haap workshop #4 › documents › haapworkshop4.pdf2/23/2018 2 lesson 13 –otoscopy & bracing...

2/23/2018

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HAAP Workshop #4LESSONS 13 - 16

Learning Objectives Identify the parts of an otoscope

Demonstrate visual inspections of the ear canal using appropriate techniques

Perform correct bracing for otoscopy, probe tube insertion, otoblock placement, and impression making.

Identify the parts of an audiometer, and demonstrate and discuss the use of each component

Draw an audiogram and explain how it is used to record hearing levels

Categorize hearing levels by degree of hearing loss

Explain how audiometric data are used by the physician and by the hearing aid specialist

Relate threshold on the “Average Auditory Area of a Normal Ear” from Lesson 4 Psychoacoustics to audiometric zero

Compare and contrast the different audiometric transducers

Describe the daily biological check and compare this with electroacoustic calibration

Instruct the patient/client on the listening task and response mode

Demonstrate proper placement of air conduction transducers

Demonstrate proper placement of the bone oscillator

Accurately determine thresholds

Document accurately the pure tone air conduction and bone conduction thresholds for each ear

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Lesson 13 – Otoscopy & Bracing

Otoscopy

visual examination of the auditory canal and the eardrum with an otoscope.

The act of using an otoscope to perform a visual examination of the pinna, mastoid process, ear canal, and tympanic membrane.

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The Otoscope

“A device that is specifically designed to provide illuminated magnification of the ear canal and tympanic membrane, and as such, allows you to see what you need to see in order to do your job” (Bankaitis, 2011).

Types of Otoscopes:

Pocket

Full-Size

Video

Pocket Otoscopes

Designed to be carried in the pocket of a lab coat.

Smaller and Lighter than full sized otoscopes.

Most use disposable batteries that are in the handle of the otoscope.

Limitation - does not offer interchangeable parts, unable to upgrade technology

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Full-Size Otoscopes

Interchangeable heads and handles

Welch Allyn’s “interlocking tool” technology

Allows for the use of new technology as it is developed

Rechargeable batteries

Video Otoscopes

Interfaces with a monitor or screen

Image is transmitted directly from the otoscope to the video output

Advantage – projection of the TM in a larger manner, offering a more detailed view of the structures

Ability to capture and print images

Direction matters

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Parts of the Otoscope

Handles/Batteries

Head

Light Source

On/Off Switch

Otoscope Handles & Batteries

Power Source for Otoscope

Holds batteries

Wall Plug for rechargeable options

Batteries:

NiCd (Nickel Cadmium)

Memory Effect

Heavy

Nickel Metal

Approx. 30% more capacity than NiCad

Lithium Ion

Highest capacity

Retain charge approx. 2 times

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Otoscope Heads Standard or Diagnostic

Wide angle-viewing lens

Usually 2.2 times magnification

MacroView

Twice the field of view

Approx. 30% more magnification than Standard heads

Focus

Speculum ejection

Pneumatic

Designed to allow observation of TM movement

Allows for a insufflator bulb to introduce puffs of air into the ear

Operating

Open-System design

Removal of speculum allows for insertion of instruments into the ear canal

Video

No eyepiece

Cable to connect to monitor

Otoscope Light Sources Light source is in the form of a bulb

Incandescent

Old school light bulb

Short life span

Fade in strength over time

Halogen

Bulb is filled with a halogen gas

Run hotter than incandescent

Xenon

Generate electrical discharge between two electrodes

LED

White in color

Not pure white, more of a whitish-blue color

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Otoscope Light Technology

Fiber Optic

Light is directed into the ear canal from the otoscope head via fiber optic cables.

Allows light to reach destination in a highly concentrated manner.

Enhanced quality of light and improved visibility and clarity.

Non-Fiber Optic

Illumination of ear canal by directing the light emitted by the bulb directly from the otoscope head into the ear canal.

Bulb will be visible through the eye piece.

Otoscope On/Off Switch

Generally on the handle.

