Otoscopy and Tympanometry Revisited Skill Refresher for SLPs

Transcription

1 Otoscopy and Tympanometry Revisited Skill Refresher for SLPs Susan Lopez, MA, CCC-A Melanie Randle, MS, CCC-A University of Mississippi

2 Learning Objectives You will learn the diagnostic goals of tympanometry and otoscopy You will understand what are appropriate follow up / referral procedures for clients who exhibit abnormal otoscopy / tympanometry You will study multiple case studies that we will present and practice your diagnostic skills according to ASHA SLP scope of practice You will learn about equipment options for limited budgets You will learn the CPT code for tympanograms and some basic guidelines for billing and reimbursement procedures

3 Diagnostic Goals for Otoscopy Normal vs.. Abnormal? What would constitute abnormal otoscopy? What if the TM is red? What if the TM is red and bulging? What if you see wax in the ear canal? What if you see a tube in the ear drum? What if you see white patches on the TM?

4 Normal Tympanic Membranes Malleus Cone of Light Umbo Right Ear Left Ear

5 Normal or Abnormal? Tympanosclerosis

6 Normal or Abnormal? Tympanosclerosis

7 Normal vs.. Abnormal? Malleus

8 Normal vs.. Abnormal? Ear Wax Ear Drum Aren t you glad you are an SLP?

9 Completely Occluding Cerumen (wax) Normal vs.. Abnormal?

10 Normal vs. Abnormal? ant

11 Normal vs. Abnormal Q-tip head

12 Normal vs. Abnormal? Confirmed Glue Ear

13 Acute Otitis Media Normal vs. Abnormal?

14 Normal vs. Abnormal This is what you might see after a child has been crying

15 Acute Otitis Media Normal vs. Abnormal?

16 Normal vs. Abnormal? Malleus Stapes Retraction Pocket

17 Normal vs. Abnormal? Large central perforation

18 Normal vs. Abnormal? Small TM perf

19 Normal vs. Abnormal? PE Tube

20 Normal vs. Abnormal? Exposed Attic Stapes Malleus PE Tube

21 Pass/Refer Criteria: Otoscopy Pass if no positive criteria result for both ears Refer if previously undetected abnormality identified via otoscopy and/or tympanometry Refer if ear canal abnormalities such as obstructions, impacted cerumen, foreign bodies, blood or other drainage, stenosis, atresia, otitis externa, perforation, or other abnormalities of the tympanic membrane are present in one or both ears

22 ASHA Guidelines for Audiological Screenings done by SLPs SLPs are responsible for screening for middle ear disorders as well as hearing loss. American Speech Language Hearing Association. (2001). Scope of Practice in Speech Language Pathology. Rockville, MD: Author. American Speech-Language-Hearing Association Audiologic Assessment Panel (1997). Guidelines for audiologic screening. Rockville, MD: Author.

23 Screening Guidelines for Outer and Middle Ear: Pediatrics Desired Outcome: identify infants and children most likely to have: a) outer and/or middle ear problems which result in hearing loss or significant health problems b) recurrent outer and middle ear disease

24 Which kids should you screen for outer/middle ear problems? Every child ages 7mo to 6 years Once a year

25 If you can t screen EVERY child 7mos - 6 yrs, then screen Kids whose first episode of otitis media was before 6 mos of age Infants who were bottle fed Kids with craniofacial abnormalities or other findings associated with outer/middle ear disorder Kids who are of ethnic populations with documented higher incidence rates of outer/middle ear disease (Native Americans, Eskimos)

26 If you can t screen EVERY child 7mos - 6 yrs, then screen Family history of chronic or recurrent OM Kids in daycare or crowded living environments Kids exposed to excessive cigarette smoke Kids with known developmental delays, learning disorders, behavior disorders, and known SNHL

27 When do you screen for outer/middle ear disorders? For kids 7 mo - 6 yrs: carry out screening in the fall in conjunction with hearing screenings where applicable Conduct a 2 nd screening session for those who were missed in the initial screening Children under care of a physician for known middle-ear disorder do not need to participate in screening program

28 Procedure for Screening for Peds Outer/Middle Ear Disorders Recommended: 1) obtain parental/guardian permission; 2) obtain limited oral case history Required! Follow guidelines for infection control and universal precautions Visually inspect ears to ensure no contraindications exist for performing tympanometry (e.g. drainage, excessive wax, foreign bodies) Use a lighted otoscope Perform tympanometry using low probe tone (220 or 226 Hz)

29 Mechanics of Tympanometry The probe plays a continuous tone, and measures the amount of sound reflected off the TM at different air pressures. You must have a seal in the ear canal for this to work.

30 Tympanometry Why perform tympanometry? 0.9 cm 3 Gives you valuable information about status of outer and middle ear!

31 Tympanometry What kinds of information should tympanometry provide? 0.9 cm 3 1) Volume of ear canal 2) The flexibility of middle-ear system (TM & Ossicles)

32 More About EC Volume Ear Canal Volume 0.9 cm 3 Normative values for children between Ages 1 and 7 years (no PE tubes) are: cm 3 Normative values for children between Ages 1 and 7 years (post PE tubes) are: cm3 Shanks, J.E., Stelmachowicz, P.G., Beauchaine, J.G., & Shulte, L. (1992). Equivalent Ear Canal Volumes in children pre- and post-tympanostomy tube insertion. JSHR, 35,

33 Flexibility of the System What sort of information about flexibility does tympanometry provide? 0.9 cm 3 1) Height of peak static compliance (SC) 2) Width of peak gradient tympanometric width (TW)

34 More on Height (Static Compliance) ASHA suggests the following for normative values for static compliance: 0.9 cm 3 If Static Compliance or the height of the peak is less than 0.2 cm 3 (infants - 1yr) 0.3 cm 3 1:0 5:11 years 0.4 cm 3 for > 6yrs Then REFER for RESCREEN!

