Audiologists DOMINIC POWER and DR BROOKE HANBY discuss the importance of using the right device to achieve excellent visualisation and depth perception for intricate procedures in the ear canal.
Mr Dominic Power and Dr Brooke Hanby spend considerable time training students and practitioners in cerumen removal and other procedures deep in the ear canal.
Power is a lecturer at The University of Melbourne and lead audiologist at its Melbourne Hearing Care Clinic, while Dr Hanby is project manager for Phonak’s Lyric hearing aids in Australia and an Ear Health Courses consultant.
Due to the demands of their roles they need to rely on equipment that won’t throw further complications into the equation. The VorOtek O Scope, invented in Australia specifically for ENT and audiological work, is their preferred teaching and in-practice tool for wax removal and deep canal procedures.
There are two versions: a head-band model and a spectacle frame model. They both combine LED illumination with a unique optical pathway for looking in ear, nose and throat cavities.
Its biggest benefits are its exceptional depth perception and stereoscopic vision due to both eyes reaching the bottom of the ear canal. This unique converged optical pathway of laser-aligned mirrors and precision magnifiers converges both eyes from 65 millimetres apart at the top to just a few millimetres apart at the bottom.
In conventional loupes and phone otoscopes, sight from only one eye reaches the bottom of the ear canal, providing poorer depth perception and monocular vision, VorOtek says. This indirect pathway can’t achieve the same level of depth perception as the VorOtek O Scope or provide binocular vision in narrow ENT cavities, making it more difficult to accurately judge small distances.
For practitioners, including Power and Dr Hanby, proper depth perception dramatically enhances their ability to judge very small distances. This minimises patient discomfort, reduces the risk of accidental contact with sensitive ear structures, and helps avoid complications such as pushing earwax deeper into the canal or accidental eardrum damage including perforation. It also enables hearing care professionals to work more efficiently and effectively.
The design enables viewing to the bottom of the ear canal into a very narrow cavity. Natural, bright light and illumination is directed into the space.
Light, optics and field of vision in some competitors’ products are broader however and use a narrow prism lens to converge, Power says. This loses some of your peripheral vision which gives cues such as if the patient is uncomfortable.
Peripheral vision also helps when introducing instruments from the periphery.
“If you can do your job with greater precision, it will be more comfortable for the patient,” Power says. “If using light that’s colouring the skin, you can’t see where some of those subtle bruises or irritation scratches are so it helps to keep the anatomy neutral.”
Various uses including more through otoscopy
He says the VorOtek O Scope is mainly used for wax removal, but an equally important application is for more thorough otoscopy.
“It gives us greater accuracy and precision over finer, more detailed techniques we need to apply when identifying whether anything suspicious is going on in the ear, removing bits that have fallen off hearing aids, doing wax removal, or manipulating or placing small objects in the ear, such as a probe or microphone tubes,” he says.
“For trickier cases, having good illumination and magnification makes difficult tasks much easier.”
The O Scope also helps place probe microphones for certain hearing aids close to the eardrum.
“Being able to visualise and gauge the depth perception and distance from the eardrum at the end of a probe microphone gives greater confidence that we’ve placed it in the right spot,” he says. “It also allows for more accurate adjustment of hearing aids when fitted deep in the canal.”
Removal of foreign bodies is another procedure where the device proves its worth. “You can’t do foreign body removal without having good depth of perception, light and magnification for removing hearing aid domes or wax filters that have dislodged in ear canals,” Power says.
“If removing beads, Lego, styrofoam balls, dead bugs – which I have – we must remove these objects safely without causing bleeding, scratching or other trauma to the ear canal.”
Perforated eardrum a risk from inferior scopes
A perforated eardrum was the main risk of not being able to see deep into the ear canal to perform procedures or place hearing aids, Power explains.
“I’ve seen many ears unfortunately that have been syringed out by GPs or practice nurses, where they have not visualised the ear canal properly,” he says, noting some GPs ask patients to sign a waiver, indicating risks.
“With the VorOtek O Scope you can be much more precise where you are removing the wax from and have better judgement on whether the wax should be left alone or the best way of removing a foreign body. It allows for safer, more precise, more effective and gentle care of the ear.”
