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The O’Neill Grading System for Evaluation of the
Tympanic Membrane
A Practical Approach for Clinical Hyperbaric Patients
Owen J. O’Neill, MD, FACHM, FAPWCA, CHT
Medical Director, Department of Hyperbaric Medicine
Phelps Memorial Hospital Center
Clinical Assistant Professor of Medicine
New York Medical College
Clinical Assistant Professor of Emergency Medicine
Upstate Medical University
1
Words of Wisdom
Food for Thought……
“The dogmas of the quiet
past are inadequate to the
stormy present. The
occasion is piled high with
difficulty, and we must rise
with the occasion. As our
case is new, so we must
think anew and act anew.”
Learning Objectives
“As our case is new, so we must think anew
and act anew………………”
• Review evaluation of the tympanic membrane; Eustachian Tube
dysfunction (ETD) and Middle Ear Barotrauma
• Explore the relevance and practicality of the current
classification system (Teed’s Classification) and the “Modified
Teed’s Classification”.
• Define otic barotrauma (Teed’s Classification) and its
ineffectiveness relating to the clinical hyperbaric patient.
• Why do we grade otic barotrauma or anything in clinical
medicine?
• All of us are practicing clinical hyperbaric medicine using the
same (ineffective) standard when grading otic barotrauma
Lastly……..Is there a more efficient and uniform way
to classify ETD and MEB………………..?????????
Middle Ear Barotrauma (MEB)
• Most common secondary effect of HBO2T
• 5-40 % incidence in certain studies
• Effects all patients and HBO Team members
• May be avoided in some instances when Eustachian tube
dysfunction is documented prior to treatment
• Can occur when not expected to
Laryngoscope. 1997 Oct;107(10):1350-6.
Beuerlein M, Nelson RN, Welling DB.
Middle Ear Barotrauma (MEB)
• Tympanograms fail to predict MEB
• Proper patient education with equalization
technique
• Slowing the rate of compression
• Addition of certain medications and/or routine
minor surgery.
Laryngoscope. 1997 Oct;107(10):1350-6.
Beuerlein M, Nelson RN, Welling DB.
Definition of Routine Minor Surgery
“Surgery that is performed on someone
else besides you or me………...”
Middle Ear Barotrauma (MEB)
Eustachian Tube Dysfunction
Pressure in
during
compression of
the hyperbaric
chamber
Pressure needs to
be equalized during
various
equalization
maneuvers with
pressure in through
Eustachian Tube
Middle Ear Barotrauma (MEB)
Is It Predictable and Preventable?
•
Define the incidence and significance of HBO-related barotrauma.
•
Wanted to establish guidelines for prophylactic myringotomy or tympanostomy tube placement.
•
Patients were stratified into two groups, those able to autoinflate and those unable to autoinflate
the middle ear.
•
Barotrauma was assessed by otoscopy, tympanometry, high-frequency audiometry.
•
91% from the noninflater group suffered middle ear barotrauma.
•
37% from the autoinflater group sustained middle ear barotrauma.
Conclusion
“Patients unable to autoinflate the middle ear were shown to have a higher
incidence and greater severity of barotrauma than patients able to autoinflate…
myringotomy and tympanostomy tubes should be considered in patients with
artificial airways or have failed autoinflation techniques and medical
intervention.
Department
of Otolaryngology, The Ohio State University
Laryngoscope. 1997 Oct;107(10):1350-6.
Beuerlein M, Nelson RN, Welling DB.
The O’Neill Grading System will allow
us to follow these items routinely!!!
Middle Ear Barotrauma
Tx Interventions
Predisposing Factors
•
•
•
Inability to autoinflate the middle ear
•
Re-education and coaching in proper
on direct otoscopic evaluation
middle ear pressure equalization
Patients with prior head and neck
techniques
radiation Tx
•
Slowing compression rates
Nasal obstruction/pathology/allergies
•
Non-linear compression
(Rhinitis)
•
Trial of medical therapy*
•
URI (inflammation and edema)
• Treat underlying cause
•
Oral obstruction (ET Tubes)
• Prevention
•
Pediatric patients not expected to
•
Myringotomy*
cooperate with equalization
•
Myringotomy tubes*
maneuvers.
