exam 1 Flashcards
norms for ear canal volume
0.3 to 2.0 ml
anything below 0.4 is considered very low ECV
what is ear canal volume
an estimate of the volume of the cavity the probe encounters
what is compliance
the height of the peak which indicates the mobility of the eardrum in response to pressure change
the higher the peak, the more compliant the eardrum (the more it moves)
a low peak indicates a less compliant eardrum (stiffness)
if compliance is outside of the norms, it may be indicative of a problem in the middle ear
compliance = where on the y axis the peak occurs
compliance norms
NORM= 0.2 mL (greater than 0.2 = pass)
no max for peak height, but it would indicate hyperflaccid TM (but we dont refer for this)
if compliance is less than 0.2 mL, fail tymp, refer for rescreen in 6-8 weeks
patient fails tymp and fails hearing test- what do you do?
refer to MD and then to AuD for follow up
patient fails tymp and but passes hearing test, you refer them for rescreen in 6-8 weeks. they come back and compliance is less than 0.2- what do you do?
refer to MD and then to AuD
things we screen for during otoscopy (5 things)
impacted cerumen
foreign body in ear canal
perforation of TM
blood in ear canal - bright red, active bleeding (not scab or scar)
Obvious abnormality of the ear, head, or neck that was previously undetected
infection control protocol
sanitize hands between every patient
can use the same specula for both of the patients ears but always use a new one between patients
if you see blood, infection, or fungus in the ear, tell jennifer (speculum will be discarded)
Otoscopy protocol
- ask/tell patient you’re going to look in and touch their ear, ask to move their hair
- pull up and back on pinna with L hand and notice how the opening changes shape as you pull. find the point of the pull that provides the largest, roundest, opening
- hold otoscope like a pencil, use your pinky against the side of patients face to brace the head - may need to kneel or bend down so you’re at their level
- you might need to aim the light towards the patients nose
- look for malleus (bone connected to the ear drum), cone of light, and that the eardrum is a normal color (no blockage from cerumen)
REFERRAL CRITERIA FOR OTOSCOPY
- impacted cerumen COMPLETLEY fills the ear canal
- foreign body in the ear canal- refer to MD
- perforation (hole) of TM- refer to MD
- blood in the ear canal - refer to MD
- obvious abnormality of the ear, head or neck that was previously undetected - refer to school for advice
NOTE: scarring of the TM is not a criterion for referral but should be noted on the screening form as baseline/ history info. Wax is a normal condition but may require professional removal
patient passes hearing screening and otoscopy but fails tymp (either from gradient or compliance or both)- what do you do ?
refer for rescreening in 6-8 weeks
REFERRAL CRITERIA FOR OUTER EAR EXAM
refer to MD for …
1. ear drainage
2. structural deficit of the ear that has been previously undetected
3. cereumen impactation, foreign bodu, or blood in ear canal upon visual exam
4. perforation of TM or abnormally high ECV AND flat tymp (usually indicated by NP) or blocked PE tube
when to refer to AUD for eval
if prechool age 3-18 and thresholds greater than 20dB HL at 1K, 2K, or 4K in either ear
if adult over 18, and thresholds greater than 2 dB at 1K, 2K, or 4K in either ear
when to refer to MD and then AuD
when pt has middle ear AND inner ear concerns (fails tymp and hearing screen) OR middle ear concerns at rescreen (fails tymp at rescreen)
adult screen recomendations
hearing within typical limits and no history of noise exposure/ medical concerns: rescreen in 10 years
hearing within typical limits and positive history of noise exposure/ medical concerns: rescreen in 5 years
hearing is within typical limits with tinitis- refer for complete aud exam
hearing is outside of typical limits at any frequency- refer for complete aud exam
otoscopic examination atypical - consult MD
goal of school hearing screenings
to identify children with hearing impairments and related problems and to refer them to the appropriate professionals for follow up
otitis media
caused by an open eustation tube which cannot effectively equalize air pressure in the middle ear to atmospheric pressure.
ET dysfunction causes the middle ear space to be sealed for an abnormally long period of time. The mucosal lining tissue of the middle ear requires oxygen so without a fresh supply of oxygen, the pressure in the middle ear becomes negative in relation to atmospheric pressure –> pressure in the middle ear builds up because it pulls O2 from air in the middle ear space and becomes a higher pressure area than whats outside the ear.
ET dysfunction: when pressure is negative in relation to atmospheric pressure (but if peak height and gradient are WNL –> pass tymp)
early stages of otitis media (mild OM)
middle ear fluid secreted from lack of oxygen to middle ear space (bc ET isn’t opening) –> likely to clear up without treatment
if you see this with no other abnormalities –> PASS screening
if child complains of ear pain or you see redness of TM and/or bubbles from fluid on the inside of TM
consider discussing concerns with family as they may want to have a referral
later stages of otitis media
middle ear fluid infectioed, viscous, puss-like, TM movement may be compromised.
