Jacob Johnson, MD

Partner, San Francisco Otolaryngology Medical Group

Assistant Clinical Professor, UCSF

Medical Advisor, Phonak

Otoscopy: What Every Audiologist Should Know

Today’s Presentation

Visualizing the Ear

Medical Considerations

Common Ear Diseases

Visualizing The Ear canal

� Ear Canal Opening� Cerumen Quality� Skin Integrity� Ear Canal Dimensions� TMJ Collapse� Bony Cartilaginous Joint� Bony Canal Anatomy� Tympanic Membrane

� Tools for visualization: � Otoscope� Headlight� Magnified Headlight� Video-otoscope� Microscope

Visualizing the ear and tympanic membrane

Medical Considerations:

Tools & Techniques

� Techniques for visualization:� Equipment� Positioning

� Patient� Practioner� Ear canal anatomy

� Talking to the patient� Pre, during & post� Following trauma

Visualizing the ear and tympanic membrane

Medical Considerations:

Tools & Techniques

� 1983

� Looking in the canal

� 1993

� Academy responded with regional training� CIC deep fitting trainings

� Cerumen management workshops

� 2013

� As a field take responsibility for learning the ear canal � Position point for field

� Autonomy

� Cerumen management

� Microscope use

Everything old is new again

Audiologist Perspective

Medical Considerations: Assessment

� Differential diagnosis� Location� Type of Hearing Loss� Urgency/ Severity

Location

� Outer ear (TMJ)� Middle ear/ Mastoid� Inner ear� Face, Salivary glands, Neck� Central, Cranial Nerves� Systemic (Eyes, Thyroid, Heart, Kidney)

Type of Hearing Loss

� Conductive� Sensori-neural� Mixed Hearing Loss

�Hearing�Tinnitus�Vertigo�VII Cranial N.�TMJ/ Ear Pain�Skin Quality�CNS� Immune System�General Health �Motivation

Ear Assessment and Anatomy

““““Many look, few see””””

Medical Considerations: Management

Location

� Outer ear (TMJ)

� Description: keratin & oil material in ear canal

� Management: cerumen loop, irrigation, suction

� Deep fitting candidacy: moderate concern and needs active management

Identified as: Cerumen Impaction

Common Ear Diseases

� Description: white patches in ear canal opening with crusting

� Management: gentle cleaning, lubrication, topical steroid cream

� Deep fitting candidacy: moderate concern and needs active management

Identified as: Dermatitis

Common Ear Diseases

� Description: conchal bowl cartilage protrudes toward tragus

� Management: surgical

� Deep fitting candidacy: mild to moderate concern

Identified as: Collapsing Ear Canal

Common Ear Diseases

� Description: underdeveloped ear and no ear canal

� Management: surgical, prosthetic, stem cells, BAHA

� Deep fitting candidacy: contraindicated

Identified as: Microtia and Atresia

Common Ear Diseases

� Description: non-healing ulcers, nodules, shiny lesions, wounds

� Management: biopsy, chemical, surgical

� Deep fitting candidacy: after medical management and based on surgical alteration

Identified as: Basal cell and Squamous cell carcinoma

Common Ear Diseases

� Description: line of blisters along concha bowl, ear canal onto TM

� Management: Acyclovir/ Valtrex, prednisone

� Deep fitting candidacy: medical clearance (pain issues)

Identified as: Shingles

Common Ear Diseases

� Description: swollen ear canal opening with wetness and white debris in bony canal

� Management: keep ear dry for 6 weeks, clean debris, antibiotics/steroid drops, possible ear wick, possible oral antibiotics for immuno-compromised patients

� Deep fitting candidacy: contraindicate if recurrent

Identified as: Otitis Externa

(Swimmer’s ear)

Common Ear Diseases

� Description: fuzzy dark or white patches or growth on layers of pus or keratin

� Management: ear canal cleaning, dry ear precautions, topical alcohol, acetic acid (Vosol), anti-fungal or boric acid treatments