Medical Intervention to Decrease the Risk
of MEB
Oral Therapy
•
•
•
Decongestants
Inhaled Therapy
•
Decongestants
–
Pseudoephedrine
–
Phenylephrine
–
Phenylephrine
–
Oxymetazolone
Antihistamines
–
Diphenhydramine
–
Clemastine
–
Chlortrimeton
–
Loratidine
•
Antihistamines
•
Anti-inflammatory
agents / Cromolyn
Anti-inflammatory
agents / Cromolyn
Medical Intervention to Decrease the Risk
of MEB
Oral Therapy
• Decongestants
A Double-Blind Comparison Between Oral Pseudoephedrine and
Topical Oxymetazolone in the Prevention of Barotrauma During
Air Travel
Pseudoephedrine 120 mg 30/min prior to flight
Symptom
(N=41)Pseudoep
hedrine
Oxymetazolone 2 sprays 30/min prior to flight
(N=42)Oxymetaz
olone
(N=41)
Placebo
P
Ear Pain
9 (22%)
18 (43%)
20 (51%)
.031
Blockage
11 (27%)
23 (55%)
22 (59%)
.016
Hearing Loss
7 (17%)
14 (33%)
16 (39%)
.079
Dizziness/Verti
go
3 (7%)
2 (5%)
3
(7%)
.861
Tinnitus
2 (5%)
3 (7%)
1
(2%)
.607
Asymptomatic 27 (66%)
15 (36%)
12 (29%)
.002
American Journal of Emergency Medicine - Volume 16, Issue 3 (May 1998)
Prophylaxis Against Middle Ear Barotrauma in US
Hyperbaric Oxygen Therapy Centers
These results show that there is great variance in clinical practice with
regard to middle ear barotrauma prophylaxis among US HBO centers.
Many centers are using unproven therapies such as topical nasal
decongestants.
• Phone survey to all HBO centers in the USA (1995/ 375 centers).
• Routine practice regarding MEB prophylaxis.
• 1/5 performed prophylactic myringotomy on patients intubated
and infants.
• Less than ½ performed the procedure prophylactically.
• 1/3 of centers administered prophylactic drugs before HBO2T.
• Topical nasal decongestants preferred to systemic oral
medications.
Capes JP, Tomaszewski C. Am J Emerg Med. 1996 Nov;14(7):6458.
Prevention of Hyperbaric-Associated Middle Ear Barotrauma
•
60 patients randomized into two treatment arms.
•
Oxymetazolone or Placebo (nasal saline) 2 sprays in each nostril 15 minutes
prior to hyperbaric exposure.
•CONCLUSION:
Collected data included patientThe
demographics,
ear examinations
results
of thisbefore and
after hyperbaric oxygen treatment, and subjective ear complaints.
pilot study suggest that topical
RESULTS: The treatment groups were similar with regard to age, sex,
decongestants
mayduring
nothyperbaric
be effective
in
and medical history. Ear discomfort
oxygen therapy
was present in 63% (19 of 30) of those receiving oxymetazoline versus
preventing
middle
barotrauma
67% (20 of 30) of the control
group ear
(P = .99).
Likewise, both groups had
similar Teed scores after hyperbaric oxygen therapy (P = .88). No
during
hyperbaric oxygen therapy.
adverse effects were noted.
Carlson S, Jones J, Brown M, Hess C.
Ann Emerg Med. 1992 Dec;21(12):14 68-71.
Medical Implications
Preventing or Treating MEB
•
Controversy still exists regarding the best overall therapy and prophylaxis.
•
Patients may be prescribed oral antihistamines, oral or nasal decongestants,
steroids, or a combination of these prior to HBO2T for prophylaxis or
treatment.
•
Specific disease entities (such as allergies) will be treated with the
“appropriate usual accepted therapy”.
•
Relative contraindications to the use of all medications are considered when
making a medication choice.
•
Myringotomy tubes (minor surgery) are used as a last resort in those
patients who’s hyperbaric treatment benefits outweigh the risk of the
procedure.
ETD/Middle Ear Barotrauma
• 0-10 FSW is
sufficient to close
the Eustachian
Tube.
• Will not reopen
unless pressure is
relieved.