Slider

Push and Rotate

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Why do we perform otoscopy?

Otoscopy will reveal if there are any conditions that require medical referral; If found STOP the process and make the referral

To inspect the ear canal for any obvious inflammation, growths, foreign objects, or excessive cerumen.

Inspect the back of the pinna as well for any evidence of surgery that may not be reported on the case history - look for any sores or lesions on the pinna itself, since it must be held while examining the ear canal

Verify that the ear canal is clear and the TM is healthy

Note any unusual landmarks, visible cartilage movement, etc.

When do we perform otoscopy? Before hearing test

When preparing to make an ear impression

Immediately after removing an ear impression and re-inspect the ear

Use to verify real ear probe tube placement (end should be 3-5mm from TM)

Before fitting hearing instruments

At follow-up visits

Annual retest

Use to see SNs, debris in receiver and/or mics

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Infection Control for OtoscopyWhat equipment and parts of myself will touch my client?

Otoscope

Specula

Hands

For all equipment that will be coming into contact with the client: use a germicidal wipe (such as the Sani-Cloth) to wipe down your otoscope and specula.

Remember to allow the equipment to Air Dry!

Be mindful of the possibility of cross contamination. Always use a new speculum for each ear.

Infection Control for Otoscopy

Hand Washing:

Apply liquid hand soap

Rub hands together thoroughly for at least 20 seconds

including the areas

Between fingers

Backs of hands

Fingernails

Rinse with water

Dry hands with disposable paper towel.

Hand sanitizer is accepted as “hand washing”

Apply appropriate amount of degermer (Approx. a quarter size amount)

Rub hands together as when washing hands

Rub until hands are dry

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Infection Control for Otoscopy

Hand Washing

Hand Washing

Don Gloves Clean Otoscope Remove Gloves

Don Gloves Perform Otoscopy

Otoscopy – Safe Support Techniques

Safe Support or Bridge and Brace techniques are an important part of member safety.

Costco Hearing Aid Centers has a culture of Best Practices

IHS Clinical Practice Guideline: Bridge-and-Brace Technique for Patient Safety

https://www.ihsinfo.org/IhsV2/professional-development/pdf/2017/IHS%20Clinical%20Practice%20Guideline%20on%20Bridge-and-Brace%20Technique.pdf

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Otoscopy – Safe Support Techniques

Performing Otoscopy

Step 1: Non-tool hand is used to pull up and back on the pinna to straighten the canal and improve view of the canal and TM

Step 2: Tool hand braces head or completes a bridge to non-tool hand

Step 3: Speculum attached to otoscope approaches and then enters ear canal

Step 4: Verify that the ear canal (Scratches, blood, redness, and excessive wetness are all signs of an abnormality) and the TM is healthy (pearly gray & cone of light)

Step 5: Remove first speculum and place clean speculum on otoscope

Step 6: Repeat steps above for 2nd ear.

(Picture made without gloves to better show bracing.)

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Anatomy & Characteristics of the Ear

Before looking into the ear, it is important to carefully

look at the outer ear (Pinna) and the mastoid process

behind the ear.

Signs of previous surgery or other malformation should

be noted.


Once you have evaluated the pinna and mastoid process you

will place your otoscope into the client’s ear and evaluate

the ear canal.

The ear canal should be smooth and pinkish in

appearance.

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Otoscopy – Abnormal Ear Canals

Fungal Infection Exostosis Foreign Object

Cerumen Cerumen


Once you have evaluated the ear canal it is time to evaluate the TM.

The TM should be light gray and shiny. The cone of light should be clearly visible

on the bottom half.

Note the other landmarks present such as the malleus and annular (tympanic) ring.

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Otoscopy – Abnormal TM’s

Perforation PE Tube

Otitis Media Cholesteatoma

Following Otoscopy

Step 1: Remove 2nd speculum from otoscope and dispose

Step 2: Remove and dispose of gloves

Step 3: Clean hands with soap and water or hand sanitizer

Step 4: Share otoscopy findings with the member: professional and do not diagnose

“Your ear canal is clear and I can see all of your ear drum.”

