Utility of a smartphone-enabled otoscope in the instruction of otoscopy and middle ear anatomy.

PURPOSE: To present the utility of a smartphone-enabled otoscope as a teaching adjunct in pre-clinical otoscopy training. METHODS: 60 pre-clinical medical students were randomized into either a control group using a conventional otoscope or an experimental group using a smartphone-enabled otoscope. Participants in each group were trained to use their assigned device and were given time to practice on a colleague's ear. Participants then completed a questionnaire indicating their ability to visualize anatomical landmarks of the middle ear as well as their confidence in performing a middle ear examination using their device. RESULTS: Compared to participants using the conventional otoscope, significantly more students using the smartphone-enabled otoscope identified the umbo (93% versus 63%, P = 0.005), the short process of the malleus (67% versus 33%, P = 0.008), the cone of light (100% versus 70%, P = 0.001), and the pars flaccida (60% versus 33%, P = 0.03). Furthermore, participants who used the smartphone-enabled otoscope reported significantly increased confidence in performing otoscopy compared to those who used a conventional otoscope (4.1 ± 0.7 versus 2.8 ± 0.9, P < 0.001). Finally, participants rated the smartphone-enabled otoscope as an excellent teaching aid for otoscopy training. CONCLUSION: The smartphone-enabled otoscope serves as a valuable teaching tool for pre-clinical otoscopy education. After using the device, pre-clinical students were more confident in performing a middle ear examination and in identifying important anatomical landmarks of the middle ear.

A survey comparison of educational interventions for teaching pneumatic otoscopy to medical students.

BACKGROUND: Though pneumatic otoscopy improves accurate diagnosis of ear disease, trainees lack proficiency. We evaluated the effect of three different training techniques on medical students' subsequent reported use of basic and pneumatic otoscopy in patient encounters. METHODS: Pediatric clerkship students participated in an ear exam workshop with randomization to one of three educational interventions: task trainer (Life/form®, Fort Atkinson WI), instructional video, or peer practice. Each student received an insufflator bulb and logbook to record otoscopic exams and completed an 18-item anonymous survey at clerkship conclusion. RESULTS: 115 of 150 students (77%) completed the survey. There was no significant difference in number of basic or pneumatic otoscopic exams performed based on method of training. Most students (68-72%) felt more likely to perform pneumatic otoscopy after training. Though the majority of students performed basic otoscopy on patients when an ear exam was indicated, they used pneumatic otoscopy less than 10% of the time. Students reported significant barriers to otoscopy: time, access to equipment, cerumen impaction, patient hold, and anxiety. Student comments described a culture where insufflation was neither practiced nor valued by supervising physicians. CONCLUSION: Training in pneumatic otoscopy can increase student comfort, but barriers exist to using the skill in clinical practice.

Minimally invasive laser vibrometry (MIVIB) with a floating mass transducer - A new method for objective evaluation of the middle ear demonstrated on stapes fixation.

Ossicular fixation through otosclerosis, chronic otitis media and other pathologies, especially tympanosclerosis, are treated by surgery if hearing aids fail as an alternative. However, the best hearing outcome is often based on knowledge of the degree and location of the fixation. Objective methods to quantify the degree and position of the fixation are largely lacking. Laser vibrometry is a known method to detect ossicular fixation but clinical applicability remains limited. A new method, minimally invasive laser vibrometry (MIVIB), is presented to quantify ossicle mobility using laser vibrometry measurement through the ear canal after elevating the tympanic membrane, thus making the method feasible in minimally invasive explorative surgery. A floating mass transducer provides a clinically relevant transducer to drive ossicular vibration. This device was attached to the manubrium and drove vibrations at the same angle as the longitudinal axis of the stapes and was therefore used to assess ossicular chain mobility in a fresh-frozen temporal bone model with and without stapes fixation. The ratio between the umbo and incus long process was shown to be useful in assessing stapes fixation. The incus-to-umbo velocity ratio decreased by 15 dB when comparing the unfixated situation to stapes fixation up to 2.5 kHz. Such quantification of ossicular fixation using the incus-to-umbo velocity ratio would allow quick and objective analysis of ossicular chain fixations which will assist the surgeon in surgical planning and optimize hearing outcomes.

Foam pad of appropriate thickness can improve diagnostic value of foam posturography in detecting postural instability.

OBJECTIVE: The present study investigated the effect of foam thickness on postural stability in patients with unilateral vestibular hypofunction (UVH) during foam posturography. METHODS: Static and foam posturography were performed in 33 patients (UVH group) and 30 healthy subjects (control group) with eyes open (EO) and closed (EC) on firm surface and on 1-5 foam pad(s). Sway velocity (SV) of center of pressure, standing time before falling (STBF) and falls reaction were recorded and analyzed. RESULTS: (1) SVs had an increasing tendency in both groups as the foam pads were added under EO and EC conditions. (2) STBFs, only in UVH group with EC, decreased with foam thickness increasing. (3) Significant differences in SV were found between the control and UVH group with EO (except for standing on firm surface, on 1 and 2 foam pad(s)) and with EC (all surface conditions). (4) Receiver operating characteristic curve analysis showed that the SV could better reflect the difference in postural stability between the two groups while standing on the 4 foam pads with EC. CONCLUSION: Our study showed that diagnostic value of foam posturography in detecting postural instability might be enhanced by using foam pad of right thickness.

The video ocular counter-roll (vOCR): a clinical test to detect loss of otolith-ocular function.

CONCLUSION: vOCR can detect loss of otolith-ocular function without specifying the side of vestibular loss. Since vOCR is measured with a simple head tilt maneuver, it can be potentially used as a bedside clinical test in combination with video head impulse test. OBJECTIVE: Video-oculography (VOG) goggles are being integrated into the bedside assessment of patients with vestibular disorders. Lacking, however, is a method to evaluate otolith function. This study validated a VOG test for loss of otolith function. METHODS: VOG was used to measure ocular counter-roll (vOCR) in 12 healthy controls, 14 patients with unilateral vestibular loss (UVL), and six patients with bilateral vestibular loss (BVL) with a static lateral head tilt of 30°. The results were compared with vestibular evoked myogenic potentials (VEMP), a widely-used laboratory test of otolith function. RESULTS: The average vOCR for healthy controls (4.6°) was significantly different from UVL (2.7°) and BVL (1.6°) patients (p < 0.0001). The vOCR and VEMP measurements were correlated across subjects, especially the click and tap oVEMPs (click oVEMP R = 0.45, tap oVEMP R = 0.51; p < 0.0003). The receiver operator characteristic (ROC) analysis showed that vOCR and VEMPs detected loss of otolith function equally well. The best threshold for vOCR to detect vestibular loss was at 3°. The vOCR values from the side of vestibular loss and the healthy side were not different in UVL patients (2.53° vs 2.8°; p = 0.59).

Differential Intracochlear Sound Pressure Measurements in Human Temporal Bones with an Off-the-Shelf Sensor.

The standard method to determine the output level of acoustic and mechanical stimulation to the inner ear is measurement of vibration response of the stapes in human cadaveric temporal bones (TBs) by laser Doppler vibrometry. However, this method is reliable only if the intact ossicular chain is stimulated. For other stimulation modes an alternative method is needed. The differential intracochlear sound pressure between scala vestibuli (SV) and scala tympani (ST) is assumed to correlate with excitation. Using a custom-made pressure sensor it has been successfully measured and used to determine the output level of acoustic and mechanical stimulation. To make this method generally accessible, an off-the-shelf pressure sensor (Samba Preclin 420 LP, Samba Sensors) was tested here for intracochlear sound pressure measurements. During acoustic stimulation, intracochlear sound pressures were simultaneously measurable in SV and ST between 0.1 and 8 kHz with sufficient signal-to-noise ratios with this sensor. The pressure differences were comparable to results obtained with custom-made sensors. Our results demonstrated that the pressure sensor Samba Preclin 420 LP is usable for measurements of intracochlear sound pressures in SV and ST and for the determination of differential intracochlear sound pressures.

The measurement of Eustachian tube function in a hyperbaric chamber using an ear canal microphone.

OBJECTIVE: The purpose of this study was to further the understanding of the opening of the Eustachian tube in relation to changes in barometric pressure. DESIGN: An ear canal microphone was used to measure the specific sounds related to tube opening and possible eardrum movements. Five subjects with normal tube function were examined in a hyperbaric chamber (up to 304 kPa). All active and passive equalization events were recorded and correlated with the subjectively perceived pressure regulation in the measured ear. RESULTS: The signals recorded were clear and reproducible. The acoustic analysis distinguished between the different kinds of equalization. Subjective impressions were confirmed by the recorded frequency of acoustic phenomena (clicks). During compression, the sequence of active equalization manoeuvres was in a more regular and steady pattern than during decompression, when the click sounds varied. CONCLUSION: The study established a simple technical method for analyzing the function of the Eustachian tube and provided new information about barometric pressure regulation of the middle ear.

A programmable acoustic stimuli and auditory evoked potential measurement system for objective tinnitus diagnosis research.

This paper presents the development of a single platform that records auditory evoked potential synchronized to specific acoustic stimuli of the gap prepulse inhibition method for objective tinnitus diagnosis research. The developed system enables to program various parameters of the generated acoustic stimuli. Moreover, only by simple filter modification, the developed system provides high flexibility to record not only short latency auditory brainstem response but also late latency auditory cortical response. The adaptive weighted averaging algorithm to minimize the time required for the experiment is also introduced. The results show that the proposed algorithm can reduce the number of the averaging repetitions to 70% compared with conventional ensemble averaging method.

Comparison of screening methods for conductive hearing loss identification in children: low-cost proposal.

OBJECTIVE: To evaluate the effectiveness of two screening methods (imitanciometry screening and questionnaire) to identify children at risk for conductive hearing loss, comparing this data with complete audiologic evaluation. METHODS: Of 507 children aged between three and six, 111 completed all procedures. The observational methods used were: imitanciometry screening, a questionnaire to identify risk factors for hearing loss and complete audiologic evaluation. Results obtained in the first two instruments were compared with results from complete audiologic evaluation (gold standard). From these comparisons, sensitivity and specificity, accuracy, positive and negative predictive values, and odds ratio were determined for the two screening methods and for the combination of both methods. RESULTS: The two methods applied in series (questionnaire and after imitanciometry screening) showed a greater odds ratio and better correlation between sensitivity and proportion of false-positives (ROC curve). CONCLUSION: Combining the two tests in series improved screening accuracy. This combination was the best tool for identifying children at risk for conductive hearing loss.

Development and validation of a novel ear simulator to teach pneumatic otoscopy.

INTRODUCTION: Otoscopy is an important skill in diagnosing conditions of the middle ear. This study evaluated the ability of a novel ear simulator to teach medical students diagnostic and pneumatic otoscopy. We hypothesized that exposure to this simulator improves the ability of medical students to apply an appropriate pneumatic pressure during insufflation and accurately identify the presence of a middle ear effusion in a simulated setting. METHODS: An ear simulator was created to teach otoscopic skills to medical students. Third-year medical students attended a workshop on pediatric otoscopy, including a demonstration, videos, and verbal instruction on otoscope use. A cohort of these students then practiced pneumatic otoscopy with the simulator. All students, as well as a group of experts who had not been exposed to the trainer, then diagnosed the presence or absence of middle ear fluid in six simulator ears and pneumatic pressures generated were recorded. RESULTS: Interaction with the simulator enabled students to insufflate with pressures in the proper range (0.4-20 in H2O) more often, apply an average pressure (12.7 in H2O) in the appropriate range, and diagnose middle ear fluid more accurately (79.2%) than students who were not exposed to the trainer (57.3%). The students exposed to the simulator also performed closer to the level of the experts who diagnosed presence of effusion 100% accurately with an average insufflation pressure of 3.8 in H2O. DISCUSSION: Medical students trained with the ear simulator applied appropriate pneumatic pressure more consistently and diagnosed the presence of effusion more accurately and more like experts than students not exposed to the simulator. This ear trainer is a valuable tool for teaching pneumatic otoscopy.

Oto-endoscopy: a reliable and validated technique for phenotyping otitis media in the mouse.

The mouse is a widely used model for investigating the pathophysiological and genetic bases of otitis media (OM). It has proven a valuable tool for investigating the multifactorial bases of OM including the role of pathogens, anatomical factors, inflammatory mediators and susceptibility loci. However, straightforward and robust phenotyping tools for identifying murine otitis media are lacking, which has precluded for example the identification of mice with OM in genetic screens without resorting to time-consuming histopathology. We have set out to develop a phenotyping platform for the detection of OM in mice utilizing oto-endoscopy. We have applied the technique to a cohort of mice genetically susceptible to chronic otitis media. We show that oto-endoscopy is a safe, reliable and valid method for detecting otitis media in the mouse and discuss its utility in screens to identify novel genes involved with susceptibility to OM.

Sonotubometry with perfect sequences: First results in pathological ears.

CONCLUSION: Sonotubometry with perfect sequences (PSEQ) was able to detect eustachian tube (ET) openings in both normal and pathological ears. Impaired ears showed ET openings in almost all cases; however, these proved to be not only less frequent, but also with lower amplitude and shorter duration. OBJECTIVES: To investigate the function of impaired ET under physiological conditions, using a novel kind of sound stimulus for sonotubometry ­ the PSEQ. METHODS: Twenty otologically healthy subjects (40 normal ears) and 32 patients with ear diseases (40 pathological ears) were examined sonotubometrically using noise signals with an ideally flat spectrum (PSEQ). Dry swallowing, water swallowing, and Toynbee maneuver were used to induce ET openings. Analysis was performed regarding the frequency of occurrence, duration, amplitude, and form of the ET openings. RESULTS: PSEQ allowed the detection of an ET opening in all 40 normal ears (91% of the performed maneuvers) and in 87.5% of the ears with impaired ET function (but only 47% of the maneuvers). The average amplitude of the openings in healthy ears was 16.86 dB, the average duration was 363 ms. In diseased ears these values were significantly lower: 9.73 dB, p < 0.001 and 280 ms, p < 0.05.

¿Es el oído medio el primer filtro de selección frecuencial? / Is the middle ear the first filter of frequency selectivity?

Introducción y objetivos: La cóclea es considerada el primer filtro de selección frecuencial en la vía auditiva debido a la acción contráctil de las células ciliadas externas. Sin embargo numerosas evidencias en animales de experimentación, algunas anatómicas (conexiones entre la vía auditiva y los núcleos motores de los músculos del oído medio) y otras fisiológicas, apuntan a que el oído medio pudiera ser el primer filtro gracias al cual comienza a discriminarse un determinado sonido de un entorno ruidoso. Métodos: En colaboración con el Departamento de Ingeniería Mecánica de la Escuela Técnica Superior (ETS) de Ingenieros Industriales de la Universidad de Valladolid (UVa) hemos desarrollado y puesto a punto un nuevo admitancímetro capaz de analizar los cambios de impedancia que ocurren en el oído medio humano en función de la frecuencia. Con él hemos cuantificado la variación de la impedancia del oído en 7 voluntarios otológicamente sanos sometidos a diferentes entornos sonoros. Resultados: Hemos hallado que la impedancia del oído no es constante sino que la atención que los sujetos explorados ofrecen para discriminar una conversación en un ambiente ruidoso hace que la impedancia del oído varíe en las frecuencias agudas. Conclusiones: A la vista de los resultados consideramos que el oído medio no es un mero actor pasivo durante la audición sino que la contracción de los músculos endotimpánicos hacen posible variaciones de la impedancia de forma que la frecuencia de resonancia del oído se desplace hacia frecuencias agudas mejorando la discriminación de la palabra en ambientes ruidosos (AU)

Introduction and objectives: The cochlea has traditionally been considered as the first frequency selection filter in the auditory pathway due to the contraction of its external ciliated cells. Yet, much evidence has emerged from work carried out during experiments with animals, some of which is anatomical (connections between the auditory pathway and motor nuclei of the middle ear muscles) and other physiological, which indicates that the middle ear might be the first filter through which specific sounds from noisy environments may initially be isolated. Methods: In cooperation with the Department of Mechanical Engineering of the Technical School of Industrial Engineering at the University of Valladolid (UVa) we have developed and refined a new admittance meter capable of evaluating changes in impedance that occur in the human middle ear depending on frequency. Using this device we have measured variation in impedance in 7 otologically healthy volunteers submitted to a varied range of sound environments. Results: We have found that hearing impedance is not constant but rather that the attention offered by the examined subjects when following a conversation in a noisy environment leads to variations in hearing impedance at high frequencies. Conclusions: In the light of these findings we feel that the middle ear does not play a merely passive role in hearing but rather that the contraction of the endotympanic muscles makes possible variations in impedance such that the resonance frequency of the ear shifts towards higher frequencies, thus enhancing sound discrimination in noisy environments (AU)

Ménière disease: diagnostic instrumental support.

The current guidelines of the American Academy of Otolaryngology-Head and Neck Surgery entrust the diagnosis of Ménière disease (MD) only to the clinical presentation and the pure tone audiometry. However, most otolaryngologists request a widened instrumental evaluation of the patients suspected of MD. The effective reliability of the further instrumental support for the diagnosis of MD is still debated in the literature because of nonstandardized procedures and sometimes incoherence among authors. New and more sophisticated diagnostic tests have been developed both in audiovestibology and in imaging in the last few years. A review of the recent literature on this controversial subject is provided.

[Idiopathic sudden sensorineural hearing loss is not, at this time, an otologic emergency]. / La surdité brusque idiopathique n'est pas, aujourd'hui, une urgence sensorielle.

OBJECTIVES: To evaluate the influence of the treatment delay for sudden sensorineural hearing loss (SSHL) on the final hearing recovery and the prognostic value of the audiometric shapes and the hearing recovery at the end of treatment. PATIENTS AND METHODS: Prospective study including 321 patients admitted in the emergency care center for a recent idiopathic SSHL. Classification according to the audiometric shape in 5 types. All patients received steroids (1 mg/kg per day) and, in case of ascending shape, steroids and mannitol during 6 days. Hearing recovery was evaluated according to the following parameters: 1) hearing recovery (initial PTA-PTA at D6 or D30); 2) incidence of hearing recovery (initial PTA-PTA at D6 or D30)/initial PTA x 100%). RESULTS: Whatever the audiometric type, delay in initiating treatment did not have any influence on the final outcome. Audiometric classification had a good prognostic value, since the ascending shape had a better hearing recovery than descending shape or the sub or total anacusis. Hearing recovery at D6 is a prognostic factor on the final outcome. CONCLUSIONS: Idiopathic SSHL cannot be considered, nowadays, as an otologic emergency.

Prevalencia de cerumen obstructivo y avaluación de un método de limpieza con cureta luminosa / Prevalence of occluding cerumen and evaluation of a removal method based on a light-incorporated curette in primary care

Objetivo. Valorar la prevalencia de cerumen obstructivo y la utilidad de un método de limpieza con cureta luminosa en una consulta de atención primaria pediátrica. Pacientes y métodos. Estudio prospectivo-descriptivo de un año en pacientes con sintomatología que comporta exploración otoscópica y con presencia de cerumen que impide una correcta visualización. Se practica timpanometría concomitante. Se hace intento de limpieza con cureta con fuente de luz incorporada. Resultados. En 1.165 casos, el cerumen obstructivo que impide el examen otoscópico se ha constatado en el 10.7%. En el 85.6% de los mismos se ha podido hacer un diagnóstico timpanométrico. La limpieza se ha hecho con éxito en un 54%. Los motivos más frecuentes de fracaso han sido el cerumen impactado en el 58.6% y el dolor en el 36.1%. Conclusiones. La presencia de cerumen obstructivo no es tan frecuente como se cree. El timpanómetro permite hacer el diagnóstico en la mayor parte de estos casos. La cureta luminosa es eficaz en más de la mitad de los casos

Objective. To assess the prevalence of occluding cerumen in children and to evaluate the efficacy of a new cleaning method based on a light-incorporated curette in a primary care center. Patients and Methods. One-year prospective-descriptive study including symptomatic patients on whom otoscopy was required but limited by occluding cerumen. Results. Occluding cerumen was found in 10.7% of the 1,165 otoscopy procedures. In 85.6%, a tympanogram was obtained. Successful cerumen removal was possible in 54% of the cases. Impacted dry cerumen and pain were responsible for the removal failures in 58.6% and 36.2% of the cases, respectively. Conclusions. Occluding cerumen is less frequent than previously thought. Tympanometry is still possible and allows diagnosis in the majority of the cases. The light-incorporated curette is useful in over half of the cases

Prevalencia de cerumen obstructivo y avaluación de un método de limpieza con cureta luminosa / Prevalence of occluding cerumen and evaluation of a removal method based on a light-incorporated curette in primary care

Objetivo. Valorar la prevalencia de cerumen obstructivo y la utilidad de un método de limpieza con cureta luminosa en una consulta de atención primaria pediátrica. Pacientes y métodos. Estudio prospectivo-descriptivo de un año en pacientes con sintomatología que comporta exploración otoscópica y con presencia de cerumen que impide una correcta visualización. Se practica timpanometría concomitante. Se hace intento de limpieza con cureta con fuente de luz incorporada. Resultados. En 1.165 casos, el cerumen obstructivo que impide el examen otoscópico se ha constatado en el 10.7%. En el 85.6% de los mismos se ha podido hacer un diagnóstico timpanométrico. La limpieza se ha hecho con éxito en un 54%. Los motivos más frecuentes de fracaso han sido el cerumen impactado en el 58.6% y el dolor en el 36.1%. Conclusiones. La presencia de cerumen obstructivo no es tan frecuente como se cree. El timpanómetro permite hacer el diagnóstico en la mayor parte de estos casos. La cureta luminosa es eficaz en más de la mitad de los casos

Objective. To assess the prevalence of occluding cerumen in children and to evaluate the efficacy of a new cleaning method based on a light-incorporated curette in a primary care center. Patients and Methods. One-year prospective-descriptive study including symptomatic patients on whom otoscopy was required but limited by occluding cerumen. Results. Occluding cerumen was found in 10.7% of the 1,165 otoscopy procedures. In 85.6%, a tympanogram was obtained. Successful cerumen removal was possible in 54% of the cases. Impacted dry cerumen and pain were responsible for the removal failures in 58.6% and 36.2% of the cases, respectively. Conclusions. Occluding cerumen is less frequent than previously thought. Tympanometry is still possible and allows diagnosis in the majority of the cases. The light-incorporated curette is useful in over half of the cases

Development of a practical tool for assessing the severity of acute otitis media.

BACKGROUND: Watchful waiting management of nonsevere acute otitis media (AOM) can reduce the use of antibiotics, but it requires a reliable means of assessing clinical severity. OBJECTIVE: We present the development of a pocket AOM card with which the clinician can rapidly assess total AOM severity. DESIGN/METHODS: The components of the pocket card consisted of a faces scale, to assess parent perception of severity, and a standard set of tympanic membrane photographs, with which the pediatrician can grade the severity of tympanic membrane inflammation. The components of the pocket card were tested for validity, reliability and responsiveness with the use of data from parents, pediatricians and pediatric otolaryngologists. STATISTICS: Instruments were assessed for concurrent correlation, sequence validity and reliability against previously published questionnaires with the use of Spearman correlation. Responsiveness was calculated with the use of enrollment, day 12 and day 30 data from a randomized clinical trial. RESULTS: The components of the pocket AOM card demonstrated excellent sequence validity, concurrent correlation and reliability (r = 0.58-0.99). Total AOM card severity, consisting of the sum of the 2 scales, demonstrated better responsiveness to change than any of the scales taken individually. CONCLUSIONS: The AOM card combines a parent assessment of symptoms and the clinician assessment of the tympanic membrane to provide an assessment of total AOM severity that can be used to facilitate shared decision making between parent and clinician. The combined score of the AOM card was more responsive to change than any of the instruments used alone. The AOM card provides a useful tool for teaching and research.