Use of the Otoscope in Athletic Training

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 • < $50 • Clinical model • $200 - $400+ Pocket style Clinical model

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 • Specialtests • 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. 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.

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. 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.

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 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.

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. 1999. Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999.