Tips For Conducting The Otoscopic Examination

Use the best angle of the otoscope. Use the largest possible speculum. A larger speculum will allow you to visualize the tympanic membrane better. A small speculum may not provide a seal for pneumatic otoscopy. Don't apply too much pressure. Too much pressure will cause the child to cry and may cause false-positives on pneumatic otoscopy. Insert the speculum V4 to V2 inch into the canal. First find the landmarks.

Sometimes the ear canal resembles the tympanic membrane—don't be fooled! Note whether the tympanic membrane is abnormal. Remove cerumen if it is blocking your view, using Special plastic curettes A moistened microtipped cotton swab Flushing of ears for older children Special instruments that can also be purchased.

Not only are there two positions for the child lying down or sitting, there are two ways to hold the otoscope, as illustrated by the following photos. The first is the method generally used in adults, with the otoscope handle pointing upward while you pull up on the auricle. Hold the lateral aspect of your hand that has the otoscope against the child's head to provide a buffer against sudden movements by the patient.

Clinical Examination The Child

The second technique (see p. 679) is used by many pediatricians because of the different angle of the auditory canal in children. This involves holding the otoscope with the handle pointing down toward the child's feet while you pull up on the auricle. Hold the head and pull up on the auricle with one hand, while you hold the otoscope with the other hand.

Hot Hold Otoscope

Learn to use a pneumatic otoscope to improve your accuracy of diagnosis of otitis media in children. This allows you to assess the mobility of the tympanic membrane as you increase or decrease the pressure in the external auditory canal by squeezing the rubber bulb of the pneumatic otoscope.

First, check the pneumatic otoscope for leaks by placing your finger over the tip of the speculum and squeezing the bulb. Note the pressure on the bulb. Then insert the speculum, obtaining a proper seal; this is critical because failure to obtain a seal can produce a false-positive finding (lack of movement of the tympanic membrane).

When air is introduced into the normal ear canal, the tympanic membrane and its light reflex move inward. When air is removed, the tympanic membrane moves outward, toward you. This to-and-fro movement of the tympanic membrane has been likened to the luffing of a sail. If the tympanic membrane fails to move perceptibly as you introduce positive or negative pressure, then the child is likely to have a middle ear effusion. A child with acute otitis media may flinch because of pain due to the air pressure.

Absent Tympanic Membrane

Acute otitis media is a common condition of childhood. A symptomatic child has a red, bulging tympanic membrane, with a dull or absent light reflex and diminished movement on pneumatic otoscopy. Purulent material may also be seen behind the tympanic membrane. See Table 17-14, Abnormalities of the Eyes and Ears, p. 771.

This movement of the tympanic membrane is absent in middle ear effusion (otitis media with effusion).

Significant, temporary hearing loss for several months can accompany otitis media with effusion.

Gently move and pull on the pinna before or during your otoscopic examination. Carefully inspect the area behind the pinna, over the mastoid bone.

With otitis externa (but not otitis media), movement of the pinna elicits pain.

With acute mastoiditis, the auricle may protrude forward,

Although formal hearing testing is necessary for accurate detection of hearing deficits in young children, you can grossly test for hearing by whispering at a distance of 8 feet, asking the child questions or giving simple commands. All children above age 4 years should have a full-scale acoustic screening test.

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