1. Use of the Otoscope in Athletic Training

2. 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

3. Types & Features of the Otoscope

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

5. 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)

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

7. Features of the Otoscope
Speculum
Variety of sizes
Reusable or disposable

8. Overview of Otoscopic Assessment

9. Examination of the Ear History Observation Palpation Special tests
Otoscopic assessment

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

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

12. Examination of the Ear
Palpation
Gentle pressure on tragus

13. Examination of the Ear
Palpation
Traction on ear lobe & pinna

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

15. 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

16. 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)

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

18. 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.

19. 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.

20. 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

21. 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

22. Otoscopic Assessment
Pencil Grip
Hammer Grip

23. 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.

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

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

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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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”

38. Instructional Overview

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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)

46. 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?

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

48. 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

49. 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.

50. 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
Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL

51. 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

52. 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

53. Educational Resources

54. 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.

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

56. 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:

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

58. 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

59. 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.

60. Summary
Proficiency requires PRACTICE, PRACTICE, & more PRACTICE!

61. Feel free to contact me with further questions:
What Questions Do You Have?
Feel free to contact me with further questions: