. Whereas other times when I was first doing it, I was doing a full microscopic ear exam with removal of wax to see how good they would do, how well they would tolerate that.
Now, if they can just tolerate a standard otoscopy in a reasonable manner without too much upset, and the family's good at just holding the kid on their lap and moving the ear to the side, to me that's good enough. Because I know that's going to be the same process once we're doing it, and I'm going to have to do the swaddle. I try not to use the word restraint because there's more paperwork with that. I know that's going to have to happen either way in those age groups, and so if I can get a reasonable view with the otoscope in the clinic and it's a kid that needs tubes, we'll have the discussion, talk about pros and cons of both options and let them decide.
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It’s a Team Effort: Dr. Schramm’s In-Office Ear Tube Placement Technique
Maintaining an organized workflow allows Dr. Schramm to perform in-office ear tube placements with minimal discomfort to his patients. First, the iontophoresis system anesthetizes the ear drum. In bilateral cases, both ear drums are anesthetized simultaneously. Dr. Schramm has a medical assistant keep an eye on the system during the ten minutes needed to anesthetize, so if there’s a problem, it is immediately rectified. When the ten minutes are up, his staff moves the patient to a separate room with the otologic microscope for placement. Medical assistants swaddle the child (using stretchable cloth swaddles) while he or she lies down, and Dr. Schramm quickly inserts the tube(s). Speed in performing this procedure is essential to minimize distress on the child’s behalf.
[Dr. Gopi Shah]
Is the child just sitting in the parent's lap when you're numbing them up for those 10 to 15 minutes, or are they in the position? I just keep thinking of the chair flattened, the baby in papoose. I can't imagine them keeping in papoose for 15, 20 minutes. How's the positioning for the numbing and then is it the same as they are just ready to go for that 15, 20 minutes?
[Dr. Jordan Schramm]
In order to do this efficiently, again, the analogy would be trying to do otoacoustic emissions on a child, once you put those plugs in, you don't want to pull them out, so right at the beginning, if it's a very young child, I will briefly swaddle them so we can just get all those little connections set up properly, and get the iontophoresis running, and that's usually no more than three to five minutes.
They don't have to be laying down necessarily, I tend to do that because my goal is to do it as quickly as possible because I find that minimizes the distress to the child if we can get it done quickly. I get it all set up, then as soon as it's set up and running, we loosen up their hands, get them in mum or dad's lap, get them watching a movie, get him eating a sucker or whatever treat they have.
As it runs in the great majority of cases, they just sit there being distracted, but they're not held flat in that position that you're going to have them for the actual tube insertion. Once that's all done running, you can take all that out. In many cases, I actually have a separate clinic room where I'm doing the iontophoresis then I move them to the room that I have my microscope. Then that's where I really swaddle them up, get them nice and still, parents are well informed beforehand that we'll be doing this and that for the very young children, they're not going to be happy with us because we're going to be holding them still.
A lot of good help with MAs and nurses to just get them swaddled, positioned, and get the tube inserted as quickly as we can on one side, swap them to the other side and then release them and give them some type of a toy or sticker or something and get them out of the door.
Administrative Considerations for In-Office Ear Tube Placement
While in-office ear tube placement helps families avoid the OR (with its associated risks), insurance and logistical barriers remain. Currently, Tula ear tube insertion is covered by a Category 3 “Emerging Technologies” CPT code. Dr. Schramm finds that many smaller insurers in his region cover the procedure, though Cigna is the only national insurance company to currently do so. When starting to perform Tula tube insertions in clinic, it helps to have a staff that’s familiar with in-office pediatric procedures. Clearly outlining the procedural workflow – and having staff that understand that workflow – is a must.
[Dr. Jordan Schramm]
It was like, wow, I just spent basically an hour of my time and I got four sets of tubes in without any OR time.
[Dr. Ashley Agan]
That's amazing.
[Dr. Jordan Schramm]
I stopped to think about it and looked at reimbursement rates aren't-- like, you're not doing this for the money by any means, but compared to what they pay for the OR, it's probably came out of ahead on those days, saved the patient's money and did better for my office. It can be done, but it's not day one.
[Dr. Ashley Agan]
Just thinking about your time when I moved to start doing things in the office, it's just so like, I'm the rate limiting step as opposed to when you're in the operating room, there's a lot of, you're waiting on things to happen that are just out of your control. There's something really nice about being able to run your procedure days because you're saving your time too, which is also very valuable.
[Dr. Jordan Schramm]
100%. I couldn't agree more. I'm fortunate the last couple years at a couple of the surgery centers where I operate, where they've given me two rooms at a time and those are the days in the OR where I actually become the rate limiting step, but most ORs you're not the rate limiting step. You have a lot of built-in time for turnover, talking to families, anesthesia time. In the office, I truly am the rate limiting step, just like when you're seeing regular clinic patients. For sure you can boost your efficiency that way.
Podcast Contributors
Dr. Jordan Schramm
Dr. Jordan Schramm is a pediatric otolaryngologist and head and neck surgeon with Peak ENT Associates in Salt Lake City, Utah.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 21). Ep. 131 – In-Office Ear Tubes in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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