Use of the Otoscope in Athletic Training

Objectives Briefly discuss the types and features of the otoscope Provide an overview of otoscopic assessment procedures Present a clinical teaching model for teaching your students to properly use the otoscope Provide educational resources for teaching otoscopy

Types & Features of the Otoscope

Types of Otoscopes Pocket style Clinical model < $50 $200 - $400+

Features of the Otoscope Power source Battery (most common in athletic training clinical setting) Electric Light source Incandescent bulb (produces a yellow light) Hallogen bulb (best – produces a white light)

Features of the Otoscope Magnifier Not available on all models Provides better view of tympanic membrane, particularly for beginners

Features of the Otoscope Speculum Variety of sizes Reusable or disposable

Overview of Otoscopic Assessment

Examination of the Ear History Observation Palpation Special tests Otoscopic assessment

Examination of the Ear History Trauma Allergies, colds, sinus drainage Changes in pressure (flying, diving) Dizziness Changes in hearing Duration of symptoms

Examination of the Ear Observation Redness Swelling Drainage Foreign object Cuts, scrapes, bruises

Examination of the Ear Palpation Gentle pressure on tragus

Examination of the Ear Palpation Traction on ear lobe & pinna

Otoscopic Assessment Evaluate the noninvolved ear first This practice provides a basis for comparison AND prevents cross-contamination

Otoscopic Assessment Step 1: Place your patient in a seated position with his/her head turned slightly downward and away from the ear to be examined

Otoscopic Assessment Step 1 (cont.): I teach this as the “puppy position” (puppies always cock their heads to the side when you talk to them)

Otoscopic Assessment Step 2: Select the largest possible speculum that can be comfortably inserted into the ear

Otoscopic Assessment Step 2 (cont.): When inserted, the speculum should fit snugly in the outer third of the canal and rest against the tragus and anterior wall of the canal Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 2 (cont.): Choosing a speculum that is too small will cause movement within the canal Excessive movement can cause discomfort for your patient Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 3: Hold the otoscope with the same hand as the ear you are examining right ear, right hand left ear, left hand

Otoscopic Assessment Step 3 (cont.): The otoscope should be stabilized by placing the ring and little finger resting on the patient’s cheek or temple

Otoscopic Assessment Pencil Grip Hammer Grip

Otoscopic Assessment Step 4: Pull the pinna upward and backward to straighten the canal Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 5: While maintaining traction on the pinna, place the speculum of the otoscope at, but not in the ear canal

Otoscopic Assessment Caution: Never insert the otoscope blindly Always “Watch your way in”

Otoscopic Assessment Tip: If the patient experiences pain, reposition the canal by adjusting the angle and degree of traction on the pinna

Otoscopic Assessment Caution: If the patient’s discomfort persists even after readjustment of the canal, halt the examination and refer the patient to a physician.

Otoscopic Assessment Step 6: Once the tympanic membrane comes into view, rotate the speculum to view as much of the membrane as possible Posterior superior Anterior superior Anterior inferior Posterior inferior Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.

Otoscopic Assessment Tip Like trying to view the corners of a room through a key hole Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1. Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Tip Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54. The posterior inferior portion of the membrane is often difficult to see This is due to the angle of the membrane within the canal Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 7: Inspect the membrane for color, clarity, & position Pearly gray Semitransparent Not bulging or retracted L R Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment Step 8: Identify key landmarks Malleus Manubrium Short process Malleus Manubrium Short process Umbo Umbo L R Light reflex Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment Step 8 (cont.): Identify key landmarks Note that manubrium angles toward the 10:00 position in the left ear and the 2:00 position in the right ear L R Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment Step 8 (cont.): Identify key landmarks Pars flaccida Step 8 (cont.): Identify key landmarks Pars flaccida Pars tensa L Annulus R Pars tensa Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment Step 8 (cont.): Identify key landmarks Look beyond the membrane Stapes Incus Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53.

Otoscopic Assessment Step 9: Look for abnormalities Fluid Perforations Fluid & Air Bubbles Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994; 29:54. Perforation Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8.

