Chapter 43. Otoscopic Examination

• • Examination of the tympanic membranes and ear canals is part of routine health maintenance.

  • Tympanic membranes should also be visualized with complaint of ear pain, upper respiratory tract infection, or fever.

  • Serial examinations are indicated over several months to check for resolution of effusion.

  • A complaint of hearing loss should also prompt a careful otoscopic examination.

Relative

• • In the presence of otitis externa, the tympanic membrane will be difficult to visualize because of occlusion with pus.

  • Presence of cerumen in the canal may require removal with a curette or irrigation in the office or alternatively use of a cerumen-reducing agent at home with return for reexamination in a few days.

• • Otoscope with insufflator attachment.

  • Ear curettes.

  • Hydrogen peroxide diluted 1:1 with lukewarm water.

• • If an uncooperative child is not held completely still, there is a risk of laceration to the ear canal.

• • While most offices have disposable tips for the otoscope, use of the tips supplied by the manufacturer tend to have a better fit and yield more accurate results on pneumatic otoscopy.

  • A 10-mL syringe with a cut-off angiocatheter plastic tip is useful for instillation of dilute hydrogen peroxide when irrigation is required.

• • Warn the patient that a pressure sensation and possibly pain will be experienced when using the insufflator.

• • Patient must be still for an adequate examination, including visualization of the tympanic membrane and insufflation.

  • There are 2 positioning alternatives for children who need to be held:

  • • Supine with arms held by parent or an assistant down at the patient’s sides.

    • Sitting in the parent’s lap with arms held to body in bear hug position.

  • The clinician should hold the head steady with 1 hand and also pull the pinna cephalad and posterior with that same hand; the other hand is holding the otoscope and insufflator.

• • Normal tympanic membrane landmarks include the malleus and incus as well as the pars tensa and pars flaccida (Figure 43–1).

• • The light reflex should be sharp on a normal tympanic membrane.

• • Using an otoscope, examine the ear canal and remove any occluding cerumen.

  • Choose the appropriately sized ear tip for the patient’s ear canal and affix it to the otoscope.

  • Grasp the helix and pull up and back gently to straighten the ear canal.

  • Insert the speculum tip into the entrance of the ear canal to visualize the tympanic membrane.

  • An airtight seal will need to be obtained when performing pneumatic otoscopy.

  • To insufflate, squeeze the bulb to deliver positive pressure against the tympanic membrane while observing for mobility. Also observe for movement when releasing the bulb and generating negative pressure.

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