Use of the Otoscope in Athletic Training Louise Fincher, EdD, ATC, LAT Associate Professor/Program Director The University of Texas at Arlington

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 „ < $50

‹Clinical model „ $200 - $400+

Pocket style Clinical model

Features of the Otoscope ‹Power source „ Battery (most common in

athletic training clinical setting) „ Electric ‹ Light source „ Incandescent bulb (produces a

yellow light) best – „ 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 istory ‹H History bservation ‹O Observation alpation ‹P Palpation pecial tests ‹S Special „ 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 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 ¾right ear, right hand ¾left 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 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 ¾ Posterior superior ¾ Anterior superior ¾ Anterior inferior ¾ 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 Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.

Otoscopic Assessment ‹Tip „ 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.

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 L — —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.

R

Otoscopic Assessment ‹ Step 8: „ Identify key landmarks

Short process

— —Malleus

• Manubrium • Short process • Umbo — —Light reflex

L

Umbo

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

R

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

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

R

Otoscopic Assessment ‹ Step 8 (cont.):

Pars flaccida

„ Identify key landmarks —Pars flaccida —Pars tensa

L

—Annulus

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.

R

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

-on learning time „ Optimize hands hands-on „ Provide formative feedback throughout formal and

informal practice time „ Encourage and develop confidence, critical critical-thinking, and problem -solving problem-solving

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

Guided, Self-Directed Activities ‹Initially completed PRIOR to lab, but

may be repeated throughout learning process as needed „ Multimedia

-based programs „ Web Web-based „ 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 problem-solving critical -thinking critical-thinking

Guided, Self-Directed Activities ‹Advantages „ Provide students with essential

knowledge „ Requires student to assume responsibility for their own learning -on time in lab „ Optimizes hands hands-on „ Promote problem solving & critical thinking

Instructional Lab ‹Structured „ Begin with questions to check

understanding of self -directed activities self-directed „ Brief overview of otoscopic exam (2nd exposure of material) „ Organized lab activity emphasizing step step-by -step procedures by-step „ 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

-studies „ Case Case-studies „ Problem solving scenarios „ Literature reviews

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

Guided, Self-Directed Activities – Post Lab ‹Content „ 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.

Guided, Self-Directed Activities – Post Lab ‹Content „ 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.

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 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 “real-life” 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. 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. 1994;29:52-59.

Educational Resources ‹Articles

-Miola E. The otoscope „ Sloand Sloand-Miola otoscope:: an update on assessment skills. J Ped Nurs Nurs.. 1994; 9: 283 -286. 283-286. „ Kaleida PH. The COMPLETES exam for

otitis otitis.. Contemporary Pediatrics. 1997;14(9): 93 -101. 93-101.

Educational Resources ‹Books „ Hawke M, Keene M, Alberti PW.

Clinical Otoscopy 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. 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,,

PRACTICE PRACTICE,, & more PRACTICE PRACTICE!!

What Questions Do You Have?

Feel free to contact me with further questions: [email protected]