Otoscopic Assessment Step 10 Work with your team physician to develop your confidence and skill PRACTICE, PRACTICE, PRACTICE !!! You must look at many ears to develop to become comfortable with “normal”

Instructional Overview

Instructional Overview Ear exam, ear pathology, and use of otoscope discussed in classroom setting Skills taught and practiced in lab setting Proficiency developed in clinical setting Goals Optimize hands-on learning time Provide formative feedback throughout formal and informal practice time Encourage and develop confidence, critical-thinking, and problem-solving

Clinical Teaching Model Guided, self-directed activities (pre-lab) Instructional Lab Guided practice with peers under supervision of ACI (learning lab) Guided, self-directed activities (post-lab) Guided, clinical practice Implementation into clinical practice; clinical decision-making

Guided, Self-Directed Activities Initially completed PRIOR to lab, but may be repeated throughout learning process as needed Multimedia Web-based programs Article/chapter reading Worksheets Peer learning

Guided, Self-Directed Activities Content Essential anatomy Features of the otoscope Steps for using the otoscope Test for understanding Open ended questions to begin development of problem-solving and critical-thinking

Guided, Self-Directed Activities Advantages Provide students with essential knowledge Requires student to assume responsibility for their own learning Optimizes hands-on time in lab Promote problem solving & critical thinking

Instructional Lab Structured Begin with questions to check understanding of self-directed activities Brief overview of otoscopic exam (2nd exposure of material) Organized lab activity emphasizing step-by-step procedures Formative evaluation with feedback

Guided Practice with Peers Supervision of ACI Students are tentative and awkward in this stage of learning They typically leave out steps – checklists are helpful for remediation of necessary steps Not comfortable with practicing skill in public (on their athletes/patients within the clinical setting)

Guided Practice with Peers Structured practice Complete 20 correct evaluations (10L, 10R) – documented by ACI and/or peer Worksheets Drawing what they see Recording what they see Presence of wax? Were they able to see the membrane? What did the membrane look like?

Guided, Self-Directed Activities – Post Lab Types of activities Worksheets Multimedia Case-studies Problem solving scenarios Literature reviews

Guided, Self-Directed Activities – Post Lab Content Recognition of pathology Red, tender canal inflammation otitis externa Bright red membrane inflammation otitis media Yellowish membrane pus/fluid otitis media Bluish membrane blood skull fx Bubbles behind membrane fluid otitis media Absent light reflex bulging of TM otitis media Oval dark areas perforation rupture of TM Malleus very prominent retraction of TM obstruction ET

Guided, Self-Directed Activities – Post Lab Content Recognition of pathology – visual images Perforation Middle ear fluid Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8. Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 3.

Guided, Self-Directed Activities – Post Lab Content Recognition of pathology – visual images Perforation Otitis Media Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999. Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999.

Guided Clinical Practice Under supervision of ACI Students begin to develop confidence in the procedures of an otoscopic exam Students gain confidence in identifying landmarks of membrane

Implementation into Clinical Practice Occurs during following semester Any clinical rotation Colds, flus, allergies occur throughout all sports (i.e., upper and lower extremity sports, equipment intensive sports, etc.) General medical rotation Proficiency developed & evaluated through “real-life” cases or scenario-based presentations

Educational Resources

Educational Resources Articles Lenker C. Traumatic tympanic membrane perforation in a collegiate football player. Athletic Therapy Today. 2000;5(1):43-44. Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:52-59.

Educational Resources Articles Sloand-Miola E. The otoscope: an update on assessment skills. J Ped Nurs. 1994; 9: 283-286. Kaleida PH. The COMPLETES exam for otitis. Contemporary Pediatrics. 1997;14(9): 93-101.

Educational Resources Books Hawke M, Keene M, Alberti PW. Clinical Otoscopy: An Introduction to Ear Diseases. 2nd ed. New York, NY: Churchill Livingstone; 1990. Swartz MH. Textbook of Physical Diagnosis: History and Examination. W.B. Saunders; 2002:273-276.

Educational Resources Team physician Nursing or other allied health departments on your campus

Summary Although otoscopy is a new skill for athletic trainers, it is one that can be easily mastered with proper instruction and guided practice. ACIs and CIs must also be proficient with using the otoscope if they are to direct and supervise the students’ clinical education experiences involving ear evaluation

Summary The 10 step process for otoscopy outlined in this presentation is intended to serve as foundation for learning and becoming comfortable with using the otoscope for ear evaluation.

Summary Proficiency requires PRACTICE, PRACTICE, & more PRACTICE!

Feel free to contact me with further questions: What Questions Do You Have? Feel free to contact me with further questions: Lfincher@uta.edu