Otoscopy and Tympanometry

Revisited
Skill Refresher for SLPs
Susan Lopez, MA, CCC-A
Melanie Randle, MS, CCC-A

University of Mississippi
 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
 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?
Normal Tympanic Membranes
Malleus Cone of Light

Umbo

Right Ear Left Ear

Normal or Abnormal?

Tympanosclerosis
Normal or Abnormal?

Tympanosclerosis
Normal vs.. Abnormal?

Malleus
 Normal vs.. Abnormal?

Ear Wax

Ear
Drum

Aren’t you glad you are an SLP?

 Normal vs.. Abnormal ?

Completely
Occluding
Cerumen
(wax)
Normal vs. Abnormal?

ant
Normal vs. Abnormal

Q-tip head
Normal vs. Abnormal?

Confirmed “Glue Ear”

 Normal vs. Abnormal?

Acute
Otitis
Media
 Normal vs. Abnormal

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

Acute
Otitis
Media
 Normal vs. Abnormal?

Malleus
Stapes

Retraction Pocket
Normal vs. Abnormal?

Large central perforation

Normal vs. Abnormal?

Small TM perf
Normal vs. Abnormal?

PE Tube
 Normal vs. Abnormal?
Exposed
Attic

Stapes

Malleus

PE Tube
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
 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 1996. (1997). Guidelines
for audiologic screening. Rockville, MD: Author.
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

Which kids should you screen for
outer/middle ear problems?

Every child ages 7mo to 6 years

Once a year
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)
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
 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 2nd 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
 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)
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.
Tympanometry
Why perform 0.9 cm3
tympanometry?

Gives you valuable

information about
status of outer and
middle ear!
 Tympanometry
What kinds of
0.9 cm3
information should
tympanometry
provide?

1) Volume of ear canal

2) The flexibility of
middle-ear system
(TM & Ossicles)
 More About EC
Volume
Ear
Canal 0.9 cm3
Volume

Normative values for children between

Ages 1 and 7 years (no PE tubes) are:

0.3 - 0.9 cm3

Normative values for children between

Ages 1 and 7 years (post PE tubes) are:

1.0 – 5.5 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, 936-941.
 Flexibility of the
System
What sort of information about 0.9 cm3
flexibility does
tympanometry provide?

1) Height of “peak”
static compliance (SC)

2) Width of “peak”
gradient
tympanometric width (TW)
 More on Height
(Static Compliance)
0.9 cm3
ASHA suggests the following for
normative values for static
compliance:

If Static Compliance or the height

of the peak is less than
0.2 cm3 (infants - 1yr)
0.3 cm3 1:0 – 5:11 years
0.4 cm3 for > 6yrs

Then REFER for RESCREEN!

More on Gradient
Tympanometric
Width
0.9 cm3
ASHA suggests the following for
normative values for gradient:

If gradient or width of the peak is

greater than
235 daPa (infants - 1yr)
200 daPa 1:0 and above

Then REFER for RESCREEN!

 Abnormal
Tympanometry:
Type B (flat)
How do you interpret a flat 0.9 cm3
tympanogram (type B)?

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!

 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
 Abnormal
Tympanometry:
Type B (flat)
How do you interpret a flat 0.1 cm3

tympanogram (type B) with

a low ECV?

If the EAC is clear…

You probably have the probe

against the ear canal wall.
 Abnormal Tympanometry:
Type C (neg)
How do you interpret a
tympanometric “peak” that’s “out
0.9 cm3
of the box” to the left?

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
 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
 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
 Refer Criteria: Tympanometry
• Refer immediately if ECV > 1.0 cm3 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!)
 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 cm3 (infants - 1yr)
– 0.3 cm3 1:0 – 5:11 years
– 0.4 cm3 for > 6yrs

• Medical evaluation for children who continue to exhibit

abnormal results after 2nd screen

• Communicate promptly with parent/guardian and make

referral to family physician

• Request information regarding outcome of follow-up

evaluation with physician/audiologist
 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
CASE STUDIES
To Refer, Rescreen,
or Pass?

0.9 cm3

This would be a pass.

 To Refer, Rescreen,
or Pass?

0.9 cm3
0.9 cm3

This would be a rescreen because

of the flat tympanogram and the
normal ECV.
 To Refer, Rescreen,
or Pass?

0.9 cm3
0.1 cm3

In this case, you should repeat the

tympanogram due to the low ECV
(consistent with probe against canal
wall).
To Refer, Rescreen,
or Pass?

0.9 cm3

This would be a pass.

 To Refer, Rescreen,
or Pass?

0.9 cm3

In this case, you should refer based

on the otoscopy. The tymp alone
would indicate a rescreen.
 To Refer, Rescreen,
or Pass?

0.9 cm3

In this case, you should refer based

on the otoscopy and the tymp.
Both show a TM perforation.
 To Refer, Rescreen,
or Pass?

0.9 cm3
4.8 cm3

This is a pass. The PE tube is open,

and this person is obviously under
the care of a physician.
 To Refer, Rescreen,
or Pass?

0.9 cm30.9 cm3

In this case, you should refer because

the ECV indicates a normal volume
which means the PE tube is not open
To Refer, Rescreen,
or Pass?

0.9 cm3

This would be a pass.

To Refer, Rescreen,
or Pass?

0.9 cm3

This would be a pass.

To Refer, Rescreen,
or Pass?

0.9 cm0.9
3
cm3

This would be a pass.

 Less Expensive Equipment
Options: Otoscopes

“Piccolite Halogen “Mini Otolite” ~ $13

Otoscope” ~ $80 No magnification
3X magnification
 Equipment Options:
Tympanometry Screeners

Madsen Tymp-Screen Welch-Allyn Microtymp 2

 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 92551.

• Be aware that if you bill for screenings for

children with Medicaid, you must bill ALL
children receiving screenings.
 Any Questions?
• Susan Lopez, MA, CCC-A
smlopez@olemiss.edu
University of Mississippi
662-915-5682

• Melanie Randle, MS, CCC-A

mrandle@olemiss.edu
University of Mississippi
662-915-7924