Classification of Middle Ear
Barotrauma
• T0: Symptomatic with
normal tympanic membrane
• T1: Slight erythema
• T2: Moderate erythema
• T3: Bleeding into TM
• T4: Bleeding into the Middle
ear space
• T5: Perforated tympanic
membrane
Classification of Middle Ear
Barotrauma
What or Who is TEED??
Is everyone familiar with the origin of the
“Teed” classification system?
1. A town in Southern England where the
classification originated
2. The lead diver of the French Navy in 1950
and an original team member of Jacque
Cousteau
3. A flight Surgeon caring for air force
aviators suffering barotrauma during
WWII
4. The name of the medical student from
largest medical school in Northern
The Mystery Man
Lt. Commander R. W. Teed
• USN Dive Medical Officer
• First Described Barotrauma
in 1944
• Published in USN Medical
Journal as Teed’s
Classification
• Barotrauma suffered by
submariners during escape
training for qualification
We are Creatures of Habit
After all these years!!!
Us Followers
Middle Ear Barotrauma
What Was Dr. Teed’s Original Classification?
Dr. Teed’s Original Classification
Teed RW. Factors producing obstruction of the auditory tube in
submarine personnel. US Naval Medical Bulletin 1944;XLII:293 – 306
Special thanks to:
Erica D. Weitzner, MS IV
New York Medical College
Classification of Middle Ear Barotrauma
Modified Teed’s ???????
• T0: Symptomatic with
normal tympanic membrane
• T1: Slight erythema
• T2: Moderate erythema
• T3: Bleeding into TM
• T4: Bleeding into the Middle
ear space
• T5: Perforated tympanic
membrane
Modified Teed’s Photos
Why Classify Pathological Processes such
as Otic Barotrauma?
• Create a uniform method of describing
a pathological process
• Each pathologic process will be
classified to facilitate the need for
certain action or treatment
• Each classification level can be
followed as a guide to pathological
improvement and/or prevention
Assumes the same person is evaluating the process from baseline
and with each subsequent examination
Why Classify A Pathological Processes
Such As Otic Barotrauma?
• The classification has clinical relevance
– subjects the patient to further clinical diagnosis and/or treatment
• Based on the accuracy of the classification patients
receive appropriate and necessary treatment
– Re-education, steroids, decongestants, myringotomy tubes
• Based on the inaccuracy of the classification patients
receive inappropriate and/or unnecessary treatment
– Re-education, steroids, decongestants, myringotomy tubes
• Treatments and preventative measures also carry risk
Assumes the same person is evaluating the process from baseline
and with each subsequent examination
Treatment Plan is Based on
Pathologic Classification
• Holding treatment
schedule
• Improved ear clearing
instruction
• Nasal decongestants
• Nasal steroids
• Antihistamines
• Myringotomy tubes
Teed’s Classification of Middle Ear Barotrauma
Modified Teed’s Classification
“As our case is new, so we must think
anew and act anew………………”
Defining Middle Ear Barotrauma
• Barotrauma is physical damage to body tissues
caused by a difference in pressure.
• Barotrauma refers to injury sustained from failure
to equalize the pressure of an air-containing space
with that of the surrounding environment.
• Barotrauma is an injury caused by pressure,
especially to the middle ear or paranasal sinuses
due to an imbalance between the ambient
pressure and pressure within the cavity.
• Physical injury sustained as a result of exposure
to changing air pressure, or rupture of the
tympanic membranes, as may occur among
scuba divers or caisson workers
Middle Ear Barotrauma
• To have barotrauma the
patient must have evidence of
–Trauma
–Damage
–Injury
–Rupture
Modified Teed Classification
Middle Ear Barotrauma
• T0: Symptomatic with
normal tympanic membrane
• T1: Slight erythema
• T2: Moderate erythema
• T3: Bleeding into TM
• T4: Bleeding into the Middle
ear space
• T5: Perforated tympanic
membrane
Middle Ear Barotrauma
According to the Real Dr. Teed
Nowhere is there any mention of fluid in the
middle ear space
Teed’s or Modified Teed’s
What’s the Point?