35 More on Gradient Tympanometric Width ASHA suggests the following for normative values for gradient: 0.9 cm 3 If gradient or width of the peak is greater than 235 dapa (infants - 1yr) 200 dapa 1:0 and above Then REFER for RESCREEN!

36 Abnormal Tympanometry: Type B (flat) How do you interpret a flat tympanogram (type B)? 0.9 cm 3 If ECV is WNL, and EAC is clear Then, you have something in the middle ear space keeping the system from moving with the pressure change Middle Ear FLUID!

37 Abnormal Tympanometry: Type B (flat) How do you interpret a flat tympanogram (type B)? If ECV is high: Perforation of the TM Patent (open) PE tube

38 Abnormal Tympanometry: Type B (flat) How do you interpret a flat tympanogram (type B) with a low ECV? 0.1 cm 3 If the EAC is clear You probably have the probe against the ear canal wall.

39 Abnormal Tympanometry: Type C (neg) How do you interpret a tympanometric peak that s out of the box to the left? 0.9 cm 3 Notice the peak pressure Normal values should roughly be between -150 and +50 dapa This means the middle ear system is retracted or pulled in towards the head. NOTE: Asha does not recommend using peak pressure for a screening measurement

40 Abnormal Tympanometry: Type As (shallow) How do you interpret a tympanogram (type A) with low compliance (peak)? You have a stiff middle ear system: could be recovering from otitis media glue ear scar tissue on the TM

41 Abnormal Tympanometry: Type Ad (deep) How do you interpret a tympanogram (type A) with high compliance (peak)? You have a floppy TM / middle ear system: could be a loose section of the TM (retraction pocket) Minimal scar tissue

42 Refer Criteria: Tympanometry Refer immediately if ECV > 1.0 cm 3 and accompanied by a flat tympanogram (no peak) to select those at risk for perforation of TM. Do not refer if PE tube is in place or if perforation is under management of a physician Immediate medical referral of any child with demonstrated otalgia (pain) and / or otorrhea (gook!)

43 Rescreen Criteria Rescreen within 6-8 weeks any child with a tympanogram with static compliance below the cut-off, and a normal ECV 0.2 cm 3 (infants - 1yr) 0.3 cm 3 1:0 5:11 years 0.4 cm 3 for > 6yrs Medical evaluation for children who continue to exhibit abnormal results after 2 nd screen Communicate promptly with parent/guardian and make referral to family physician Request information regarding outcome of follow-up evaluation with physician/audiologist

44 These procedures are NOT recommended for screening for outer/middle ear disorders Pure tone screening Otoscopy alone without tympanometry Acoustic reflexes Tympanometric peak pressure Otoacoustic emissions

45 CASE STUDIES

46 To Refer, Rescreen, or Pass? 0.9 cm 3 This would be a pass.

47 To Refer, Rescreen, or Pass? 0.9 cm cm 3 This would be a rescreen because of the flat tympanogram and the normal ECV.

48 To Refer, Rescreen, or Pass? 0.9 cm cm 3 In this case, you should repeat the tympanogram due to the low ECV (consistent with probe against canal wall).

49 To Refer, Rescreen, or Pass? 0.9 cm 3 This would be a pass.

50 To Refer, Rescreen, or Pass? 0.9 cm 3 In this case, you should refer based on the otoscopy. The tymp alone would indicate a rescreen.

51 To Refer, Rescreen, or Pass? 0.9 cm 3 In this case, you should refer based on the otoscopy and the tymp. Both show a TM perforation.

52 To Refer, Rescreen, or Pass? 0.9 cm cm 3 This is a pass. The PE tube is open, and this person is obviously under the care of a physician.

53 To Refer, Rescreen, or Pass? 0.9 cm cm 3 In this case, you should refer because the ECV indicates a normal volume which means the PE tube is not open

54 To Refer, Rescreen, or Pass? 0.9 cm 3 This would be a pass.

55 To Refer, Rescreen, or Pass? 0.9 cm 3 This would be a pass.

56 To Refer, Rescreen, or Pass? 0.9 cm0.9 3 cm 3 This would be a pass.

57 Less Expensive Equipment Options: Otoscopes Piccolite Halogen Otoscope ~ $80 3X magnification Mini Otolite ~ $13 No magnification

58 Equipment Options: Tympanometry Screeners Madsen Tymp-Screen Welch-Allyn Microtymp 2

59 Reimbursement An SLP cannot bill for tympanometry and get reimbursed for it like an audiologist can. The CPT code, 92567, is only available for audiologists (lobby ASHA!) However, if you are doing pure tone screenings, you can include otoscopy and tympanometry screenings in the fee (charge more!) and use code Be aware that if you bill for screenings for children with Medicaid, you must bill ALL children receiving screenings.

60 Any Questions? Susan Lopez, MA, CCC-A University of Mississippi Melanie Randle, MS, CCC-A University of Mississippi