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 model

$50 - $400+

Clinical
$200

Pocket style Clinical model

Features of the Otoscope

Power

source

(most common in athletic training clinical setting) Electric Light source

Incandescent bulb (produces a yellow light) Hallogen bulb (best produces a white light)

Battery

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

History
Observation Palpation Special

tests
assessment

Otoscopic

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 crosscontamination

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
I

1 (cont.):

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 right ear, right hand left ear, left hand

Otoscopic Assessment
Step

3 (cont.):

The

otoscope should be stabilized by placing the ring and little finger resting on the patients 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, 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 patients 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 Posterior superior Anterior superior Anterior inferior 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 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.

Otoscopic Assessment
Step

8:
Short process L

Identify key landmarks Malleus Manubrium Short process Umbo

Light

reflex

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.

Otoscopic Assessment
Step

8 (cont.):
that manubrium angles toward the 10:00 position in the left ear and the 2:00 position in the right ear

Identify key landmarks

Note

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

flaccida Pars tensa 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.

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
Optimize hands-on learning time Provide formative feedback throughout formal and informal practice time Encourage and develop confidence, criticalthinking, and problem-solving

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

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 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 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
Structured
Begin

with questions to check understanding of self-directed activities Brief overview of otoscopic exam (2nd exposure of material) Organized lab activity emphasizing stepby-step procedures Formative evaluation with feedback

Guided Practice with Peers

Supervision
Students

of ACI

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 Case-studies Problem

solving scenarios Literature reviews

Guided, Self-Directed Activities Post Lab

Content
Recognition of pathology Red, tender canal inflammation Bright red membrane inflammation Yellowish membrane pus/fluid Bluish membrane blood Bubbles behind membrane fluid Absent light reflex bulging of TM Oval dark areas perforation Malleus very prominent retraction of TM otitis externa otitis media otitis media skull fx otitis media otitis media rupture of TM obstruction ET

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, 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 Resources

Educational Resources
Articles
Lenker

C. Traumatic tympanic membrane perforation in a collegiate football player. Athletic Therapy Today. 2000;5(1):43-44.
Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:52-59.

Fincher AL.

Educational Resources
Articles
Sloand-Miola

E. The otoscope: an update on assessment skills. J Ped Nurs. 1994; 9: 283-286.

PH. The COMPLETES exam for otitis. Contemporary Pediatrics. 1997;14(9): 93-101.

Kaleida

Educational Resources
Books
Hawke

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

Swartz

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, & more PRACTICE!

What Questions Do You Have?

Feel free to contact me with further questions: Lfincher@uta.edu