otoscope Q

[mcs1505]

We are practicing using the otoscope in lab and I am so afraid of inserting it too far into the ear that I don't insert it far enough. Looking around I saw student going varying depths and I've combed through my books and the web but can't seem to find anyone who mentions approx. how far it should go.

Can anyone help me out? I know it's silly but my ears are really sensitive and I don't want to hurt my fellow students or patients.

[Daytonite, BSN, RN]

I've looked in 3 books that I have on physical examination and the only information that was given on this that comes close to answering your question comes from Health Assessment Made Incredibly Visual, page 39:

"Hold the otoscope handle between your thumb and fingers and brace your hand firmly against the patient's head. Doing so keeps you from hitting the canal with the speculum.

Insert the speculum one-third its length gently down and forward into the ear canal. Be careful not to touch either side of the inner portion of the ear canal wall because this area is covered by a thin epithelial layer that is sensitive to pressure."

"Practical Guide to Clinical Medicine" from the medical school at University of California at San Diego (http://meded.ucsd.edu/clinicalmed/head.htm) says:

• Grasp the scope so that the handle is either pointed directly downward or angled up and towards the patient's forehead. Either technique is acceptable. The scope should be in your right hand if you are examining the right ear.
  
• Place the tip of the specula in the opening of the external canal. Do this under direct vision (i.e. not while looking through the scope).
  
• Gently grasp the top of the left ear with your left hand and pull up and backwards. This straightens out the canal, allowing easier passage of the scope.
  
• Look through the viewing window with either eye. Slowly advance the scope, heading a bit towards the patient's nose but without any up or down angle. Move in small increments. Try not to wiggle the scope too much as the external canal is quite sensitive. I find it helpful to extend the pinky and fourth fingers of my right hand and place them on the side of the patient's head, which has a stabilizing effect. As you advance, pay attention to the appearance of the external canal. In the setting of infection, called otitis externa, the walls becomes red, swollen and may not accommodate the speculum. In the normal state there should be plenty of room. If wax, which appears brownish, irregular and mushy, obscures your view, stop and go to the other side.
  

From Textbook of Physical Diagnosis: History and Examination by Mark H. Swartz, M.D., page 206:

"The straighter the canal, the easier the visualization and the more comfortable the examination will be for the patient. . .[a] second position involves holding the otoscope

upward

as the speculum is introduced into the canal. This technique feels more comfortable, but a sudden movement of the patient can cause pain and injury to the patient."

It is interesting that the photos in the Swartz textbook show the examiner holding the handle of the otoscope completely vertical to the head, rather than downward or horizontal compared to all the other photos I've seen. This automatically puts the position of the speculum downward and turning it slightly forward puts it in the same direction that the ear canal is going. I thought that was interesting.

[mcs1505]

Thanks so much, that's a lot more detail than I found, it helped a lot.