“There appears to be a build-up of wax in your ear canals and I will not be able conduct your hearing test until it is removed.”

Step 5: Make medical referral based on otoscopy as needed

Abnormality? Foreign Body? Obstruction?

Refer???

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Lesson 14Introduction to Audiometric Evaluation

Audiometric Evaluation

A painless, noninvasive test to measure a person’s ability to hear different sounds, pitches, or frequencies.

Pure Tone Audiometry measures the softest sounds that a person can hear.

Word recognition or Speech discrimination assesses a person's ability to understand speech.

(Lockhart, 2016)

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Two ways sound travels to the cochlea:

Air Conduction

Acoustic energy from the atmosphere through the ear canal, middle ear, and to the inner ear

Bone Conduction

Bypasses the middle ear and stimulates the inner ear through vibrations

The Measurement of Hearing

The purpose of an audiometric evaluation is to measure an individual’s hearing levels at discrete frequencies and also with speech as a stimulus.

The procedure measures the sensitivity of a person’s hearing.

Results are compared that of the average normal hearing individual.

Information is displayed on an Audiogram

Application of Data:

Referrals

Hearing Management Program

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The Audiogram

Pure Tone Air and Bone Conduction thresholds are recorded on a graph called an audiogram.

The Y-axis represents intensity in decibels hearing level (dB HL).

The X-axis represents the frequency in Hertz (Hz).

Low to High 125 Hz to 8K Hz

The Audiogram

Octave

A mathematical doubling of frequency.

250 Hz to 500 Hz is an octave.

Inter-octave (Half-octaves)

500 Hz to 750 Hz

Note that an inter-octave to an inter-octave makes an octave.

1K dividing line

High & Low Freq.

Normal Hearing

20 dB HL and below

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Audiometric Zero

Audiometric Zero = 0 dB HL

Softest intensity the average individual can detect

The softest intensity in dB SPL is different at each freq.

Normalization

The process of converting the dB SPL in a normal-hearing population to 0 dB HL.

Straight lines rather than curves.

Audiometric Symbols

Indicate Test Ear (TE) transducer used and if masking was employed.

The appropriate symbol is placed on the audiogram at the intersection of the frequency tested and the intensity in dB HL.

Thresholds are the measured intensity at which the member responds to 50% of the stimulus presentations.

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Degrees of Hearing Loss

Terms to be clearly defined for proper understanding and communication of audiometric results:

Normal Hearing (0 to 20 dB HL) – Intensity range defined as normal audibility

Mild Hearing Loss (20 – 40 dB HL)

Moderate Hearing Loss (40 – 70 dB HL)

Severe Hearing Loss (70 – 90 dB HL)

Profound Hearing Loss (90 dB HL and greater)

Elevated Hearing Thresholds – thresholds that are worse than the normal range or that are worse than previously tested.

The Test Environment

Best performed in a sound controlled environment.

In every environment, take precautions to ensure that the test area is as quiet as possible.

Turn off and/or remove any competing sound sources to optimize the validity of your test results.

Ambient noise can be measured with a sound level meter.

Typical ambient noise level allowed for hearing testing is 55 dB SPL or less.

Most critical for BC testing

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Audiometer

An audiometer is the tool used to measure hearing.

Computer-based or free standing

Audiometer

It is your responsibility to be completely familiar with the options and functions of every control/switch on your audiometer.

Consult the manufacturer’s user manual.

Job Aids on the Intranet

Aurical – The Cube.

Common Features/Functions:

Transducers:

Insert Earphones

Supra-aural Earphones (and/or Circumaural earphones)

Bone Conduction Oscillator

Sound field Speakers

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Audiometer Common Features/Functions:

Transducer Selectors:

Selects the appropriate transducer

Right/Left/Both Ears

Freq. Selector

Interrupter Switch:

Stimulus Type Selector:

Pure Tones

Warble Tones

Pulsed or Continuous tones

Masking Noise

Narrow Band Noise

Speech Nosie

Microphone

Speech Inputs:

CD

WAV Files

Audiometer

Common Features/Functions:

Intensity Control (Attenuator)

A VU Meter:

To calibrate recorded speech

Monitored Live Voice Testing

Talk-Over system

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Electroacoustic Calibration

Audiometric equipment must be calibrated at least once a year.

