audiometry

Introduction to Otoscopy

Otoscopy (pronounced ‘oat-os-k-pee’) is looking in people's ear canals to see the condition of the ear canal and the ear drum. Otoscopy is also called otoscopic inspection.

It does not take much time to look in your client's ears. An average amount of time spent on otoscopy is one minute. Although it does not take much time to perform the otoscopic inspection it is a very important part of your role as an audiometrist.

From now on we will switch to the more correct medical names and use their abbreviations. The ear canal is called the External Auditory Meatus - EAM. The eardrum is called the Tympanic Membrane - TM.

To perform otoscopic inspection you must know how to do it but more importantly you must know how to understand what you see in relation to the normal EAM and TM. If you observe something in the EAM and the TM that is not what you would normally expect to see you need to know what action to take.
If your otoscopic inspection shows all is normal then you can go on with what you need to do. However, when your otoscopic inspection does NOT show all is normal there are many different possible causes and many different possible ways of reacting.

This topic covers how to perform otoscopy, what to look for and what actions to take when you see something that is not what you would normally see.

As an audiometrist you will use otoscopy when doing a hearing assessment, before taking an impression of the ear for hearing aid fitting and when assessing hearing aids. Your observations of the EAM and the TM will affect the decisions you make. If you observe abnormalities in the EAM or TM at the hearing assessment you will have to make decisions about referral to a doctor. Your observations will also affect your recommendations about hearing devices.


Components and Function of the Otoscope

To perform otoscopy you need an instrument called an otoscope. Another name for an otoscope is an auriscope. Oto- and auri- both mean ear and are both used in medical terminology. It may look like this:

otoscope.png

Some clinics may have a video otoscope. This is an otoscope attached to a viewing screen. This allows you to show the client what their EAM and TM look like and you can usually take a picture of the TM with a video otoscope.

The function of the otoscope is to provide a method for examining the EAM and the TM. It provides a concentrated light source in an easy to hold container. A magnifier is attached to aid visual inspection of the EAM and TM. It is essentially a specialised torch.

An otoscope has
• a power source, usually batteries
• a light bulb
• a magnifier
• a funnel shaped attachment at the top of the otoscope
• a removable speculum.

Have someone show you how to take an otoscope apart and then put it back together. Do it yourself until you are confident that you can do it by yourself and that you could, if necessary, replace the batteries and the bulb.

Speculae
The speculum (pronounced ‘speck-you-lum’) is not permanently attached to the head of the otoscope. It is made of plastic and is shaped like a cone with holes at both ends. It is used to focus the light down the ear canal. Speculae (the plural of speculum) are available in different sizes. It is best to use the largest size that will fit in the ear canal comfortably so you can get a good view of the ear canal. Speculae also come in different lengths. The shorter ones or the ones with the smaller hole for the EAM are usually recommended for use with children.

The speculum is the only part of the otoscope that enters the ear canal and therefore must be clean.

Hygiene is important. It is recommended that disposable speculae are used. That is, you would use one for a client and then throw it away. Some otoscopes cannot be used with disposable speculae. If you need to reuse speculae they must be cleaned between clients. There are various methods that are advised but most use a form of alcohol. You will have to check with the clinic you go to for the procedure that they follow.

One recommendation is:
• remove debris (wax or other material) manually or with an ultrasonic cleaner
• soak in alcohol for a short period of time or wipe with an alcohol swab.

Make sure you ask your supervisor what method to follow.

Procedure for otoscopy

1. Follow hygiene procedure.
2. Inform and position the client.
3. Use the largest speculum possible.
4. Check the pinna.
5. Check the entrance to the ear canal.
6. Hold the otoscope properly.
7. Gently pull the pinna to straighten the ear canal.
8. Insert the speculum into the ear canal.
9. Move the speculum around to view the entire TM.
10. Make a note of what you see.