He says other otoscopes, including pen and phone versions, have much lower resolution, less light and lower quality of optics and illumination which can provide inaccuracies in colour and representation. This can make it harder to detect differences between where the eardrum starts and the canal is. People might be left guessing if it’s wax or a shadow.
“Using both eyes is what gives depth of perception. You can work in that visual field and if using a curette or suction cannula, depth of perception guides precisely where you need to place your instrument.”
The university has several VorOtek O Scopes in its prac room and Power and others train audiology students in their correct use for otoscopy and cerumen removal.
While an operating microscope is the gold standard, it’s more expensive and less portable, making the VorOtek O Scope the best option for audiologists, he adds.
Power says cerumen removal workshops are popular because audiologists recognise it as a knowledge gap. “It’s something we are hoping that audiologists as a profession can be the gatekeepers to,” Power says.
Demand is increasing for cerumen removal as is community awareness that audiologists have the skills and techniques to perform it, he adds. It also needs to be done for hearing aid maintenance.
“People who wear hearing aids all day, every day, have to ensure that when wax blocks their ears, practitioners can remove it quickly and easily so it doesn’t get in the way of their hearing aid use,” he says.
Fitting hearing aids
The VorOtek O scope has been equally invaluable for Dr Hanby who trained in audiology in America before arriving in Australia 14 years ago to launch Lyric. Apart from being the Lyric project manager for Phonak, she also teaches cerumen removal to hearing care providers, GPs and nurses. Dr Hanby sometimes also teaches with Dominic Power.
Additionally, she teaches people across Asia-Pacific how to use the VorOtek O Scope to place Lyric invisible hearing aids deep inside the ear canal.
“I’m passionate about VorOtek. When teaching I make it clear that it’s not complicated when you’re using the right tool,” she says. “You can’t be confident with a procedure if you can’t see what you’re doing and if you’re going to do it the right way, you can’t fly blind.”
Dr Hanby has used the device for 14 years since its launch. “When we launched Lyric people had to use a certain operating microscope from Germany. After a few years, it became clear that some clinics didn’t have the footprint or space to house it so we investigated a solution for smaller visiting sites.”
She started looking into other options and met Melbourne ENT surgeon, Dr John Vorrath AM, who invented and manufactured the VorOtek O Scope which is now used by nearly all Australian ENTs.
“He just wanted the best optics for what he needed to do and that was working in the ear canal but he couldn’t find anything so he designed it himself,” she says.
“As soon as I used it I knew this was going to change the Lyric market which it did by opening the door to the number of providers, who became confident in Lyric fitting. Many prefer it for wax management, since it is easier to bend in certain positions that you cannot with the microscope.”
This also makes it ideal for practitioners dealing mostly with elderly people who find it hard to bend their stiff neck, she says.
Dr Hanby says when looking at that tiny space, people often can’t see around it because there’s a block to the canal. “With the VorOtek O Scope I love the visual because your two eyes converge like laser beams coming together. There’s a 12-millimetre space at the start but by the time it hits the ear canal with your working distance, it’s about three millimetres.”
She refuses to sign-off on those undertaking the cerumen removal course if they use other illumination, as she believes other devices are a liability. Typical head loupes don’t focus on the ear canal, she adds, as one eye looks through the lens but the other looks elsewhere.
“I tell my students to be careful because in our field there’s a lot of equipment that’s designed for other health professions; for example, equipment to remove dental plaque and flush water was used in ear irrigation and that’s why there’s perforations,” says Dr Hanby, adding that patients traumatised by wax removal by irrigation are transferring to safe microsuction.
“The O Scope is specific to ears. We should be so proud of VorOtek in Australia.
“Working distance is important because equipment’s often designed for other professions who are at arms’ length from a surgical patient. When working up close with little tools in ears, we must ensure people don’t move so the instrument won’t perforate the eardrum.
“We need to be close, so our arms aren’t stretched out and we have a good base, which you won’t see in a lot of head loupes.”
Convergence goes to that spot; the inferior posterior is important when performing wax removal and especially in such a tiny space. “It’s important because it’s where foreign objects sit or the thickest part of the wax to be removed is, the most crucial part.
“I think that’s why Dr Vorrath felt so passionate; he couldn’t find anything to do the job properly, so he invented his own form of illumination and it’s the safest way.”
For more information see vorotek.com
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