When you read about diseases and conditions of tympanic membranes and external auditory canals (eardrums and ear canals), the books show you nice little pictures of otitis externa, fungal infections, foreign objects in the ear canal, clean tympanic membranes and ones with perforations, cholesteatomas, infections and fluid levels, etc. The pictures show beautiful ear drums with the little bones clearly visible, and the cone of light (known as the umbo, love that word) which all indicate a nice healthy ear, or ones with a nice clear line of fluid visible and a bulging membrane.
It looks so simple…”Of course I can see the difference between and healthy and a diseased ear, it is so obvious!”.
Ha! Not so fast. Obviously the ears in the pictures are attached to unconscious people who have just had their ears thoroughly cleaned for ease of viewing. The picture is nicely magnified and crystal clear.
I practice, it is a little different. The patient looks at you with a dubious frown as you approach them with the otoscope. You reassure them it is nothing but a light and proceed…you pull on the pinna, brace your hand against their head to hold them still, insert the little funnel hoping it is far enough but not too far, and… all heck breaks loose. The child cries, squirms, bats at your hands and generally lets you know this is NOT what they had in mind. The mom holds the hands and you peer at the little lens and see…not much. The ear canal isn’t straight enough. You pull out and repull the pinna. Okay now you see…ear wax. Is that a little tiny bit of tympanic membrane behind the wax? Oooh, I think I see the cone of light, but is the tympanic membrane a little grey? Child squirms some more, picture lost. Crap. Okay, the other side, this one doesn’t have as much wax, you can see a little better, now you see the tympanic membrane is a little red, but is it because of the crying? Or is it really inflamed?
I watch the NP who is my preceptor do an exam. She smoothly puts the otoscope in, 1 second and she’s done. “Yep”, she says, “I see that the TM is opaque and there is a fluid level.”
Sigh… It is going to take a lot of practice to get this particular skill right.