Conductive hearing loss

During the Renaissance, Andreas Vesalius, a Belgian anatomist, described the ear and ossicles (ie bones of the middle ear), and Bartolommeo Eustachio, an Italian anatomist, wrote the first book devoted exclusively to the human ear.(1) Several hundred years later, Antonio M. Valsalva, an Italian anatomist, characterized the ear as having three distinct parts--external, middle, inner--and described a maneuver that relieves negative pressure in the middle ear (ie, inhaling, forcing the diaphragm and chest muscles against the closed glottis).(2)

In the nineteenth century, interest in the physiology of hearing and pathology of the human ear increased.(3) Joseph Toynbee, an English otologist, studied temporal bones extensively and demonstrated the fatal course of a cholesteatoma (Table 1). He died while attempting to relieve his own tinnitus with chloroform.(4) Adam Politzer, a nineteenth-century Austrian otologist, described the pyramid of light visible on the tympanic membrane and developed the technique known as politzerization (ie, occluding one side of the nose, forcing air into the other nostril with a politzer bag as the patient swallows) to open blocked eustachian tubes.(5)

Ossicular chain disorders. Ossicular chain disorders include fibrous unions, disarticulations, fixations, and dislocations. Fibrous unions are composed of scar tissue that replaces the long process of the incus. Erosion of the long process of the incus--caused by a persistent retracted tympanic membrane, middle ear effusions, or recurrent otitis media--with replacement of the bone by scar tissue (ie, fibrous union) is the most common indication for ossicular chain reconstructive surgical procedures.(17) Surgical repairs of fibrous unions require placement of incus autografts or replacement prostheses.

Disarticulations of the ossicles can be caused by cholesteatomas or previous surgical procedures. Cholesteatomas are growths of squamous epithelium through marginal tympanic membrane perforations into middle ears and mastoid cavities (Figure 3). Cholesteatomas tend to become infected and are characterized by foul, draining discharge. If they destroy the ossicles, conductive hearing loss can be severe. Surgical removal of cholesteatomas may require mastoidectomy procedures and removal of the ossicles and middle ear mucosa. Restoration of lost hearing may be performed in staged reconstructive procedures.(18)

[Figure 3 ILLUSTRATION OMITTED]

Fixations may be of congenital origin or be caused by cholesteatomas, otosclerosis, or tympanosclerosis. Congenital malformations and cholesteatomas may occur along any part of the ossicular chain. Otosclerosis is a hereditary defect of unknown cause and is the most common cause of conductive hearing loss in people between 15 and 50 years of age.(19) Normal bone in the bony labyrinth is absorbed and replaced by otosclerotic bone, which causes a progressive fixation of the stapes footplate and results in conductive hearing loss. This hearing loss progresses slowly and usually is noticed first in late adolescence or early adulthood.(20) Surgical repair of conductive hearing loss caused by otosclerosis involves removal of the stapes or creation of a small hole in the fixed footplate and insertion of a stapes replacement prosthesis.

Another cause of fixation is tympanosclerosis, which is characterized by progressive deposition of hyaline material around the tympanic membrane or ossicles. Tympanosclerosis results from long-standing inflammatory disease. Large hyaline deposits can lock the stapes footplate into place and may form about the heads of the incus and malleus, fixing them into place. As the ossicular chain becomes impaired, hearing decreases.(21) Conductive hearing loss caused by tympanosclerosis is less amenable to surgical repair because the basic disease process recurs.(22)

Dislocations most often are caused by trauma. Skull fractures, explosive blasts, and foreign bodies projected through the tympanic membrane can dislocate the ossicles. Incus disarticulations at the incudostapedial joint are the most common traumatic injury to the middle ear, followed by subluxation of the stapes or fracture of the stapes into the vestibule.(23) The stapes and malleus are less likely than the incus to be dislocated because of their respective attachments to the oval window and tympanic membrane. Surgical repair depends on the extent and type of dislocation.

