Interview with Craig Derkay M.D.
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Topic: Laser Myringotomy
AO/Beck: Good Morning Dr. Derkay. Thanks for spending a little time with me this morning.
Derkay: You're welcome. Glad to be here.
AO/Beck: Can you please give us a thumb-nail sketch of your professional background?
Derkay: Yes, I'd be happy to. I've been in Norfolk for 13 years. I am a professor of otolaryngology and pediatrics at the Eastern Virginia Medical School in Norfolk, Virginia and I'm the director of pediatric otolaryngology in the children's hospital. I attended medical school at the Medical College of Virginia and I did my residency in ENT at the Pittsburgh Eye and Ear Hospital and my fellowship was in pediatric otolaryngology at the Children's National Medical Center in Washington DC.
AO/Beck: That's an impressive background. I think you've obviously received an excellent academic and clinical background. Let's go ahead and jump into the topic of laser myringotomy. How long has laser myringotomy been around?
Derkay: Actually it's been around for more than a decade in one fashion or another.
Of course as lasers have become more and more available and the tools themselves have become improved, the applications have become more refined. I think Dr. Silverstein in Florida was probably among the first people to use a laser for myringotomy. Dr. Silverstein noted that how long the hole stayed open was in part based on the wattage and the power of the laser. More recently, the OTO-LAM is a flash-scan laser that was first marketed about 3 years ago for the specific application of myringotomy. This tool produces a hole that stays in the eardrum for approximately three weeks. The idea is that a standard knife myringotomy typically closes in about 72 hours, and if you insert a ventilation tube, the hole stays open somewhere between 6 months and 2 years. So the technology was developed to allow the hole to stay open for an intermediate period of time, and that seems to work our fairly well. With some children and adults it is desirable to have the hole open for more than 3 days, but also for less than 6 months to 2 years, and for that niche, the laser myringotomy offers an alternative.
AO/Beck: What happens to the margins of the laser hole? I can imagine that the laser myringotomy would produce a very clean margin, and I'm wondering if it heals with less scar tissue, or without a visible remnant from the laser myringotomy?
Derkay: That's a great question and it is a research interest being addressed but as of now, the jury is still out. There is a thought that it should heal more uniformly, but we know that all laser holes don't heal. About 97 to 98 percent do close, and that usually occurs in the first month, but not all of them do heal. The healing time and the closure versus non-closure issues probably relate to patient specific issues.
AO/Beck: Based on your knowledge of clinical issues related to otitis media and laser myringotomy, does laser myringotomy have routine clinical utility in the normal, day-to-day myringotomy routine, or is it more of an anomaly?
Derkay: In my opinion, generally speaking, the primary group of patients for myringotomy will be children aged 6 months to three years. Creating a hole in the eardrum for 21 days is not going to relieve their recurring acute otitis media problem. The second most common population that we place tubes in, are those with a persistent middle ear effusion. Generally, they've had effusion for three months or more, and the infection is not responding to antibiotics or tincture of time. Typically, those individuals have poor eustachian tube function secondary to allergy or enlarged adenoids, and the middle ear fluid is thick and viscous and it usually requires a large bore suction to evacuate it from the middle ear. So, for the second group, laser myringotomy will not be the procedure of choice. For me, the bottom line is that laser myringotomy may be most useful for older kids with a unilateral middle ear effusion, or perhaps in an adult with an acute otitis - particularly if the adult has to be on an airplane flight later that week or the next day. So all-in-all, I think it's useful for the minority of patients, but it is useful for the right patient in the right situation. Another benefit which has come about as a result of this technology is the way that we anesthetize the ear with local medicine. Tetracaine has
been used to numb the ear canal using an otowick, whereas the previous way involved using a needle to inject the ear. So that too, is an important step and leads to less pain and less apprehension for the patient.
AO/Beck: what about surgical time? Any difference between the standard protocol and the laser protocol?
Derkay: No, actually the surgical time is about the same. The biggest difference is the cost. The myringotomy knife can be resterilized, is reusable and costs about ten dollars. The laser system costs about 75 thousand dollars. The surgeon is paid the same amount of money for either protocol, about 110 dollars is pretty typical for the surgical fee.
AO/Beck: Dr. Derkay, thank you for your time and this overview on laser myringotomy.