� Deep fitting candidacy: contraindicated

Identified as: Fungal Otitis Externa

Common Ear Diseases

� Description: smooth protrusions into the bony canal (single or multiple)

� Management: vented ear plugs, surfer’’’’s hood, surgery

� Deep fitting candidacy: contraindicated

Identified as: Osteoma/ Exostosis (Surfer’s ear)

Common Ear Diseases

� Description: foreign body

� Management: removal

� Deep fitting candidacy: check device each time it is removed

Identified as: Foreign body

Common Ear Diseases

Location

Middle ear/Mastoid

� Description: blister on TM

� Management: observation, lance

� Deep fitting candidacy: consider if device touched TM

Identified as: TM Bulla (Blister)

Common Ear Diseases

� Description: bubbles behind TM

� Management: observation, myringotomy if persistent

� Deep fitting candidacy: important to do tympanogram, medical clearance

Identified as: Serous Otitis Media

Common Ear Diseases

� Description: hazy, bulging, congested TM

� Management: oral antibiotics, myringotomy

� Deep fitting candidacy: remove device to evaluate TM, refit when well

Identified as: Acute Otitis Media

Common Ear Diseases

Mastoiditis

� Description: silver or colored hole in TM (standard vs. extended)

� Management: observation, treatment of underlying issue

� Deep fitting candidacy:contraindicated, concern with T-tube

Identified as: Ear Tubes

Common Ear Diseases

� Description: hole in TM, clear edge with no thin TM covering hole (““““monomeric”””” membrane)

� Management: observation, tympanoplasty

� Deep fitting candidacy: medical clearance (dry vs. wet)

Identified as: TM Perforation/

Myringosclerosis

Common Ear Diseases

� Description: chronic ear drainage (wet ear canal) with TM perforation

� Management: medical, imaging and possible tympano-mastoidectomy

� Deep fitting candidacy: contraindicated

Identified as: Chronic otitis media (Draining ear)

Common Ear Diseases

� Description: retracted TM, white pearls, red polyp, debris

� Management: observation, cleaning, tympano-mastoidectomy

� Deep fitting candidacy: contraindicated

Identified as: Cholesteatoma

Common Ear Diseases

Canal Wall Down Mastoidectomy

Location

� Inner Ear

� Description: red or blue lesions on or behind the TM

� Management: referral, imaging, surgical, observation

� Deep fitting candidacy: contraindicated until cleared

Identified as: Glomus tumor/

Hemotympanum

Common Ear Diseases

Temporal Bone Fractures

Longitudinal or otic capsule sparing Transverse or otic capsule violating

Within skeleton, matrix material properties are anatomically-distinct

- J.D. Currey, J. Exp. Biol 1999

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Bone matrix material properties

- elastic modulus and hardness- independent of bone mass and geometry

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6.7 GPa11.2 GPa18.5 GPa

21.8 GPa

25.4 GPa

34.1 GPa

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Inner ear

Superior SCC Dehiscence Acoustic neuromaInner Ear Fistula

� Management versus referral

� Assessment

� Urgency

� Commitment to learning (practice)

Medical Considerations: Management

Day 0 Days 1-7 Days 8-14 Days 15-21 Days 22-30 Days Over 30

<=27 Insertions 9.47% 15.15% 32.14% 17.86% 6.82% 4.49%

Between 28 - 224 Insertions 5.51% 16.10% 11.74% 8.34% 5.42% 2.16%

Over 225 Insertions 5.84% 13.44% 8.68% 5.71% 4.47% 1.98%

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DOW

DOW for Ear Irritation Medical Removal Reasonfor All Lyrics US Subscriptions

Comparing Accounts by the Number of Insertion Experiencefrom 2012- 2013

As of December 16, 2013

<=27 Insertions Between 28 - 224 Insertions Over 225 Insertions

Expert- 10,000 hours