Mixed hearing loss. Mixed hearing loss is a combination of sensorineural and conductive hearing loss. The conductive component is treatable. Individuals with mixed hearing loss can have difficulty using hearing aids because sound specificity between low and high frequencies may be insufficient.(24)

OSSICULAR CHAIN RECONSTRUCTION PROCEDURES

Ear surgery has come of age in this century. With the availability of antibiotics to manage ear infections, modern otorhinolaryngologists have been able to devote their efforts to reconstructing ear structures and restoring hearing.(25) Julius Lempert, MD, an American otorhinolaryngologist, introduced the operating microscope in the 1940s and devised a fenestration procedure for creating an opening into the ear labyrinth to restore hearing that had been lost from otosclerosis.(26) In the 1950s, American surgeons described mobilization of the stapes and developed new stapedectomy procedures.(27)

Ossicular prosthetic development proliferated in the 1960s with the development of alloplastic prostheses. Working with a magnification loupe and several middle ear bones, a surgical instrument and orthopedic implant manufacturer created a hand-carved polytetrafluoroethylene implant for a patient with otosclerosis. The patient's hearing improved immediately after implantation of this prototype prosthesis.(28) The next generation of alloplastic prostheses included polyethylene prostheses, which were used with vein grafts (Figure 4) over the oval window; polytetrafluoroethylene pistons; stainless steel pistons and wire struts; absorbable gelatin sponge wire prostheses; and struts designed to replace one or all damaged or missing ossicles. In the past two decades, otorhinolaryngologists and biomedical engineers have begun using the acronyms TORP (ie, total ossicular replacement prosthesis) and PORP (ie, partial ossicular replacement prosthesis) to describe the newest prostheses and surgical procedures.

[Figure 4 ILLUSTRATION OMITTED]

The early alloplastic prostheses had high extrusion rates. To counteract this problem, surgeons began placing porous polyethylene implants combined with cartilage between the prostheses and patients' tympanic membranes. Hydroxyapatite prostheses, which did not require cartilage to prevent extrusion, gradually replaced the polyethylene prostheses. Incus homografts and autografts also were popular for many years, but homograft use has declined recently because of concerns about infectious disease transmission.

Ossicular chain reconstruction procedures continue to be challenging for otorhinolaryngologists and patients because the acoustic features of ossicular replacement prostheses are still in their early development. The search continues for the ideal prosthesis--one that is relatively easy to insert, bio-compatible, and stable and that transmits sound well and improves patients' hearing.(29)

The goal of ossicular chain reconstruction procedures is to restore vibration from the tympanic membrane to the oval window to allow sound transmission. When contemplating surgical reconstruction procedures for ossicular chain disorders, otorhinolaryngologists and patients must consider both intrinsic and extrinsic factors.

Intrinsic factors. Intrinsic factors that can affect the outcome of ossicular chain reconstruction procedures include the severity of disease, eustachian tube function, and the status of the ossicles. The most common ossicular defects involve the long process of the incus, entire incus, arch of the stapes, entire malleus, head of the malleus, and handle of the malleus.(30) Reconstruction procedures are based on the remaining ossicular elements rather than the missing portions. For example, if the malleus handle and stapes arch are both present, the surgeon most likely will perform a malleus-stapes assembly, but if the malleus is present and the stapes arch is absent, a malleus-footplate assembly or a TORP insertion is performed.

Extrinsic factors. Extrinsic factors include the surgical technique, the staging of surgery, and the type of prosthesis to be used. Prosthetic selection takes into account the presence or absence of the patient's malleus, the position of the malleus in relation to the stapes, the need for tympanic membrane grafting, and the severity of eustachian tube dysfunction.(31)

Preoperative care. Perioperative nurses use nationally recognized standards of care (eg, published by AORN, the Society of Otorhinolaryngology and Head-Neck Nurses, the American Nurses Association(32)) to guide them in the care of patients undergoing ossicular chain reconstruction procedures. This patient care is based on comprehensive preoperative assessments that incorporate each patient's physical, psychological, and education needs.

During the preoperative patient interview, the perioperative nurse

* assesses the patient's and family members' perceptions and expectations related to health care;

* confirms the patient's current diagnosis and treatment plan;

* reviews his or her medical history; and

* determines the patient's communication ability, body image concerns, and sensory perception status.

The nurse conducts the interview in an unhurried manner, knowing the patient may have a significant hearing deficit and may require extra time to comprehend information and answer questions. If needed, the nurse obtains the services of a sign-language interpreter.

