1. Louise Fincher, EdD, ATC, LAT Associate Professor/Program Director The University of Texas at Arlington 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  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 < $50 < $50  Pocket style < $50 < $50 Pocket style Clinical model  Clinical model $200 - $400+ $200 - $400+  Clinical model $200 - $400+ $200 - $400+

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

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

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

8. Overview of Otoscopic Assessment

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

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

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

12. Examination of the Ear  Palpation Gentle pressure on tragus Gentle pressure on tragus

13. Examination of the Ear  Palpation Traction on ear lobe & pinna 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 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) 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 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 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 Choosing a speculum that is too small will cause movement within the canal Excessive movement can cause discomfort for your patient Excessive movement can cause discomfort for your patient Choosing a speculum that is too small will cause movement within the canal Choosing a speculum that is too small will cause movement within the canal Excessive movement can cause discomfort for your patient 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 Hold the otoscope with the same hand as the ear you are examining  right ear, right hand  left ear, left hand Hold the otoscope with the same hand as the ear you are examining 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 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 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 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 Never insert the otoscope blindly Always “Watch your way in” Always “Watch your way in” Never insert the otoscope blindly Never insert the otoscope blindly Always “Watch your way in” 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 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. 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 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  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 Like trying to view the corners of a room through a key hole Like trying to view the corners of a room through a key hole  Tip 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. This is due to the angle of the membrane within the canal Otoscopic Assessment  Tip The posterior inferior portion of the membrane is often difficult to see The posterior inferior portion of the membrane is often difficult to see Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54. Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

31. Otoscopic Assessment  Step 7: L R Inspect the membrane for color, clarity, & position Inspect the membrane for color, clarity, & position  Pearly gray  Semitransparent  Not bulging or retracted Inspect the membrane for color, clarity, & position Inspect the membrane for color, clarity, & position  Pearly gray  Semitransparent  Not bulging or retracted 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 Identify key landmarks  Step 8: Identify key landmarks Identify key landmarks L R Umbo Short process  Malleus ManubriumManubrium Short processShort process UmboUmbo ManubriumManubrium Short processShort process UmboUmbo  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 Identify key landmarks  Step 8 (cont.): Identify key landmarks Identify key landmarks L R  Note that manubrium angles toward the 10:00 position in the left ear and the 2:00 position in the right ear 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 Identify key landmarks  Step 8 (cont.): Identify key landmarks Identify key landmarks L R Pars tensa  Pars flaccida  Pars tensa  Annulus Pars flaccida 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 Identify key landmarks  Look beyond the membrane StapesStapes IncusIncus Identify key landmarks Identify key landmarks  Look beyond the membrane StapesStapes IncusIncus 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 Look for abnormalities  Fluid  Perforations  Step 9: Look for abnormalities Look for abnormalities  Fluid  Perforations Perforation Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8. 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.

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

38. Instructional Overview

39.  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 Optimize hands-on learning time Provide formative feedback throughout formal and informal practice time Provide formative feedback throughout formal and informal practice time Encourage and develop confidence, critical- thinking, and problem-solving Encourage and develop confidence, critical- thinking, and problem-solving  Skills taught and practiced in lab setting  Proficiency developed in clinical setting  Goals Optimize hands-on learning time Optimize hands-on learning time Provide formative feedback throughout formal and informal practice time Provide formative feedback throughout formal and informal practice time Encourage and develop confidence, critical- thinking, and problem-solving Encourage and develop confidence, critical- thinking, and problem-solving

40. Clinical Teaching Model Guided, self-directed activities (pre-lab) Instructional Lab Guided, self-directed activities (post-lab) Guided practice with peers under supervision of ACI (learning 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 Multimedia Web-based programs Web-based programs Article/chapter reading Article/chapter reading Worksheets Worksheets Peer learning Peer learning Multimedia Multimedia Web-based programs Web-based programs Article/chapter reading Article/chapter reading Worksheets Worksheets Peer learning Peer learning

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

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

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

45. Guided Practice with Peers  Supervision of ACI Students are tentative and awkward in this stage of learning Students are tentative and awkward in this stage of learning They typically leave out steps – checklists are helpful for remediation of necessary steps 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) Not comfortable with practicing skill in public (on their athletes/patients within the clinical setting) Students are tentative and awkward in this stage of learning Students are tentative and awkward in this stage of learning They typically leave out steps – checklists are helpful for remediation of necessary steps 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) 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 Complete 20 correct evaluations (10L, 10R) – documented by ACI and/or peer Worksheets Worksheets  Drawing what they see  Recording what they see Presence of wax?Presence of wax? Were they able to see the membrane?Were they able to see the membrane? What did the membrane look like?What did the membrane look like? Complete 20 correct evaluations (10L, 10R) – documented by ACI and/or peer Complete 20 correct evaluations (10L, 10R) – documented by ACI and/or peer Worksheets Worksheets  Drawing what they see  Recording what they see Presence of wax?Presence of wax? Were they able to see the membrane?Were they able to see the membrane? What did the membrane look like?What did the membrane look like?

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

48. Guided, Self-Directed Activities – Post Lab  Content Recognition of pathology Recognition of pathology  Red, tender canalinflammation otitis externa  Bright red membraneinflammation otitis media  Yellowish membranepus/fluid otitis media  Bluish membraneblood skull fx  Bubbles behind membranefluid otitis media  Absent light reflexbulging of TM otitis media  Oval dark areasperforation rupture of TM  Malleus very prominentretraction of TM obstruction ET Recognition of pathology Recognition of pathology  Red, tender canalinflammation otitis externa  Bright red membraneinflammation otitis media  Yellowish membranepus/fluid otitis media  Bluish membraneblood skull fx  Bubbles behind membranefluid otitis media  Absent light reflexbulging of TM otitis media  Oval dark areasperforation rupture of TM  Malleus very prominentretraction of TM obstruction ET

49. Guided, Self-Directed Activities – Post Lab  Content Recognition of pathology – visual images Recognition of pathology – visual images  Content Recognition of pathology – visual images Recognition of pathology – visual images Perforation Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8. Middle ear fluid 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 Recognition of pathology – visual images  Content Recognition of pathology – visual images Recognition of pathology – visual images Perforation Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999. Otitis Media Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999.

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

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

53. Educational Resources

54.  Articles Lenker C. Traumatic tympanic membrane perforation in a collegiate football player. Athletic Therapy Today. 2000;5(1):43-44. 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. Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:52-59. Lenker C. Traumatic tympanic membrane perforation in a collegiate football player. Athletic Therapy Today. 2000;5(1):43-44. 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. 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: 283-286. 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. Kaleida PH. The COMPLETES exam for otitis. Contemporary Pediatrics. 1997;14(9): 93-101. Sloand-Miola E. The otoscope: an update on assessment skills. J Ped Nurs. 1994; 9: 283-286. 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. Kaleida PH. The COMPLETES exam for otitis. Contemporary Pediatrics. 1997;14(9): 93-101.

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

57. Educational Resources  Team physician  Nursing or other allied health departments on your campus  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  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. What Questions Do You Have? Feel free to contact me with further questions: Lfincher@uta.edu