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Year : 2001  |  Volume : 3  |  Issue : 2  |  Page : 62-65

Training of health care workers in the use of the otoscope

Security Forces Hospital, Riyadh, Saudi Arabia

Date of Web Publication9-Jul-2020

Correspondence Address:
Siraj M Zakzouk
P.O.Box 3848, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289367

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Introduction: Otoscopy, a subjective clinical method, is used by many physicians and nurses to assess the condition of the ear canal, the tympanic membrane and the presence or absence of otitis media.
Objectives: To train doctors and nurses working in health centers to perform otoscopy and assess their ability to distinguish between normal and abnormal ears, when to treat or refer patients for further management.
Materials and Methods: Twenty doctors and twenty nurses were given basic intensive courses in the ear and the use of otoscopy. They were given 10 patients to examine each, before and after the course.
Results: Results showed marked improvement in the average competence level of both doctors and nurses in using otoscopes.
Conclusion: If these training courses were adopted for health-care workers the results would help to increase the overall quality of care, rationalize and minimize referral to ENT specialists and help in carrying out the proper treatment at an early stage.

Keywords: Otoscopy- Training, Health centre, doctors, nurses

How to cite this article:
Dasugi A, Zakzouk SM. Training of health care workers in the use of the otoscope. Saudi J Otorhinolaryngol Head Neck Surg 2001;3:62-5

How to cite this URL:
Dasugi A, Zakzouk SM. Training of health care workers in the use of the otoscope. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2001 [cited 2021 Nov 29];3:62-5. Available from: https://www.sjohns.org/text.asp?2001/3/2/62/289367

  Introduction: Top

The Ministry of Health (MOH) in Saudi Arabia developed a National Health Service program over the last 8-10 years by establishing a series of primary health- care centres in almost all cities of the Kingdom. In this respect, the M. O .H. have more than 2,000 centres along the 13 administrative areas of the Kingdom.[l] Each centre is provided with health delivery workers, and family health files, and each family is registered in one centre where they live. The shift from tertiary to primary care setting is well practiced in this country and disease prevention, health promotion and early intervention are emphasized. The nurses and general physicians in Saudi Arabia are the primary health care providers, and referral for secondary health care in hospital is strictly applied for those who actually need this service. The Ministry of Health statistics have shown that 50% of the Kingdom’s inhabitants are children (below 15of age) and the number of women in the active productive period (15-49 years) constitute 20%of the total population[1] This means that the Ministry of Health has to provide an increasing amount of health care to these groups who are prone to many factors affecting their health and the role they are playing.

In this respect, the health status has improved considerably by the reduction in the death rate of children below 5years old, the death rate of mothers, and the reduction of low birth weight born infants. In addition, the rate of infection and epidemic diseases has been lowered.

The rapid development of Saudi Arabia and the increased agricultural and horticultural sectors with imported trees, etc. affects the atmosphere and the pattern of diseases. Allergic diseases have been rising and upper respiratory tract infection and middle ear problems are increasing. The number of children with allergic rhinitis, otitis media with effusion and suppurative otitis media with consequent hearing loss are frequently encountered in this country.

The burden on the health service providers in the primary health care centers is increasing and the health provider relies on both doctors and nurses, sufficiently trained to help provide primary health care especially for children. In many countries, as well as in Saudi Arabia, there is a clear shift in environment for clinical practice from tertiary to primary care settings as disease prevention, health promotion and early intervention are emphasized. Paediatric nurses and public health nurses are important as health service providers for children in the community .

The ear canal, the tympanic membrane and the middle ear continue to change after birth, mainly in the first year of life, Cavanaugh (1989)[2] describe these changes as reflected by otoscopic examination. With aging, the ear drum ages in a way similar to the aging skin, becoming thinner, less cellular, less vascular, less elastic and more rigid.[3],[4] Otoscopy is a subjective clinical method used by many physicians at health centers, where General Practitioner or a trained nurses are working. Otoscopy can give an indication of the condition of the ear canal, tympanic membrane and presence or absence of middle ear fluid (OME). It can therefore, help to screen patients with ear disease for treatment or referral to ENT specialists. Therefore, training of the otoscopist is important not only on how to use the otoscope, but how the findings are interpreted for children and adults. The aims ofthis study was to train 2 groups of doctors and nurses working in primary health centres to perform otoscopy and conduct an assessment of the value of training in

  1. The ability to distinguish between normal and abnormal ear .
  2. When to interfere and manage at health centres level
  3. When to refer patients to secondary care hospitals and to address the need for follow-up of those referrals.

  Materials and Methods Top

Health centres in Saudi Arabia serve a specific population and often has female doctors to treat female patients and children attended by their mother and a male doctors to treat male patients and children attended by their fathers. Twenty doctors, 10 females and 10 males were selected together with twenty nurses working in the same centres. They were divided into two groups. The male doctors were in the first group: the female doctors and nurses were the second group. Basic intensive, simplified lectures, 2 hours/ day for two weeks were given to each group. There are two types of otoscopes available in health centers, the Welsh- Allenn ® with a magnifying lens giving a much more detailed look at the tympanic membrane and canal. The other type is the otoscope is from Keeler Both types have a side tube for pneumatic testing of drum mobility There were two ways of holding the otoscopes. The first hold is straightforward, providing an easy and direct view of the tympanic membrane (TM), and is very comfortable for the examiner. It is perfectly safe with adults, adolescents, and cooperative children. The second method is more protective. In this position, the side of the examiner’s hand is placed against the head of the child, thereby protecting the ear canal from trauma with any sudden jolt, slip, or move. It is safe for all patients and is mandatory when assessing active, fearful, screaming, or uncooperative children. The function of the ear and hearing assessment using simple tools and tympanometry were explained. The common diseases of ear, nose and throat were explained in various slides, ear models and charts. Clear pictures of the normal and abnormal appearance of the ear drum were shown. The use of otoscopes was explained. A questionnaire was designed to answer specific questions regarding previous ENT training, ear examination, diagnosis of otitis media performing, certain procedures as ear syringing, tympanometry and when to refer patient for further consultation. The trainees were instructed to see normal ears and to locate the landmarks on each TM, to examine and to draw on papers their findings. They had to look for any variations from normal. As most of ear complaints are unilateral, the examiner was instructed to look at the normal non-symptomatic unaffected ear first and then examine the diseased ear and then compare the unaffected normal ear with the problem ear .This was followed by inspection of the ear canal for any swelling, discharge, lesions, foreign body present. Trainees were also instructed about the use of different sizes of the cones used with otoscopes and how far one should introduce the cone in the canal. Each trainee was asked to examine 10 ears and report on the findings. The instructor then examined the same patients and recorded the findings, discussed these with the trainee and then rechecked the examined ears. The curriculum was designed to cover the basic anatomy of the ear and anatomic variation during development, sensory nerve supply to understand otalgia, Eustachian tube and its relation.

  Results Top

Twenty doctors and 20 qualified nurses answered the same questionnaire before and after training to ascertain the value of the course, in which all patient examination was performed using otoscopes (pneumatic, Welsh Allen ® and Keeler ®), The scores before and after training are as as shown in [Table 1].
Table 1: Scores befor and after training

Click here to view

  Discussion: Top

De Melker (1992)[5] conducted a study to determine the value of pneumatic otoscopy for determining otitis media with effusion in primary care. He concluded that otoscopy is an adequate, inexpensive method of diagnosing effusion in children, and recommended it’s use in primary healthcare.

In a study to assess the otoscopic skills of general practitioners and medical students, Fisher and Pfleiderer (1991)[6] found that the two groups showed similar abilities in identifying the tympanic membrane and distinguishing normal from abnormal ears. The medical students ability to identify specific features of the tympanic membrane was however significantly higher than that of general practitioners (p<0.01). they concluded that the mastery of otoscopic skills should be actively fostered the final medical qualification for all trainees. They suggested three approaches to achive this; one would be to improve the undergraduate curriculum an ear, nose and throat medicine. The school approach would be to increase the prominence of ear, nose, and throat medicine in vocational training schemes, this could consist of clinic visit during which clinical skills could be monitored and built upon. The final approach would to foster the attendance of courses for established practitioner and allow revision of basic anatomy as well as more clinically related knowledge.

Miola (1994)[7] at the school of nursing at the University of Maryland in Baltimore, gave an excellent paper on the otoscope, with an update on assessment skills. This indicated clearly the increasing demands of the paediatric nurse in clinical practice regarding primary care responsibility, and the requirement for assessment skills using non traditional equipment such as the otoscope, where proficient use is of increasing importance. Diseases of the upper respiratory tract are responsible for more than 20% of the consultation in general and paediatric clinics. At some stage of vocational training skills in the diagnosis of such conditions should therefore be acquired[8]. Otoscopy is an important skill for the general practitioner but this skill is rarely assessed at either undergraduate or postgraduate level.[9]

It is clear that the training provided in the current study resulted in a marked improvment in the average competence level of both doctors and nurses in using otoscopes, with nurses benefiting most. If the training course were adopted for health-care workers, the results would help to increase the overall quality of care, rationalize and minimize referral to ENT specialist and help in carrying out the proper treatment at an early stage. The following points are noted with regard to the specific tests:

  • Correct diagnosis of acute otitis media (ASOM) and of otitis media with effusion (OME :these conditions are particularly important in the early recognition of problems in children. The results of this training show good benefits in this regard.
  • Recognition of safe perforation (as central): general improvements noted in both doctors and nurses. This is important with regard to recommendation for surgical interference.
  • Recognition of unsafe perforation (as marginal): results could be better. Improvements in the training programme have been developed to achieve better results in the future.
  • Using tympanometry in diagnosis of OME: the nurses are more competent in this area, perhaps because this forms a part of their work already. However, good improvements were still noted in both groups as a result of the training.
  • Correct referral to specialist: there was a remarkable improvement in this area by nursing staff, which originally had littleability in this area.

  Conclusion: Top

  1. Diagnosis of some pathology in the external auditory canal is possible using otoscopy, but the diagnosis of the presence or absence of otitis media with effusion can be difficult using the otoscope alone.
  2. Ability to diagnose the presence of O.M.E, improves with training, especially if the trainee spends sometime in the E.N.T. department.
  3. We recommend that all general practitioners and paediatricians should have training in otoscopy by spending some of their training period in the E.N.T. department. They should also be trained in how to remove wax in order to be able to visualize the drum.
  4. Nurses or health care provider especially those working with paediatrics populations, should be trained and supervised in dealing with simple ear problems and referral of those who need further management. This will reduce the burden on hospital referrals.
  5. It is clear that the training provided resulted in a marked improvement in the average competence level of both doctors and nurses in using the otoscopes, with nurses benefiting most. It is also clear that the improvements will be more marked as experience allows the refinement of the training programme.

  References Top

Annual Report of the Ministry of Health, Saudi Arabia. Ministry of Health, Saudi Arabia. 1994 .  Back to cited text no. 1
Cavanaugh RM. Pneumatic Otoscopy in healthy full-term infants. Pediatl990; 79:4:520-523.  Back to cited text no. 2
Ruah CB, Schachern P, Paparella MM. The development and changes of the normal human tympanic membrane with age. Otorhinolaryngology, Head and Neck Surgery, Proceedings of the XIV World Congress of Otorhinolaryngology, Head and Neck Surgery. Madrid, Spain 1989. (Sacristan T, Alvarez-Vincent JJ, Bartual J, Antoli Candela F, Rubio L ed.) Kugler & Ghedini Publications, Amsterdam p. 111-114.  Back to cited text no. 3
Ruah CB, Schachern, PA, Zelteman D, Paparella MM, Yoon TH. Age-related morphologic changes in the human tympanic membrane. A light and electron microscopic study. Archives of Otolaryngology, Head and Neck Surgery 1991; 117:627-634.  Back to cited text no. 4
De Melker RA. Evaluation of the diagnostic value or pneumatic otoscopy in primary care using the result of tympanometry as a reference standard. British J Gen Practice 1993; 49: 22-4.  Back to cited text no. 5
Fisher, E. Assessment of the otoscopic skills of general practitioners and medical Students: is there room for impro vement? British J Gen Practice, 1992; 42: 65-7  Back to cited text no. 6
Miola ES. The otoscope An Update on Assessment Skills. J Pediat Nur 1992; 9:283-85.  Back to cited text no. 7
Gansel TM, Martinez SA. Are we teaching medical students what they need to know? Otolaryngol Head Neck Surg 1989; 100:339-344.  Back to cited text no. 8
Lund VJ. Otolaryngology in the curriculum - 10 years on. J.R Soc Med 1990; 83:377-379.  Back to cited text no. 9


  [Table 1]


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