As part of this comprehensive assessment, the nurse verifies the patient's identity and understanding of the planned reconstruction procedure and checks for a signed surgical consent. The nurse inquires about allergies and physical limitations and checks the patient's record for a recent medical history and physical examination, laboratory test results, and results of indicated diagnostic tests (eg, chest x-ray, electrocardiogram). The nurse also reviews the preoperative audiometric test results to understand the patient's hearing levels and deficits. Depending on the patient's degree of hearing impairment, the nurse may plan to

* remain in the patient's line of vision,

* use gestures and therapeutic touch,

* keep conversation to a minimum,

* speak close to the patient's ear, and

* suggest that the patient wear his or her hearing aids into the OR.(33)

The perioperative nurse analyzes these assessment data; validates nursing diagnoses with the patient, family members, and other health care providers; identifies expected outcomes; and develops a plan of care that incorporates interventions to attain the desired patient outcomes. The nurse helps the patient prepare psychologically for the ossicular chain reconstruction procedure by reiterating that he or she may not notice results from the procedure for several weeks because dressings and postoperative edema will interfere with hearing.

The nurse also instructs the patient about postoperative positioning and activity restrictions (eg, dizziness is common, lying on the surgical side can disturb the graft, forceful blowing of the nose can push purulent material into the eustachian tube, shampooing and showering are not permitted for several days after surgery). Throughout this assessment interview, the nurse encourages the patient and family members to express their anxiety and concerns and to ask questions about the surgical procedure and the patient's postoperative care.

The nurse and other perioperative team members implement this plan of care, and the nurse continually evaluates the patient's progress toward attaining the specified outcomes. For example, the circulating nurse ensures that the patient's dependent pinna is protected from pressure during surgery, and he or she inspects the patient's skin for pressure injury after surgery. The perioperative nurse also may perform preoperative and immediate postoperative assessments (eg, test the patient's fields of gaze, facial symmetry, hearing, sense of taste) to evaluate the patient's cranial nerves that can be affected by the procedure or positioning.(34)

Equipment, supplies. The circulating nurse and the scrub person work together to assemble all necessary equipment and supplies so they may give their full attention to the patient after he or she enters the OR. They obtain lint-free drapes and powder-free gloves to prevent granuloma formation in the oval window, which could cause irreversible sensorineural hearing loss.

The scrub person handles delicate microsurgical instruments carefully to avoid damaging them. These instruments are contained in a holder or protective rack to keep them separate from the rest of the surgical instrument set. The scrub person may need a magnifying glass to check the microsurgical instrument tips for damage, burrs, and sharpness. He or she examines the variety of picks and hooks for breakage and ascertains their degree of bend (eg, 15 [degrees], 45 [degrees], 90 [degrees]). Forceps and scissors used in middle ear surgical procedures (eg, Bellucci scissors, microcup forceps, alligator forceps) should not be bent and should open and close easily.

The circulating nurse ensures that prosthetic devices in an assortment of types and sizes are available and alerts the tissue bank of the possible need for homografts. The nurse asks the surgeon about using a nerve stimulator or evoked potential audiometry to identify and monitor the patient's facial, acoustic, cochlear, and vestibular nerve branches. If the surgeon plans to open the patient's temporal bone, the circulating nurse and the scrub person obtain the appropriate instruments, including powered drills. The circulating nurse also acquires and tests the function of any lasers that the surgeon may use to control bleeding, divide nerves, or vaporize tissues.(35)

The circulating nurse and the scrub person reverse the OR bed to accommodate the operating microscope and to permit the surgeon to sit at the head of the bed with room for his or her knees while performing the ossicular chain reconstruction procedure. They ensure that the drawsheet is high enough on the OR bed to tuck the patient's arms at his or her sides, and they count sponges and needles before bringing the patient into the OR.

Patient preparation. The circulating nurse and anesthesia care provider bring the patient into the OR and assist him or her into a supine position on the OR bed. The nurse moves the patient as close to the surgical side of the bed as possible to provide the surgeon optimal access to the patient's ear. The circulating nurse secures a safety belt across the patient's thighs and adds any special padding needed if the patient has back or neck problems. He or she then places a foam donut under the patient's head and turns the patient's head to the side with the affected ear up. The circulating nurse ensures that the patient's dependent ear is not subjected to undue pressure and tucks the patient's arms at the sides, protecting the patient's elbows with foam padding. He or she adds foam heel pads, places a pillow beneath the patient's knees for comfort, and applies the electrosurgical unit dispersive pad to a well-muscled area on the patient's thigh.