1. Follow hygiene procedure
As discussed above you will need to establish the correct procedure for your clinic. You will also need to be careful not to expose yourself to any risk. For example, you should be following universal precautions if there is any blood present – yours or the client’s.

2. Inform and position the client
It is best to tell your client what you are doing beforehand. For example, you could say, "I would like to look in your ears" and show them the otoscope. Most people have had this done at the doctor's surgery so they will know what you want them to do but it is still good to tell them, "It will only take a minute, just sit still for me please".

You will be getting very close to the client and this might be the first time you have met them. It is for this reason that many clinicians wait until after they have done the hearing assessment to view the EAM and the TM. It is, however, preferable to do so before the hearing assessment because what you see may well affect the test.

The exception to this is when dealing with children and babies. Children and babies often object to having their ears looked in, therefore, because you want their cooperation for the assessment, it is best to wait until the assessment is finished.

If you are looking in the ears of babies and young children it is best to ask the parent or care-giver to hold them securely in their lap. You can ask them to hold the child so that the head is held against the chest firmly with one hand and the other hand is around the child so that the child’s arms are restrained. If necessary the legs of the child can be held between the legs of the parent/care-giver.

Otoscopy with an older child or adult is usually done while they are seated in a chair. It is advisable to use a chair that is easily accessible from both sides so that you can obtain a good view of the EAM and TM. You might like to ask the client to tilt their head slightly.

You will probably be doing some bending to do this so you need to be careful to follow the rules of back care, ie bend with you knees. This may seem like a trivial point but if you stay in audiometry you will be looking in a lot of ears and doing a lot of bending.

3. Use the largest speculum possible
You will get a better look at the EAM and TM if you use the largest size speculum that will comfortably fit. Speculae are available in different sizes and lengths.

There are paediatric speculae that are used for children. These are usually shorter in length than the speculae recommended for use with adults. The speculae you use for children will also have a smaller hole at the end that goes into the EAM.

Speculae recommended for use with adults have different size holes at the tip of the speculum that enters the EAM. Generally, it is recommended that you use sizes 4 to 6 mm to look in an adult's ear.

If you have not already done so turn the otoscope on and check that the light is working. You should always keep spare batteries close by in case the light becomes dull.


4. Check the pinna
Before you insert the speculum in the ear canal you need to be sure that you will not be causing pain to the client.

Check if there is any tenderness around or on the pinna by gently touching the area. If there is pain and the entrance to the ear canal appears swollen and small you may decide not to proceed with the otoscopic inspection.

If the client tells you it is painful when you gently touch the ear then you may not be able to proceed with the hearing assessment or any other procedure you had in mind. If it hurts from a gentle touch then the pressure of the earphones will probably be excruciating. The client will not be able to concentrate on responding to the sounds and the test results will be questionable. The client should be referred to a doctor immediately and return for an assessment or other procedure after the cause of the pain has been treated.

During otoscopy you can check for the possibility of collapsing canals. This is where the canal is forced shut due to the pressure of the earphones. While looking at the pinna, if you push gently on the cartilage you can see if the ear canal seems to close. When you look in the ear canal the skin may seem very soft and loose, increasing the likelihood of the canals collapsing with pressure. If the canals collapse, hearing thresholds will appear worse than they actually are.

The pinna can also give you extra information about the client that may not have been revealed by the history.

For example if the pinna is an unusual shape or missing altogether. Sometimes the pinna has been damaged because of an accident or part of it has been removed by surgery. If this has happened you would like to know how and why and then decide if it will have an effect on the hearing assessment. Generally, this will have no effect on the client's hearing.

However, if it is a congenital condition, ie present from birth, it may mean that the structures of the middle ear have also been affected and so the hearing will be affected.

If the pinna is malformed and very small or absent it could be a condition called microtia. This condition may be associated with atresia. Atresia is where the baby is born without an EAM. This sometimes means the middle ear system has also been affected. In this case you can't perform otoscopy, as there is no EAM. The client would have had some medical investigation. If, during your history taking, the client did not tell you about this, you would have to ask them more questions at this stage.