Derkay: You're welcome, it's been my pleasure
Derkay: You're welcome. Glad to be here.
AO/Beck: Can you please give us a thumb-nail sketch of your professional background?
Derkay: Yes, I'd be happy to. I've been in Norfolk for 13 years. I am a professor of otolaryngology and pediatrics at the Eastern Virginia Medical School in Norfolk, Virginia and I'm the director of pediatric otolaryngology in the children's hospital. I attended medical school at the Medical College of Virginia and I did my residency in ENT at the Pittsburgh Eye and Ear Hospital and my fellowship was in pediatric otolaryngology at the Children's National Medical Center in Washington DC.
AO/Beck: That's an impressive background. I think you've obviously received an excellent academic and clinical background. Let's go ahead and jump into the topic of laser myringotomy. How long has laser myringotomy been around?
Derkay: Actually it's been around for more than a decade in one fashion or another.
Of course as lasers have become more and more available and the tools themselves have become improved, the applications have become more refined. I think Dr. Silverstein in Florida was probably among the first people to use a laser for myringotomy. Dr. Silverstein noted that how long the hole stayed open was in part based on the wattage and the power of the laser. More recently, the OTO-LAM is a flash-scan laser that was first marketed about 3 years ago for the specific application of myringotomy. This tool produces a hole that stays in the eardrum for approximately three weeks. The idea is that a standard knife myringotomy typically closes in about 72 hours, and if you insert a ventilation tube, the hole stays open somewhere between 6 months and 2 years. So the technology was developed to allow the hole to stay open for an intermediate period of time, and that seems to work our fairly well. With some children and adults it is desirable to have the hole open for more than 3 days, but also for less than 6 months to 2 years, and for that niche, the laser myringotomy offers an alternative.
AO/Beck: What happens to the margins of the laser hole? I can imagine that the laser myringotomy would produce a very clean margin, and I'm wondering if it heals with less scar tissue, or without a visible remnant from the laser myringotomy?
Derkay: That's a great question and it is a research interest being addressed but as of now, the jury is still out. There is a thought that it should heal more uniformly, but we know that all laser holes don't heal. About 97 to 98 percent do close, and that usually occurs in the first month, but not all of them do heal. The healing time and the closure versus non-closure issues probably relate to patient specific issues.
AO/Beck: Based on your knowledge of clinical issues related to otitis media and laser myringotomy, does laser myringotomy have routine clinical utility in the normal, day-to-day myringotomy routine, or is it more of an anomaly?
Derkay: In my opinion, generally speaking, the primary group of patients for myringotomy will be children aged 6 months to three years. Creating a hole in the eardrum for 21 days is not going to relieve their recurring acute otitis media problem. The second most common population that we place tubes in, are those with a persistent middle ear effusion. Generally, they've had effusion for three months or more, and the infection is not responding to antibiotics or tincture of time. Typically, those individuals have poor eustachian tube function secondary to allergy or enlarged adenoids, and the middle ear fluid is thick and viscous and it usually requires a large bore suction to evacuate it from the middle ear. So, for the second group, laser myringotomy will not be the procedure of choice. For me, the bottom line is that laser myringotomy may be most useful for older kids with a unilateral middle ear effusion, or perhaps in an adult with an acute otitis - particularly if the adult has to be on an airplane flight later that week or the next day. So all-in-all, I think it's useful for the minority of patients, but it is useful for the right patient in the right situation. Another benefit which has come about as a result of this technology is the way that we anesthetize the ear with local medicine. Tetracaine has
been used to numb the ear canal using an otowick, whereas the previous way involved using a needle to inject the ear. So that too, is an important step and leads to less pain and less apprehension for the patient.
AO/Beck: what about surgical time? Any difference between the standard protocol and the laser protocol?
Derkay: No, actually the surgical time is about the same. The biggest difference is the cost. The myringotomy knife can be resterilized, is reusable and costs about ten dollars. The laser system costs about 75 thousand dollars. The surgeon is paid the same amount of money for either protocol, about 110 dollars is pretty typical for the surgical fee.
AO/Beck: Dr. Derkay, thank you for your time and this overview on laser myringotomy.
Derkay: You're welcome, it's been my pleasure