If the patient has a perforated tympanic membrane, the circulating nurse places cotton in the patient's external ear before prepping the surgical site to avoid introduction of prep solution into the external ear canal. If the patient's tympanic membrane is intact, the canal may be filled with prep solution. After the surgical site is prepped, the surgeon and the scrub person apply sterile drapes to expose the patient's ear and surrounding skin.

Anesthesia. Anesthesia may be local with conscious sedation or general, depending on the type of procedure to be performed and the surgeon's and patient's preferences. If the surgeon must manipulate delicate structures in the patient's middle or inner ear, general anesthesia is used to avoid any movement by the patient. If the surgeon plans to place a graft, the anesthesia care provider discontinues nitrious oxide after induction because nitrious oxide can diffuse into the ear cavity, expand the middle ear, and disturb the graft.(36) The anesthesia care provider may administer an antiemetic medication to prevent postoperative vomiting. He or she may employ hypotensive anesthesia to create a bloodless field for ossicular chain reconstructive procedures involving microsurgical techniques. The surgeon may inject the patient's external auditory canal with lidocaine hydrochloride containing epinephrine to help control bleeding. If general anesthesia is administered, the circulating nurse assists the anesthesia care provider with the patient's induction and intubation. If the reconstruction procedure is performed with local anesthesia and conscious sedation, the circulating nurse remains close to the patient, offering reassurance.

Surgical approaches. Ossicular chain reconstruction can be performed using three possible approaches: postauricular, transcanal, or endaural (Figure 5). The approach used is determined by the surgeon's preference, the patient's disease process, and the procedural stage.

[Figure 5 ILLUSTRATION OMITTED]

Postauricular approach. The circulating nurse may need to shave a small amount of hair behind the patient's ear for this surgical approach. The surgeon injects lidocaine hydrochloride with epinephrine along the planned incision line before the circulating nurse preps the patient's skin. After the patient is draped, the surgeon places an ear speculum into the patient's external auditory canal and positions the operating microscope to permit injection of the local anesthetic agent into the canal. The surgeon then incises the skin behind the patient's ear and coagulates vessels using an electrosurgical device. He or she incises the periosteum, elevates the external auditory canal with a Lempert elevator, and then lifts the existing tympanic membrane to expose the middle ear.

Transcanal, endaural approaches. The surgeon places an ear speculum in the patient's external auditory canal and positions the operating microscope to visualize the surgical field. The surgeon gently irrigates the patient's external auditory canal to remove cerumen and debris and suctions fluid and matter from the canal with a Baron suction tip. He or she then injects the external auditory canal with lidocaine hydrochloride with epinephrine. If the surgeon is using a transcanal approach, he or she may insert a speculum holder. Two small, double-pronged, self-retaining retractors may be used with the endaural approach. When the canal is anesthetized, the surgeon creates a tympanomeatal flap and elevates the tympanic membrane to expose the middle ear.

Reconstructive procedure. After exposing the patient's middle ear, the surgeon uses the operating microscope and microsurgical instruments to inspect the ossicles and test their mobility. If the incus is eroded, the surgeon detaches it from the malleus and replaces it with an incus prosthesis or drills an autograft incus and interposes it between the stapes and malleus.(37) If both the malleus and incus are diseased or eroded, the surgeon removes them and replaces these bones with a PORP, which sits on the stapes.(38) If all three ossicles are destroyed, the surgeon removes them and inserts a TORP.(39)

The scrub person must pass each instrument in the position that facilitates its immediate use because the surgeon performs the procedure through the operating microscope and has a limited field of vision and limited mobility. The circulating nurse anticipates the surgeon's needs by understanding the goals and steps of the ossicular chain reconstruction procedure and by observing the surgeon's actions via a camera and video equipment.

After the surgeon reestablishes ossicular continuity, he or she stabilizes the prosthesis by surrounding it with tiny squares of moistened compressed gelatin sponge. The surgeon returns the tympanomeatal flap to its original location and then performs any necessary grafting procedures to repair tympanic membrane perforations. He or she packs the patient's external auditory canal with moistened compressed gelatin sponges to ensure support and maintain correct anatomic position and then places cotton lubricated with antibiotic ointment in the concha of the ear. The surgeon closes the incision with his or her suture of choice, and the scrub person applies a dressing (eg, small adhesive bandage or pressure dressing, depending on the procedure and surgeon's preference). The surgeon and scrub person wrap the patient's head if a pressure dressing is used.

POSTOPERATIVE CARE

The circulating nurse cleans any remaining prep solution and blood from the patient's skin, assesses the patient's skin condition, and calls report to the postanesthesia care unit (PACU) nurses. The surgeon and anesthesia care provider transport the patient to the PACU, where nurses monitor the patient's vital signs, oxygen saturation, and neurologic status and observe the dressing for drainage. The nurses may administer more antiemetic medication and a decongestant or antitussive medication to prevent vomiting or coughing, which could dislodge the newly placed graft or prosthesis.

Most ossicular chain reconstruction procedures are performed on an outpatient basis. The PACU nurses continue the patient education that began in the surgeon's office and which the perioperative nurse reinforced during the preoperative interview. They instruct the patient to

* not blow his or her nose for one week after surgery to prevent dislodgement of the graft or prosthesis;

* sneeze or cough with the mouth open for one week after surgery to prevent dislodgement of the graft or prosthesis;

* perform no physical activities for one week;

* return to work one week after surgery unless the job involves lifting more than 20 pounds, in which case return to work is delayed for an additional one to two weeks;

* change the cotton ball in the ear as directed by the surgeon;

* avoid getting water in the ear for several weeks (ie, do not shampoo for one week, protect the ear with petroleum-coated cotton during showers);

* take prescribed antibiotics;

* wear noise defenders or petroleum-coated cotton in the ear if working around loud noises; and

* check with the surgeon before traveling by air.

The PACU nurses also inform the patient that

* he or she may hear a variety of noises (eg, cracking, popping);

* minor ear discomfort is expected but that excessive ear pain should be reported to the surgeon;

* a small amount of bleeding from the ear will occur, but that excessive drainage should be reported to the surgeon; and

* ear packing decreases hearing in the affected ear.(40)

The patient is discharged from the PACU when his or her vital signs are stable, pain management is adequate, and the dressing is dry.

PATIENT OUTCOMES

Autogenous or homogenous incus grafts and prostheses interposed between patients' mobile stapes and intact tympanic membranes generally produce very good hearing.(41) Patients with otosclerosis who undergo ossicular chain reconstruction procedures may enjoy good hearing for many years; however, many of them develop a slowly progressive high-frequency cochlear loss. For this reason, many surgeons prefer to delay performing the procedure on the patient's opposite ear for several years after the first surgical procedure.

Occasionally, patients may have incomplete closures of their oval windows, and perilymph may leak around the prostheses and into the middle ears. In such cases, hearing that has improved may begin to fluctuate or diminish suddenly. For this reason, patients need to understand the importance of reporting hearing changes associated with tinnitus or vertigo. Subsequent surgical procedures may be required to repair these leaks and preserve patients' improved hearing.(42)

Although ossicular chain reconstruction procedures do not produce perfect hearing, most patients achieve some improvement in their hearing. Socially adequate hearing (ie, greater than 30 db) is achievable in 95% of patients who undergo straightforward myringoplasty procedures, in 80% to 90% of patients who undergo incus interpositions, and in 60% to 80% of patients who undergo more involved procedures. Often, revision procedures greatly improve the initial surgical results.(43)

CONCLUSION

Increased understanding of ear anatomy and physiology and improvements in microsurgical instrumentation and implants have advanced the specialty of ear surgery remarkably during the past 20 years. Ossicular chain reconstruction procedures continue to be challenging. Perioperative nurses contribute to the success of these procedures by understanding ear anatomy and physiology, establishing quiet OR atmospheres, incorporating patients' special needs into perioperative plans of care, and attending to the minute details involved in these delicate procedures. The reward for this attention to detail and intense teamwork is the gift of hearing.

NOTES

(1.) J Bordley. P Brookhouse, "The history of otology." in Hearing and Hearing Impairment, ed L J Bradford. W G Hardy (New York: Grune & Stratton, Inc, 1979) 4.

(2.) Blakiston's Gould Medical Dictionary, fourth ed, sv "Valsalva maneuver." 1441.