For example, you would want to know what they have been told about the condition, what medical intervention they have had, what previous hearing tests have revealed and whether they have used hearing aids before. Microtia and atresia will affect the hearing. You can still do the test by putting the headphone over the malformed ear.

Keratosis
When looking at the pinna you may observe a keratosis. This is a black pigmented area of the skin. Keratoses (plural of keratosis) are very common but they may be related to melanoma. If you see anything that look like it might be a keratosis you could say to the client: "Have you shown this spot to the doctor?" If the client says they have, ask them what the doctor said about it. If they have not, say: "It would be a good idea to show it to the doctor next time you see him/her." If the client asks you why, do not say that it could be related to melanoma. You are not medically trained and it could just be a dark mole. It is better to say that you are not sure what it is but the doctor could tell them if it something to worry about or not and that it is always a good idea to have spots looked at by the doctor.

Cauliflower ears
If the pinna is an unusual shape it could be a cauliflower ear. This is where there has been a blow to the ear/s and the cartilage in the pinna is damaged. Cauliflower ears are common in people who have been boxers. If the blow is recent, it is likely the ear canal has blood in it and is possibly infected. If you do see blood or pus on the pinna the client should be asked to see their doctor immediately, if they have not already done so. If the ear canal is filled with blood or pus it will affect the hearing assessment. Unless the client has been referred to you by a doctor, specifically to see what effect the blow has had on their hearing, do not proceed. If the blow occurred a long time ago the ear/s would have healed and there is no reason not to go on with the hearing assessment.

A very hard blow to the head may cause problems in the middle and inner ear. You should ask the client whether they have had a blow to the head and if it caused them to lose consciousness. If the answer to either question is yes, ask them for more information about what treatment they received and what they were told was the effect of the incident.

There are other conditions that you can see on the pinna. If you are at all concerned about what you see, ask the client if the doctor has told them what it is. If they do not know or if the doctor has never seen it, ask them to go to the doctor and ask their advice. Remember, you are not a medical practitioner. There are many many conditions that will not affect the hearing assessment but may affect the health of the client. The client's doctor is the best person to make decisions about whether something is a concern or not.

You will have to make the decision to proceed with the hearing assessment or not. If there is no tenderness, it is acceptable to continue with the assessment.

If you do ask the client to go to a doctor, it is best to give the client a letter. The letter for the doctor should explain why you have asked them to see the doctor and give a description of what your assessment showed. If you did not go ahead and do the assessment, explain your reasons in the letter and ask the doctor to recommend when the client can return to you.

5. Check the entrance to the ear canal
If the entrance to the EAM is filled with debris or pus or it is very swollen you may not be able to insert the speculum.

Debris is the word we use to describe a collection of skin, wax or other small fragments in the EAM. It is a useful word to use in a report to a doctor. For example, "The TM could not be viewed due to the presence of debris in the EAM." Pus is a yellowish fluid usually quite thick and usually associated with infection. Swelling often occurs in response to an infection.

Before actually inserting the speculum into the EAM, turn the otoscope on and shine the light of the otoscope on the entrance to see if there are any obvious signs that would mean you should not continue.


6. Hold the otoscope properly
The hand holding the otoscope must be "anchored". That is, you have to lean the hand holding the otoscope against the head. This is vitally important so that if the client moves you do not scrape the EAM and cause an injury. There is also a very remote possibility of bruising the TM. Children often find it difficult to sit still so you must be very careful with your technique when looking in a child’s ear.

You will have to decide for yourself what is the most comfortable way to hold the otoscope. You need to be able to hold it so that you can "anchor" your hand. You could hold the otoscope like a pen and use your little finger to "anchor" your hand. Alternatively, you could grasp the otoscope and use your index finger as the "anchor".

