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Otoscopy guideline

Introduction

  • Otoscopy should be carried out prior to any ear procedure. The practitioner should be able to identify the normal features of the tympanic membrane (TM)

Purpose

  • To correctly examine the external auditory meatus (EAM) and TM

Scope

  • Ear examination should only be carried out by practitioners who have received recognised training

Equipment requirements

  • Otoscope with a halogen bulb
  • Single use speculae

Guidance—adult patients

  • Before careful physical examination of the ear, listen to the patient, elicit symptoms, and take a careful history. Explain each step of any procedure or examination, and ensure that the patient understands and gives consent. Ensure that both you and the patient are seated comfortably, at the same level, and that privacy is maintained
  • Examine the pinna, outer meatus, and adjacent scalp. Check for previous surgery incision scars, infection, discharge, swelling, and signs of skin lesions or defects
  • Identify the largest suitable speculum that will fit comfortably into the ear and place it on the otoscope
  • Palpate the tragus in order to identify if the patient has any pain. Proceed with caution
  • Gently pull the pinna upwards and outwards to straighten the EAM (directly down and back in children). If there is localized infection or inflammation this procedure may be painful and examination may be difficult
  • Hold the otoscope like a pen and rest the small digit on the patient's cheek as a trigger for any unexpected head movement. Do not move the patient's head when the otoscope is in the ear. Use the light to observe the direction of the EAM and the TM. There is improved visualisation of the TM by using the left hand for the left ear and the right hand for the right ear but clinical judgement must be used to assess your own ability. Insert the speculum gently into the meatus to pass through the hairs at the entrance to the canal
  • Looking through the otoscope, check the EAM and TM. Adjust your head and the otoscope to view all of the TM. The ear cannot be judged to be normal until all the areas of the membrane are viewed: the light reflex, handle of malleus, pars flaccida, pars tensa, and anterior recess. If the ability to view all of the TM is hampered by the presence of wax, then wax removal may have to be carried out
  • If the patient has had canal wall mastoid surgery, methodically inspect all parts of the cavity, TM, or remaining TM, by adjusting your head and the otoscope. The mastoid cavity cannot be judged to be completely free of ear disease until the entire cavity and TM, or remaining TM, has been seen
  • The normal appearance of the membrane or mastoid cavity varies and can only be learned by practice. Practice will lead to recognition of abnormalities
  • Carefully check the condition of the skin in the EAM as you withdraw the otoscope. If there is doubt about the patient's hearing, an audiological assessment should be made. Providing they meet certain criteria stated in local referral guidelines, older adults with a bilateral hearing loss can be referred directly to the Audiology Department. Patients with a unilateral loss should be referred to the Ear, Nose, and Throat (ENT) Department
  • Document what was seen in both ears, the procedure carried out, the condition of the TM and EAM, and treatment given. Findings should be documented, with nurses following the Nursing and Midwifery Council (NMC) guidelines on record keeping and accountability. If any abnormality is found a referral should be made to the ENT Outpatient Department following local policy

Risk factors

  • Potential complications during and following procedure:
    • patient cough
    • trauma

full guideline available from…
Rotherham Primary Ear Care Centre and Audiology Services, The Rotherham NHS Foundation Trust, Rotherham Community Health Centre, Greasborough Road, Rotherham, S60 1RY
www.earcarecentre.com/HealthProfessionals/Protocols.aspx?id=8

The Rotherham NHS Foundation Trust. Otoscopy Guideline
First included: March 2016.