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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

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

Pocket style

Clinical model

features of the otoscope
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 otoscope6
Features of the Otoscope
  • Magnifier
    • Not available on all models
    • Provides better view of tympanic membrane, particularly for beginners
features of the otoscope7
Features of the Otoscope
  • Speculum
    • Variety of sizes
    • Reusable or disposable
examination of the ear
Examination of the Ear
  • History
  • Observation
  • Palpation
  • Specialtests
    • Otoscopic assessment
examination of the ear10
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 ear11
Examination of the Ear
  • Observation
  • Redness
  • Swelling
  • Drainage
  • Foreign object
  • Cuts, scrapes, bruises
examination of the ear12
Examination of the Ear
  • Palpation
  • Gentle pressure on tragus
examination of the ear13
Examination of the Ear
  • Palpation
  • Traction on ear lobe & pinna
otoscopic assessment
Otoscopic Assessment
  • Evaluate the noninvolved ear first
  • This practice provides a basis for comparison AND prevents cross-contamination
otoscopic assessment15
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 assessment16
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 assessment17
Otoscopic Assessment
  • Step 2:
  • Select the largest possible speculum that can be comfortably inserted into the ear
otoscopic assessment18
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 assessment19
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 assessment20
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 assessment21
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 assessment22
Otoscopic Assessment

Pencil Grip

Hammer Grip

otoscopic assessment23
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 assessment24
Otoscopic Assessment
  • Step 5:
  • While maintaining traction on the pinna, place the speculum of the otoscope at, but not in the ear canal
otoscopic assessment25
Otoscopic Assessment
  • Caution:
  • Never insert the otoscope blindly
  • Always“Watch your way in”
otoscopic assessment26
Otoscopic Assessment
  • Tip:
  • If the patient experiences pain, reposition the canal by adjusting the angle and degree of traction on the pinna
otoscopic assessment27
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 assessment28
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 assessment29
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 assessment30
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 assessment31
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 assessment32

Short process

Umbo

Otoscopic Assessment
  • Step 8:
    • Identify key landmarks
  • Malleus
  • Manubrium
  • Short process
  • 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 assessment33
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 assessment34

Pars flaccida

Pars tensa

Otoscopic Assessment
  • Step 8 (cont.):
    • Identify key landmarks
  • Pars flaccida
  • Pars tensa

L

R

  • Annulus

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 assessment35
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 assessment36
Otoscopic Assessment
  • Step 9:
    • Look for abnormalities
      • Fluid
      • Perforations

Fluid & Air Bubbles

Fincher AL. Use of the otoscope in the evaluation of common injuries andillnesses 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 assessment37
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 overview39
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
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
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 activities42
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 activities43
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
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
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 peers46
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
Guided, Self-Directed Activities – Post Lab
  • Types of activities
  • Worksheets
  • Multimedia
  • Case-studies
  • Problem solving scenarios
  • Literature reviews
guided self directed activities post lab48
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 lab49
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 lab50
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
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
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 resources54
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 resources55
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 resources56
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 resources57
Educational Resources
  • Team physician
  • Nursing or other allied health departments on your campus
summary
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
summary59
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.
summary60
Summary
  • Proficiency requires PRACTICE, PRACTICE, & more PRACTICE!
slide61

What Questions Do You Have?

Feel free to contact me with further questions:

Lfincher@uta.edu