7. Gently pull the pinna to straighten the ear canal
By pulling on the pinna you will straighten the cartilaginous section of the EAM. The initial third of the EAM passes through cartilage where there are 2 sets of glands which produce wax, also called cerumen, and hair follicles.

In adults the EAM usually slopes upwards and is about 2.5cm to 4cm in length. To straighten the EAM pull the pinna up and back.

In children the EAM usually slopes downwards and is about 0.7cm to 2.0cm in length. To straighten the EAM pull the pinna down and back.

When you pull on the pinna you need to "anchor", ie lean, your hand against the client's head. This is so that if the client moves their head you will not pull in the opposite direction and cause pain. If you use your thumb and index finger to pull on the pinna, you can rest the knuckle of your index finger against the head.

Try it on your own ear. Gently pull on the pinna and feel how the EAM straightens. Try pulling on different parts of the pinna and take a note which part seems to work the best. You will find that pulling on or slightly above the middle of the pinna will work best for adults. It is usually better to pull slightly below the middle part of the pinna for children.

8. Insert the speculum into the ear canal
When you perform otoscopy you need to be aware of personal safety. That is, you have to look after yourself and in particular you need to take care of your back. Rather than bending over from the waist it is better to bend your knees and keep your back straight. This may seem a trivial matter but back injuries are very painful and can occur even when doing something that does not involve lifting.

The speculum needs to be in far enough for you to be able to get a good view of the EAM and the TM but no so far in that it causes discomfort. Ask a colleague or your supervisor to look in your ear to experience what it is like. Ask them if they will allow you to look in their ear and if they could comment to you how comfortable it was.

Occasionally, if you have not put the speculum in correctly you will think there is a large chunk of wax present. When you are learning to perform otoscopy, it is best to ask your supervisor to look as well and compare what you saw.

9. Move the speculum around to view the entire EAM and TM
what you expect to see
what you don't expect to see
wax, a little wax
wax, occluding wax
hair
blood or pus
cone of light
foreign material
outline of the malleus
exostoses
the attic area
otitis externa, also known as swimmer’s ear
the annulus
perforation

scarring

redness

effusion / otorrhea

cholesteatoma

When you look through the speculum you will get a limited view of the EAM and TM. To get a complete view of the EAM and the TM you need to rotate the tip of the speculum but be careful not to scrape the walls of the EAM.

It is normal to see wax in the EAM. It varies in colour from very pale yellow to very dark brown. It is only when the wax totally occludes, ie blocks, the EAM that it becomes a problem. It is easy to think that there is a lot of wax when you first look in the EAM so be very careful to rotate the tip of the speculum to make sure the EAM is occluded before you tell the client. Even when wax totally occludes the EAM you can proceed with the hearing assessment but you have to be aware that it may cause a temporary hearing loss or make the hearing loss appear worse than it actually is. If wax occludes the EAM and you cannot see the TM you must not take an ear impression. You will need to ask the client to go to the doctor to have the wax removed. You will have to let the doctor know the reason for your request, as many doctors will not remove wax unless there is a specific purpose. For example, you could write: "Hearing assessment today shows a _ _ _ (describe degree and type of loss) hearing loss. Mr/Mrs X would benefit from the fitting of hearing aids however I was unable to proceed with taking an impression of his/her ear/s due to the presence of excessive wax. I have asked Mr/Mrs X to seek your advice about the wax and return to me on _ _ _(date) for ear impressions."

Wax serves a very important function. It stops dirt and other foreign material getting into the deep part of the EAM and the TM. A small amount of wax does not cause a problem. Clients should always be discouraged from cleaning their EAM.

The presence of blood or pus in the EAM is not normal and may indicate a problem that the doctor needs to treat. Ask the client to see their doctor if they have not already done so. You might do the hearing assessment if there is no pain involved but depending on what is causing the blood and/or pus the hearing may be affected, perhaps temporarily.

Hair follicles are found in the initial third of the EAM. Different people have varying amounts of hair in the EAM but it is very rare that there is so much hair that you cannot see the TM with the correct size speculum.