• Otolaryngologists are unaware of this
classification
• It was useful for Dr. Teed to evaluate
submariners practicing submarine escapes
in 1944
• It is not useful to us as a clinical tool
• It has been modified over the years by “who
knows who” with additions to an already
cumbersome and clinically useless grading
system
Teed’s or Modified Teed’s
What’s the Point?
• Ambiguous and subjective
grading system
• 69 years old (1944)
• Non clinical use
• No reference baseline
• Refers to barotrauma
without pathological change
to the TM
• Displays doctored
photographs
Teed’s or Modified Teed’s
What’s the Point?
• Trained eyes have
difficulty differentiating
bleeding into the TM
vs bleeding into the
middle ear space
(Grades 3-4).
• Relied on the same
person doing all the
evaluating (Dr. Teed)
• There are no
significant guidelines
for treatment based on
a Grade
Why Classify Pathological Processes such as Otic
Barotrauma?
Is the Teed’s Classification Serving Our Needs?
• The classification has clinical relevance
– subjects the patient to further clinical diagnosis and/or
treatment
NO
• Based on the accuracy of the classification patients
receive appropriate and necessary treatment
– Re-education, steroids, decongestants, myringotomy tubes
• Based on the inaccuracy of the classification
patients receive inappropriate and/or unnecessary
treatment
– Re-education, steroids, decongestants, myringotomy tubes
NO!!!!!!!
• Treatments and preventative measures also carry
risk
Is the same person evaluating the process from baseline and with
each subsequent examination
O’Neill Grading System
for Clinical Tympanic Membrane Evaluation
Objective baseline must be documented
• O’Neill Grade 0
– Baseline Photo/Normal anatomical appearance per
patient
– Symptoms without injury ( ETD) baseline reference
• O’Neill Grade 1
– erythema increase from baseline
– Increased Fluid or air trapping in the middle ear space
• O’Neill Grade 2
– Bleeding -tympanic membrane-middle ear
– Perforation
O’Neill Grading System
for Clinical Tympanic Membrane Evaluation
Objective baseline must be documented
O’Neill Grade/ Baseline Comparison
•
•
•
O’Neill Grade 0 (ETD)
– Baseline Photo/Normal
anatomical appearance per
patient
– Symptoms without injury (
ETD) baseline reference
O’Neill Grade 1
– erythema increase from
baseline
– Increased Fluid or air trapping
in the middle ear space
O’Neill Grade 2
– Bleeding -tympanic
membrane-middle ear
– Perforation
Expected Action/Treatment
• O’Neill Grade 0 (Tx 1-3)
 Teaching
 Slow compression
•



O’Neill Grade 1
Teaching
Slow Compression
Medical Therapy
• O’Neill Grade 2
 ENT Referral
 Hold treatments to baseline
Why an Objective Baseline Evaluation
of the Tympanic Membrane?
• Uniform method of description
• Baseline necessary for
comparison
• The initial evaluator may not
be the same person
examining the TM post ETD or
MEB
• The evaluator may not be a
physician
• Accurate description
(Grading) of the TM is crucial
because it leads to a Dx and
potential treatment (with risk
and secondary effects)
TM Grading Should Lead to an Action
• Reinforce equalizing
maneuvers
• Slow compression
• Tx the underlying cause of ET
dysfunction (steroids, inhaled
agents, antihistamines)
• Tx the ET dysfunction (
steroids, inhaled
decongestants, oral
antihistamines)
• HBO2T may be interrupted
• Surgery (myringotomy)
What’s the Grade?
What should I do?
Documenting the Patients
Baseline
Baseline Documentation
Documenting the Baseline
Video-Otoscopy
•
•
•
•
Readily available
Many makes and models
Relatively inexpensive
Uniform baseline description
of the TM and ear canal…it’s
a photo
• Captures the patients ability to
equalize…. It’s a video
• Objective baseline that
anyone can then access for
comparison
Video-Otoscopy
Every Patient is Not Anatomically Similar
Comparison is Essential
• What’s the patients
baseline?
• Is the tympanic
membrane anatomy
changed from
baseline?
• Teed’s 0
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill Grade 0
Baseline consultation photo
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
Teed’s ?
• What’s the patients
baseline?
