The Otoscope: Friend, Foe?

[IrishMD08]

To the Seasoned Pediatricians/Residents/etc...

When exactly did you feel comfortable with your (toddler) otoscopic exam? Intern year? Residency? Attending status?

Any special techniques you use?

I know this is like asking a magician to share trade secrets, but input much appreciated!

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[edmadison]

To the Seasoned Pediatricians/Residents/etc...

When exactly did you feel comfortable with your (toddler) otoscopic exam? Intern year? Residency? Attending status?

Any special techniques you use?

I know this is like asking a magician to share trade secrets, but input much appreciated!

I would say I was 90% comfortable upon completion of residency. My program, however, was VERY outpatient heavy. Regarding tips, distraction is great, engage the child, do your best. Sometimes, you will just need 10mg of "brutain" (brute strength) to accomplish it. Technically, always hold to scope so that some part of your hand is touching the childs head. This lets you move with the child and stay on target. There are several different ways to do this, I preferred holding the scope up-side-down and letting the entire ulnar aspect of my hand wrest on their head. One other thing, the disposible speculums are actually quite short. If you can find some, the reusable one are actually about 3 mm longer and this can make a huge difference in getting around some of that sticky wax.

Ed

 

[BigRedBeta]

Intern year I was pretty comfortable...my program is very ER heavy, which was equally helpful for getting exposure (maybe more helpful since you didn't have time taken up well-child checks). I don't claim to be able to distinguish fluid behind the year particularly well in this age, but I can tell you for sure about red, bulging vs normal light reflex/landmarks.

First, I never go for ears on patients between 9 months and 3 years without them on the parent's lap. I can pin the little ones myself (and parents are less willing/capable of helping when they're small) and most 3 year olds are over the fear and you can make it a game and they'll do okay on the exam table.
I usually start by letting them play with the light. I show the light on my hand, put my finger over it to make my finger glow, then shine the light on their hand - most usually will touch it to see if their finger will glow. I *think* that makes a difference, but it may not.

The next part is actually the most crucial - you absolutely must get the parents to hold correctly. They do that, and the kid isn't going anywhere and you'll get a good look. But unless you have a really experienced parent, you really have to tell them exactly how you want them to hold. If I want to look in the right ear, I want the kid completely turned facing that direction, both feet hanging off parents lap in that direction - none of this straddling mom or dad with a leg on either side of the body. It has to do with leverage and you put those feet into free space, there's nothing to push off of.
Next left ear placed to parent's chest. The parent then needs to use their right arm/hand to hold both wrists and bring the child's body to theirs. Taking care of those hands is crucial. The left hand is used to keep the child's head against the parent's chest, allowing me access to the ear. To see the other ear, everything gets flipped - so the child get's rotated 180 degrees to face the other direction. It's a lot of repositioning, but it's worth it to have the right hold.

 

[ZekeMD]

I think the ear exam is entirely child dependent. There are some kids that no matter what I do, the TM is impossible to see. Others are very easy to see. Yeah, there are techniques for calming the child and how to hold to otoscope that you gain during residency, but overall I think it is more dependent on the ears of the child in question. After all, even with an unruly child, brute force is usually successful .

I just can't wait until fellowship when I won't have to ever look into another ear

 

[Cuthbert]

Friend. I felt comfortable by the end of intern year.

If it is a 3-4 yo (and they are not freaking out) I let them hold the otoscope with me. This tends to work very well as a distraction and the child feels like they are helping. You have to maintain good control of the otoscope if you are going to do this of course.

If a child is crying and freaking out (typically a child between the ages of 1 and 3), I have the parent hold the child sideways on their lap with one arm over the child's arms and one hand holding the child's head to their chest. After the first ear, you turn the child in the opposite direction and repeat. I think that you are better off getting it done and doing it quickly if the child is crying anyway. I calmly explain to the parents that the child will likely not be happy, but we will get the ear exam done quickly. And I save the ear exam for last so that the parents can comfort the child after the exam and it does not interfer with the rest of the exam.

I will sometimes ask the parents what works best for looking in their child's ear (many parents have good experience with certain methods).

On a side note, the type of otoscope you use makes a difference in my opinion. I use a Welch Allyn MacroView Otoscope Head:

You get a much better view than those old school heads.

 

[Stitch]

On a side note, the type of otoscope you use makes a difference in my opinion. I use a Welch Allyn MacroView Otoscope Head:

You get a much better view than those old school heads.

I'm a fan too. It took me a little bit to get used to focusing the thing, but it's worth it.

As for the exam, I just lay the kid on his side, get the parent to hold arms/legs and look while I look in the ear. The method descirbed by BigRedBeta also works well. Getting the parents to help is crucial, and you have to be able to coach them.

 

[IrishMD08]

Thank you all for such great advice!!

 

[Powdermonkey]

I've found that we were taught wrong in school. Or well, just not the best way. In school they said to hold an otoscope like this:

But the pediatrician that I rotated with said to hold it like this:

I much prefer the second way because you have both hands stabilizing the wobbly, little heads and it makes it so much easier to control the otoscope so everytime they move you're not pushing it further into the ear canal. Another thing he told me, and that I've seemed to notice, is that if you hold it this way when you're putting the speculum into the canal make sure you stay towards the bottom of the canal. It seems to cause less irritation and pain if you stay away from the top of the ear canal as much as possible.

 

[Cuthbert]

But the pediatrician that I rotated with said to hold it like this:

Absolutely! That is the way to go, and the only way I hold the otoscope.

 

[GiardiaLOOMBlia]

For the real little ones I always have the parents hold them so that their head lays on the parent's shoulder. Child's left cheek on parent's left shoulder (parents holds head) when I want to examine the right ear and child's right cheek on parent's right shoulder when I Want to examine the left ear. This way they can't really move and so brute force wins out but slightly more comfortable for the child I think. Some of the real little ones are great though and don't mind the otoscope at all, I've had some 12 month olds who will turn their head in anticipation of the ear exam when they see me holding the otoscope!

 

[DrMed2009]

I am about to start residency in the USA this summer but already started my residency in my home country Germany. Here you can do up to 1 year in a Pediatric office and I worked the last 6 months in a pediatric practice and now feel very comfortable using my otoscope. The office consisted of 2 doctors (my boss and me) and three nurses. We saw around 60-80 during flu season up to 100 patients every day. So I saw around 50 patients and 100 ears every day ages 10 days - 18 years. The only time I have trouble seeing is when there is so much cerumen that not even a long time attending would see annything. I think it is harder sometimes to see all the back of the throat instead of ears.
The babys I usually have them laying on the examination table and turn them on the side. Toddlers - I like it when the toddler are held by the parents and have the babys head against moms/dads chest like someone above already mentioned. Or a lot of them already hold still pretty well and then I just have them sit still. Same goes with the old kids and they usually do what I tell them )