Occasionally, foreign material will get lodged in the EAM, sometimes deliberately and sometimes accidentally. For example, a child may put a bead or other small toy in their EAM or an adult may forget to remove a piece of cotton wool. Sometimes, insects will get stuck in the EAM. These will need immediate referral to the doctor for removal for obvious reasons.

Otitis externa is also known as swimmer's ear. It is an infection in the skin of the EAM and can be very painful and itchy. Usually it is difficult to assess a person's hearing because putting earphones on may be quite painful. There is not usually much effect on hearing and if there is, it is temporary. If the client has not been to see a doctor they should be encouraged to do so.

Exostoses are benign growths in the bony section of the EAM caused by repeated exposure to cold water. They are often seen in the EAM of people who have done a lot of swimming. If there is only one it is called an exostosis. Exostoses do not affect the hearing unless they have totally occluded the EAM. Treatment for exostoses involves drilling away the bone but this procedure is not performed very often. If you or the client are concerned that the exostoses are occluding the EAM you should suggest a doctors advice be sought, otherwise there is no cause for concern and you can go on with the hearing assessment.

A perforation is a hole in the TM. A perforation might happen because of sudden and extreme pressure in the middle ear cavity or the EAM or the TM may be pierced by something. They might or might not require medical attention. You cannot make this sort of decision so again it is best for the client to seek a medical opinion. You can proceed with the hearing assessment. Perforations usually affect the hearing.

Grommets are a type of deliberate perforation. They are particularly common in children and are little plastic tubes. The doctor may insert one in the TM to act as ventilation between the EAM and middle ear. Grommets are also called ventilation tubes. There are many different types and colours so do not be concerned that you see a small green or blue circle on the TM – it is probably a grommet.

A cholesteatoma is a tumour like collection of skin, fat and protein. Cholesteatomas are extremely dangerous and spread quickly. If you see an odd looking lump it may be a cholesteatoma. Any client with a suspicious lump on the TM should be urgently referred to a doctor.

Sometimes a cholesteatoma occurs with otorrhea. Otorrhea is a discharge from the ears, which often smells very badly.

Another word for discharge is effusion. If you see effusion in the EAM it is possible there is also a perforation even though you may not be able to see it because the effusion is blocking your view. Effusion can be thin and runny or thick and sticky.

You might also want to check for the possibility of collapsing canals at this stage. When you look in the ear canal the skin may seem very soft and loose, increasing the likelihood of the canals collapsing with pressure. Canals may collapse when you put the headphones on the client to do the hearing test. That is, the canal is forced shut due to the pressure of the earphones. While looking at the pinna, if you push gently on the cartilage you can see if the ear canal opening seems to close. If the canals collapse, hearing thresholds will appear worse than they actually are

There are landmarks on the TM you would expect to see. These include the cone of light, the outline of the malleus and umbo, the attic area and the annulus.

View of normal tympanic membrane
tympanicmembrane.png

One of the landmarks of the TM is the cone of light. The cone of light is a reflection of light from the otoscope. The cone of light is not always seen. This does not necessarily mean the TM is abnormal. The cone of light is often not seen in older clients.

You should be able to see the outline of the malleus and the umbo. If the malleus cannot be identified the TM may be abnormal. The umbo is at the end of the malleus in about the middle of the TM. The attic area is made up of the pars flaccida. It is the loose tissue above the malleus. Around the TM where it attaches to the EAM is the annulus. The annulus is a ring of tissue that holds the TM in place.

The TM may be scarred. If the client has had many ear infections in the past there will often be white marks on the TM. A red TM or EAM is often an indication of a current infection. You would expect to see some red on the TM which is the blood supply but if the entire TM is very red and you can’t see other landmarks of the TM then you should suggest to the client that they see their doctor.

Other things you would not expect to see when viewing the TM are:
• abnormal colour: the TM is normally a pearly grey colour
• bulging TM: normally the TM is slightly curved inwards
• fluid line on the TM: This may indicate effusion in the middle ear
• retraction: this is where the TM is pulled into the middle ear.