• Does the original or
modified Teed’s
account for middle ear
space fluid? No
• Is this actually
barotrauma or ETD?
• How will you treat this
patient?
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill Grade 1
Teed’s ?
Baseline consultation photo
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill Grade 1
Teed’s ?
Baseline consultation photo
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
Teed 1
Teed 2
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
O’NeillO’Neill
0 Grade
1
Teed 1 / Teed 2
Teed’s ?
Baseline consultation photo
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
Teed’s 1
Teed’s 2
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill 0
O’Neill 1
Teed 1 / Teed 2
Baseline
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
What’s the Teed Class?
Teed 3 ? In/behind
Teed 4 ? In/behind?
Patient has a stop at 14 FSW
due to pain in the Ear
Diagnostic Procedure?
What’s the treatment?
Withhold HBO2T?
How many days?
Meds? Tubes? ENT eval?
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill Grade 2
Withold Tx / ENT Consult
Teed 4
Patient Baseline
Patient has a stop at 14 FSW
due to pain in the Ear
Every Patient is Not Anatomically Similar
Comparison is Essential
They are all baseline photos of the TM prior to initiating HBO2T!!
O’Neill Grade 0
Every Patient is Not Anatomically Similar
Comparison is Essential
O’Neill Grading System
for Clinical Tympanic Membrane Evaluation
Objective baseline must be documented
O’Neill Grade/ Baseline Comparison
•
•
•
O’Neill Grade 0 (ETD)
– Baseline Photo/Normal
anatomical appearance per
patient
– Symptoms without injury (
ETD) baseline reference
O’Neill Grade 1
– erythema increase from
baseline
– Increased Fluid or air trapping
in the middle ear space
O’Neill Grade 2
– Bleeding -tympanic
membrane-middle ear
– Perforation
Expected Action/Treatment
• O’Neill Grade 0 (Tx 1-3)
 Teaching
 Slow compression
•



O’Neill Grade 1
Teaching
Slow Compression
Medical Therapy
• O’Neill Grade 2
 ENT Referral
 Hold treatments to baseline
O’Neill Grading System
O’Neill 0
Baseline
O’Neill 1
Erythema/serous
fluid or Air Trapping
O’Neil Grading System
O’Neill 2
Bleeding/Perforation
O’Neill Grading System for
Evaluation of the Tympanic Membrane
Baseline Photograph TM and Video of TM Motion
with Equalization Maneuvers
O’Neill Grade
O’Neill 0
Treatment Considerations
Teaching Compression Rate
Non-Linear Compression
O’Neill 1
Reinforce O’Neill O
Consider Meds / ENT Eval
O’Neill 2
Hold treatments to baseline
Mandatory ENT Referral
Variables to Keep in Mind When
Considering Medical Tx Alternatives
• Is the patient having basic ETD due to increased
pressure without a pathologic process
• Is the patient have ETD/Barotrauma due to an
underlying pathologic process ( secondary ETD)
deserving treatment
• Prevention meds have not been proven to be
successful
• Oxymetazolone/Afrin has no role without
secondary ETD
• Pseudoephedrine (to date) has been the only med
shown to reduce symptoms of ETD………..
The rest of these are merely providing a
placebo effect for our patients or us…..
Oral Therapy
•
•
Decongestants
–
•
•
Inhaled Therapy
Phenylephrine
Decongestants
–
Phenylephrine
–
Oxymetazolone
Antihistamines
–
Diphenhydramine
–
Clemastine
–
Chlortrimeton
–
Loratidine
Anti-inflammatory
agents / Cromolyn
•
Antihistamines
•
Anti-inflammatory
agents / Cromolyn
O’Neill Grading System for Evaluation of
the Tympanic Membrane
Glad to be done ??
O’Neill Grade
O’Neill 0
Questions
Treatment Considerations
Teaching Compression Rate
Non-Linear Compression
O’Neill 1
Reinforce O’Neill O
Consider Meds / ENT Eval
O’Neill 2
Hold treatments to baseline
Mandatory ENT Referral
Owen J. O’Neill, M.D.
[email protected]
[email protected]
(914) 366-6665 OFFICE
(914) 804-8671 CELL
(914) 366-3690 CHAMBER