Otoscopy

Issues of Concern

Otoscopy is routinely performed during wellness check-ups and in evaluating specific ear complaints by specialists, such as ear, nose, and throat physicians (ENTs) and primary care providers.[1] Otoscopy plays a significant role in diagnosing several ear conditions and is a key step for diagnosing some conditions, such as acute otitis media.[1][2][3] As such, familiarity with otoscopy and the conditions for which otoscopic examination aids in diagnosis is important for healthcare providers in various fields.

Clinical Significance

Examination of the tympanic membrane and middle ear by otoscopic examination can help providers diagnose various conditions, including acute otitis media, traumatic perforation of the tympanic membrane, and cholesteatoma. Delayed diagnosis of various ear pathologies can facilitate progression to more serious conditions, highlighting the importance of otoscopy. For example, untreated acute otitis media can advance to feared complications such as mastoiditis, brain abscesses, or meningitis.[1][4][5][6][7]

Before beginning the otoscopic examination, the provider can ask the patient to demonstrate the strength of their facial muscles by smiling, frowning, elevating the eyebrows, closing the eyes, keeping them closed against resistance, and puffing out the cheeks. Successful completion of these movements demonstrates the integrity of cranial nerve VII, the facial nerve. The facial nerve travels through the middle ear and can be affected by ear pathologies such as acute otitis media.[8] Following the evaluation of the facial nerve, the provider can visually examine the health of the external ear and the pinna, noting signs such as wounds, scars, and inflammation.

Next, the provider can begin the otoscopic exam. There are often multiple speculum sizes for attachment to the otoscope. The provider should select the largest speculum that the patient’s external auditory canal can accommodate, as this provides maximum lighting for optimal visualization of the ear anatomy. Providers may have their preferences regarding how to grasp the otoscope. However, holding the otoscope like a pen between the first and second fingers is generally advisable. The otoscope is usually held in the right hand when evaluating the patient’s right ear and the left hand when assessing the patient’s left ear. The provider should place the free fifth finger of the hand, holding the otoscope against the patient’s cheek to support and brace the hand during the examination.

With the hand not holding the otoscope, the provider should grasp and gently pull the patient’s pinna to help straighten the patient’s external auditory canal. This step facilitates visualization of the tympanic membrane. In a child, the examiner should pull the pinna posteriorly and inferiorly. In an adult, the examiner should pull the pinna posteriorly and superiorly. Next, the provider can gently insert the speculum into the patient’s external auditory canal. The provider should inspect the health of the external auditory canal and evaluate factors such as inflammation, discharge, cerumen, and infection.

The provider should then slowly progress the speculum into the canal until the tympanic membrane becomes visible. The provider should evaluate the health of the tympanic membrane and observe factors such as color, presence of perforation, and bulging appearance.[9] The provider should also observe tympanic membrane landmarks, including the pars flaccida on the superior aspect of the tympanic membrane, the pars tensa on the posterior aspect, the light reflex on the inferior and anterior aspect, and the handle of the malleus on the anterior aspect. Observation of tympanic membrane landmarks can help the provider evaluate the health of the middle ear. Following the inspection of the tympanic membrane, the provider can slowly remove the otoscope from the patient’s auditory canal. While removing the otoscope, the provider can continue to observe the auditory canal to evaluate its health.

Otoscopic examination is an important part of the diagnosis of several pathologies of the ear. There are multiple factors, however, that can make successful otoscopic examination difficult. For example, factors such as poor lighting of the ear canal, suboptimal positioning of the otoscope, cerumen blockage, insufficient training in otoscopic technique, and lack of confidence in performing the otoscopic examination can hinder the successful completion of the procedure.[1][10] Such factors can subsequently lead to ineffective care, as the belief is that approximately 75% of the tympanic membrane must be visualized by otoscopy for a reliable diagnosis.[1]

To alleviate some of these difficulties in performing a successful otoscopic examination, video-otoscopes have been introduced recently and studied for their efficacy in diagnosing ear conditions. Video otoscopes allow the provider to introduce a small camera into the patient’s external auditory canal to visualize the tympanic membrane. Research into the effectiveness of video-otoscopy suggests that this technique may be superior to conventional otoscopy in assessing pathological conditions of the tympanic membrane.[1]

Another development in otoscopy involves a telemedical otoscopic examination. Telemedicine, which refers to the remote care of patients using telecommunication technologies, is becoming increasingly prominent in various fields of medicine. Several video-otoscope brands exist to remotely convey images of the tympanic membrane to providers for telemedical evaluation. These systems often function as smartphone attachments that capture and transmit a patient’s otoscopic images to a provider remotely. Current research suggests that the quality of otoscopic images obtained for telemedicine seems to vary based on the video-otoscope system used.[11] Further, the appropriateness of the telemedical evaluation of the tympanic membrane also varies based on the specific condition of the tympanic membrane. For example, telemedical evaluation appears to be more accurate in evaluating a healthy tympanic membrane or cases of ear canal exostoses than in evaluating a perforated tympanic membrane.[11] As such, it seems there is potential for telemedical evaluation of ear conditions via video-based otoscopy; however, the appropriateness of this evaluation method may depend on the specific clinical scenario.

Nursing, Allied Health, and Interprofessional Team Interventions

Otoscopy is a routine exam performed by many health practitioners for both screening purposes and evaluating specific ear complaints. Given the frequent use of otoscopes, they represent a potential source for the spread of infection. Research suggests that over 40% of otoscopes may become contaminated with potentially pathogenic microbial organisms such as pseudomonas, staphylococcus, aspergillus, and candida species.[12] As such, otoscopes require regular cleaning. The cleaning and maintenance of equipment used in the otoscopic exam is an important task that various healthcare team members can perform. Otoscope heads can be cleaned with a cloth dampened by aldehydes, surfactants, or alcohol.[12] Clinicians can consult the otoscope manufacturer's instructions for more specific cleaning protocols. Such a practice can contribute to decreasing nosocomial infections.