When you have decided that your client should see the doctor you should give them a letter explaining why. You must be very careful when you are writing letters to doctors that you only describe what you see. You should not try to make a medical diagnosis.


For example, the following may be appropriate:

“Otoscopy shows discharge in the EAM. As Mr Grainger has not sought a medical opinion about this I have suggested he see you immediately.”

“Madeleine’s mother reports she has been very ill lately and complaining of ear pain. Her TM appeared very red and bulging on inspection.”

“Otoscopy revealed a large amount of debris in the EAM. As it was not possible to take an ear impression I have asked my client to seek your opinion for possible removal of the debris as he would like to proceed with hearing aid fitting.”

11. Make a note of what you see
You will need to make a note of the otoscopic inspection. Your clinic may use a client history form that has a space to make a note. If not, it is advisable to write down what you see somewhere obvious. There are a number of reasons to make notes about what you see and do with your client. One is that it will help you to remember what happened next time you see that client. Other reasons include: the client may be seen by another clinician and they need to know what happened; you have a legal and ethical responsibility to keep notes about clients.

It is best to make a note about each ear. Your notes could include the following: clear; small amount of wax, occluding wax; debris; discharge, etc.


Otoscopic technique

Ask your supervisor, workplace mentor or any other clinician who is willing, to demonstrate how they hold the otoscope to look in the EAM. Take note of their method and ask them to allow you to practice looking in their ears and use their comments to improve your technique. Ask them if they can perform otoscopy on you so that you know what it feels like.

If you have an otoscope you might like to practice on willing volunteers at home. Ask them to tell you their opinion of your technique


Sending the client to the Doctor as a result of otoscopy
You would ask the client to see their doctor if you see:
foreign bodies; keratoses not previously shown to doctor; a perforation; blood; cholesteatoma; otorrhea; pus; effusion; discharge; swelling; debris; recent trauma not investigated medically or anything abnormal not previously shown to doctor.

You would also ask them to see their doctor if they were in any pain related to the ears or if they were concerned about something medical. Always remember, you are not medically trained so you are not able to say if something is of concern or not.

Example case study
Mrs Meissner has been sent to you from Dr Leung for a hearing assessment. The Doctor is concerned because of a family history of hearing loss.

You ask the questions for the history and she informs you she is 53 years old, her mother and sister developed hearing problems in their 40s and she has had a slight pain in both ears for about 3 weeks but for the last week the pain has been much worse. She saw the doctor about 2 weeks ago but did not mention the pain to him and did not go back to him because she was coming to see you.

When you attempt to touch her ear she flinches. As you gently touch her ear you ask her "Is that painful?". She replies that it is very painful.

What do you do next?

You would probably not proceed with the otoscopic inspection or the auditory assessment. If it very painful to touch the pinna gently, then it is likely that the rest of the procedure will cause Mrs Meissner extreme pain and she could not concentrate well. You would write a letter to the doctor and book an appointment for when you expect her to feel better.

An example of a letter to the Doctor:

Dear Dr Leung,

Thank you for referring Mrs Meissner to this clinic. She attended for a hearing test today.

I attempted to inspect her ear but was unable to do so as she found it very painful for me to touch her ear. Therefore, I did not proceed with the hearing test.

I have asked her to see you about the pain and have booked an appointment for two week’s time to assess her hearing. I have suggested she cancel the appointment if she is still in pain.

I will send you a full report when the hearing test has been completed.

Regards
Audiometrist

What do you tell Mrs Meissner about what is to be done?

Tell Mrs Meissner you do not want to cause her pain and therefore you will get her to come back when she is better, that you would like her to see Dr Leung about the cause of the pain. Make sure you tell her to cancel the appointment if she is still in pain and to make another.

You might like to telephone her a day or two before the appointment to check that she is no longer in pain.