(3.) Bordley, Brookhouse, "The history of otology," 5.

(4.) Ibid.

(5.) D D DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed (St Louis: The C V Mosby Co, 1988) 354.

(6.) Ibid, 350.

(7.) Ibid, 352.

(8.) Ibid.

(9.) Ibid, 354.

(10.) Ibid, 353.

(11.) M A K Riley, Nursing Care of the Client with Ear, Nose, and Throat Disorders (New York: Springer Publishing Co, 1987)

(12.) DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed, 364.

(13.) A Stinson, "Cochlear implantations in children," AORN Journal 64 (October 1996) 561-571.

(14.) DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed, 456.

(15.) Ibid, 392.

(16.) Ibid.

(17.) H F Schuknecht, Pathology of the Ear (Philadelphia: Lea & Febiger Co, 1993) 39.

(18.) J J Ballenger, Diseases of the Nose, Throat, Ear, Head, and Neck, 13th ed (Philadelphia: Lea & Febiger Co, 1985) 1156-1160.

(19.) DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed, 456.

(20.) Ibid.

(21.) J P Harris, R A Cueva, "Conductive hearing loss: Inflammatory and noninflammatory causes," in Otolaryngology-Head & Neck Surgery, ed W L Meyerhoff, D H Rice (Philadelphia: W B Saunders Co, 1992) 298.

(22.) Ibid.

(23.) DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed, 431.

(24.) Ibid, 471.

(25.) Bordley, Brookhouse, "The history of otology," 6.

(26.) Ibid.

(27.) Ibid, 7.

(28.) H T Treace, "Biomaterials in ossiculoplasty and history of development of prostheses for ossiculoplasty," Otolaryngologic Clinics of North America 27 (August 1994) 655-662.

(29.) R L Goode, S Nishihara, "Experimental models of ossiculoplasty," Otolaryngologic Clinics of North America 27 (August 1994) 663-675.

(30.) Ballenger, Diseases of the Nose, Throat, Ear, Head, and Neck, 13th ed, 1156.

(31.) Ibid.

(32.) American Nurses Association, Society of Otorhinolaryngology and Head-Neck Nurses, Inc, Standards and Statement on the Scope of Otorhinolaryagology Clinical Nursing Practice (Washington, DC: American Nurses Publishing, 1994) 7-10; Association of Operating Room Nurses, "Standards of perioperative nursing," in AORN Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc, 1997) 105-106.

(33.) M C Redmond, "Perianesthesia communications with hearing-impaired patients," Journal of Peri-Anesthesia Nursing 11 (December 1996) 384-389.

(34.) A C Bowers, J M Thompson, Clinical Manual of Health Assessment, fourth ed (St Louis: Mosby-Year Book,Inc, 1992) 174-188.

(35.) L J Atkinson, N Fortunato, eds, Berry & Kohn's Operating Room Technique, eighth ed (St Louis: Mosby-Year Book, Inc, 1996) 730.

(36.) Ibid.

(37.) R E Wehrs, "Incus interposition and ossiculoplasty with hydroxyapatite prostheses," Otolaryngologic Clinics of North America 27 (August 1994) 677-688.

(38.) R A Goldenberg, "Operative techniques," in Otolaryngology-Head & Neck Surgery, ed W L Meyerhoff, D H Rice (Philadelphia: W B Saunders Co, 1992) 228.

(39.) Ibid, 229.

(40.) P S Coutellier, "Otologic surgery," in Alexander's Care of the Patient in Surgery, 10th ed, M H Meeker, J C Rothrock, eds (St Louis: Mosby-Year Book, Inc, 1995) 641-643.

(41.) DeWeese et al, Otolaryngology-Head and Neck Surgery, seventh ed, 467.

(42.) Ibid, 463.

(43.) Ibid, 469.

Carolyn Waddington, RN, BSN, CORLN, is a staff nurse in the otorhinolaryngology OR at The Methodist Hospital, Houston.

Ann T. McKennis, RN, CNOR, CORLN, is a staff nurse in the otorhinolaryngology OR at The Methodist Hospital, Houston.

Ann Goodlett, RN, BSN, CNOR, is a perioperative staff nurse at Parkland Memorial Hospital, Dallas.

COPYRIGHT 1997 Association of Operating Room Nurses, Inc.
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