Tymp may show a low peak, wide gradient, or both. Peak pressure may also be negative.
if you see this and child does not pass tymp but passes hearing test, rescreen in 6-8 weeks.
IF fail tymp at rescreen, refer to MD (regardless of hearing screen results)
if otitis media is left untreated, can result in perforated TM
for chronic otitis media, you might see a pressure equalizing (PE) tube in the TM to aerate the middle ear
if child passes outer / middl ear screening (otoscopy, tymp) but does not pass hearing screening for one of both ears - what do you do
refer to AuD (potential inner ear problem)
if child passes tymp and hearing screening but you see impacted cerumen in one or both ears - what do you do
Refer to MD
if child passes otoscopy and hearing screening but fails tymp what do you do
RESCREEN in 6-8 weeks
if child passes otoscopy but fails tymp and hearing screen for one or both ears
refer to MD and then to AuD
if this is a rescreen and child passes otoscopy and hearing screen but fails tymp
Refer to MD and then to AuD
tympanometry purpose
assessing the function of the TM and middle ear
how does tymp work
the probe on the device establishes a seal. device plays a sound at a certian volume level and adds pressure which pulls on the TM. when we reduce the pressure we pull on the TM which happens when the sound pressure (volume) changes of the sound that was put into the ear. if the pressure or volume change is different from the establshed norms, middle ear system is not WNL
TM is most mobile when pressure in the ear canal and in the middle ear are equal – allows us to make conclusions about the pressure in the middle ear relative to the pressure in the ear canal
steps for tymp
tell child this device is going to draw a picture with their ear, show them the screen
- look at the patients ear to determine probe tip
- put it on and make sure theres no gaps between probe and device
- place the device in the patients ear after pressing the respective button (for R or L ear) and check that you are testing the correct ear throughout
- make sure it says “test ready” before you start
- pull back the pinna with non dominant hand
- insert the probe tip to the opening of the ear canal with the screen facing towards you
- look for probe to say “in ear”
- hold still until the display says done
- remove probe by angling it inward (towards head) to break the seal. once probe is parallel to head gently pull it away to break the seal
pressure (tymp)
the pressure at which the peak occurs is an estimate of the pressure in the middle ear as related to atmospheric pressure
pressure near 0 (atmospheric pressure) = ET is functioning normally
NORM: -100 to 100 daPa (not a concern unless it’s +/- 200)
gradient
the width of the peak at 1/2 its height, indicates how the eardrum responds to pressure change (quick vs slow eardrum movement)
NORM: less than 250 dPa
if gradient iis higher than 250, fail tymp and refer for rescreen. if they fail the rescreen, refer to MD and then AuD
what does high gradient indicate
response of TM is more sluggish than normal- could be because of a middle ear problem but its not our job to figure out why
if ECV is greater than 2.0
it could mean perforation of TM OR patent PE tube
- if TM perforation, refer to MD
- if you see in otoscopy that PE tube that is open and functioning, pass + let school know and note on screening form that PE tube is functioning
inability to maintain a seal with the probe is sometimes an indication of PE tube (open)
ECV greater than 2.0 and tymp has no peak- what does this mean
perforation (refer) or PE tube (pass as long as its functioning)
why? bc this tymp result means there is a hole in the eardrum –> ECV becomes volume in ear canal + volume of middle ear –> large ECV –> no measurements for other tymp criteria bc TM is not showing any resistance to changes in pressure (bc of hole)
in what situation would you refer when ECV is below 2.0
when you see a PE tube but ECV is normal, refer to MD to clear the tube. Normal ECV with PE tube indicates that the tube is blocked.
Tube needs to be open so pressure can equalize between the middle ear and ear canal
ECV is normal bc were just pressurizing the ear canal (not ear canal + middle ear) and can get some movement of TM when the PE is blocked
what does a very low (below 0.4) ECV indicate
could be a very small ear canal, impacted cerumen, or it could be that the probe is positioned incorrectly (against the ear canal)
what does negative pressure indicate
the ET is not working to equalize pressure in the middle ear with ambient pressure- often occurs from cold or allergy. Negative pressure isn’t criteria for referral. If you see negative pressure but peak height and gradient are WNL, pass.
what to do if you see shaky lines on the tymp
repeat the test
if second test has a stable tymp, print both and attach to chart. show results to jennifer.
shaky lines/ multiple peaks is not referral criteria
could result from patient moving or chewing gum, need to make sure they stay as still as possible and that you hold the probe steady
