Each person has their own method of building a puzzle. Generally, you begin with the edges because they are the quickest to identify. One should approach screening and diagnosis in the same fashion, piece by piece discovering the overall picture. As a healthcare professional, you will need your patient to be thoroughly prepared for an audiometric test. This will include a comprehensive case history and an otoscopic examination.
An otoscopic examination is an inspection of the external ear canal and tympanic membrane. It provides an additional piece of information for making a diagnosis such as the presence of ear pathology that may exist, and that may have an impact on the audiometry results of your patient. If pathology is present, treatment might be required before a hearing test is performed. Skipping this step to look into the ear would be like building your puzzle from the centre piece outwards.
Ear pathologies that can be identified include, but are not limited to:
- Auditory Canal Atresia: The narrowing of the external auditory meatus due to birth abnormalities, polyps, infections, allergies, etcetera.
- Impacted Cerumen: This occurs when excessive wax builds up in the ear canal, making it difficult to visualise the tympanic membrane.
- Otitis Externa: This is referred to as an infection of the outer ear canal due to bacteria, fungal, viruses etc.
- Tympanosclerosis: Scar tissue forming on the tympanic membrane that typically develops due to chronic middle ear infection.
- Perforated Tympanic membrane: A hole in the eardrum or ruptured eardrum.
Clearly identifying these pathologies will recognise valuable information before any further diagnostic tests can be performed. Let us now look at the purpose and procedure for conducting an otoscopic examination.
Again picture the analogy of building the puzzle; Make sure you can visualise the edges of the tympanic membrane. This is the annulus where the tympanic membrane meets the ear canal. Sometimes pathology might hide here.
Just as when building the puzzle, first visualise the sides of the ear canal in its entirety before jumping in and visualising the tympanic membrane. Note if there are any foreign particles (or excessive wax) within the ear canal, and any redness or fluid on the tympanic membrane that may indicate an infection.
It is crucial that prior to every KUDUwave insert earphone test, that an otoscopic examination takes place. It is also critical to ensure wax will not block the tip of the KUDU foam ear tip once inserted. The other risk, although very low is that the ear tip might touch impacted wax and irritate a nerve that could induce a cough reaction. Stop immediately if a patient coughs when inserting an eartip. Another risk is that hard wax might touch the eardrum when inserting the ear tip causing pain and discomfort to the patient. Again, immediately terminate the insertion and remove the pathology before continuing with the hearing test.
Failure to visualise the ear canal and the tympanic membrane may lead to misdiagnosis. Something as simple as earwax can cause reduced hearing, resulting in temporary hearing loss shown on the audiogram.
Some valuable tips
Inform the patient of the procedure you are about to carry out. In children it helps to ask the child to let you know when the light tickles the ear too much. This conditions them to not expect pain, but an acceptable tickle.
The ear speculum, which is inserted into the ear, must be replaced by a clean speculum. HIV for instance has been isolated in ear wax, so do take precautions. Speculae come in various sizes and you should select the size that will be most comfortable for the patient's ear.
When the otoscope is used, it should be held in a way as to minimise discomfort should the patient move. It is recommended that the otoscope be held like a pencil while resting a finger against the patient's cheek. Other methods also work, placing one finger on the patient’s cheek will alleviate the situation of a person accidentally bumping your elbow and the otoscope plunging causing potential trauma.. Resting a finger on the patient’s will also enable your proprioception sense of keeping the otoscope stable.
Straighten the ear canal by grasping the pinna firmly and pulling it upward, backward and slightly away from the head. In children, pull backwards instead of upwards.
You have to know what puzzle piece you are looking for or you will never find it. The same when searching for pathology. If you do not think of certain pathologies, you will not see it. Consider the following things while doing the examination. Think size, colour, shape, position, tumour/foreign object (SCSPT):
- Look purposefully at the pinna. Think size, colour, shape, position, tumour.
- Then move the speculum into the ear canal and consider these same points i.e. size, colour, shape, position, tumour.
- Then move on to first inspect the annulus of the tympanic membrane first and then the tympanic membrane. Think size, colour, shape, position, tumour.
Record your observations immediately after carrying out the examination. Depending on the circumstances, it might also be appropriate for the examiner to make a judgement on the status of an ear i.e. the presence of an abnormality or disease.The examiner may have to take further action, such as a referral for further medical evaluations.
Then record the findings in the same order. Here is an example:
On examination (O/E): (Think size,colour,shape,position,tumour)
- Pinnae: L=R=Normal
- Ear canal: L=Soft wax; R=Red, narrow canal, swollen
- Tymp membrane: L=Light reflex; R=Red, bulges.
Diagnosis (Dx): Otitis Externa and Otitis Media Right
Plan (P): Refer to ENT
You are now ready to begin your hearing test.