Calibration measures the performance of the audiometer and compares that to a prevailing, recognized electroacoustic standard.

Ensures accuracy of test signals in terms of freq. and intensity.

Each transducer must be calibrated to the audiometer it is used on.

Test environments should be calibrated as well to ensure that they meet ambient noise standards.

Daily Biological Check

Despite the fact that your audiometer is calibrated annually, it is important to verify on a daily basis the function of the various components of the audiometer.

This should be documented

Turn on audiometer and wait one minute.

Listen to the signal at different settings through each transducer.

Check the power, attenuator, earphone, and bone vibrator cords for signs of wear or cracking.

Listen to a signal through the transducer and move the cord around – defective cords will produce static or the tone will be intermittent.

Check the audiometer controls to be certain they are functioning properly.

Listen for audible mechanical clicks through the earphone when the controls are manipulated.

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Listen to the output at both a moderate (60 dB HL) level and one below the threshold of hearing.

If clicks are present – member may respond to those rather than the tone.

Listen for static at high intensity levels, both when a stimulus signal is present and when it is absent.

Static or buzzing at levels below 60 dB HL should not be audible.

Listen to the signal while moving from maximum to minimal levels to ensure the smooth transition from one intensity level to the next.

Move through the frequencies and listen for distinct changes from one to another.

Be aware of your own thresholds to ensure the output is accurate.

If threshold appears to be erroneous, the output levels should be checked electronically.


If the member reports other irregularities, or if audiometric data irregularities are observed, stop the test and immediately perform a biological check of the equipment.

Replace defective equipment when needed.

IS Service Desk – 425-313-8001

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Play 1K Hz Calibration tone of speech stimulus

Verify that the intensity is to 0 dB or green on VU meter

If not at 0 dB adjust sensitivity of stimulus so that the calibration tone is at 0 dB.

Tympanometry (more in Lesson 23)

Measures middle ear function

Measured with a tympanometer

Results are displayed on a graph

Normal Middle Ear Function = sensory/neural hearing loss

Abnormal Middle Ear Function = related to the presence of an air-bone gap

Acoustic Reflex

Measures the activity of the stapedius muscle in response to sound

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Lesson 15Pure Tone Air Conduction Audiometry


Is dependent on accurate threshold

determination

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Audiometric Symbols

Uniform World Wide

Color Code:

Red = Right

Blue = Left

Symbol placed at the intersection of freq. and intensity that represents the threshold

If there is No Response at the intensity limit of the audiometer – use the appropriate symbol with a downward-pointing arrow to indicate that the tone was not heard

For PT UCL’s this will indicate that the member did not respond that the tone was uncomfortable

Connect the symbols with a straight line for each ear

AC Threshold Determination

Threshold determination is a precise procedure that has validity, reliability, and is standardized among all hearing healthcare professionals.

The procedure is valid in that hearing sensitivity is measured.

The extremely high test/retest reliability results from employing a consistent procedure that is globally endorsed and through the use of equipment that meets calibration standards.

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Purposes & Procedures for PT AC Testing

What is the purpose of performing Pure Tone Air Conduction?

To determine the softest sound a member can hear 50% of the time.

What is the procedure for performing Pure Tone Air Conduction testing?

Hughson-Westlake Ascending/Descending Technique

5 dB increases in presentation level / 10 dB decreases in presentation level .

Ascend = increases (louder sound) Descend = decreases (softer sound)

Why insert earphones are recommended?

Improved interaural attenuation relative to supra- and circumaural earphones

Better isolation from ambient noise

Improved infection control (disposable, one time use tips)

Better comfort than supra- and circumaural earphones

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Member Instructions

Instructions Matter!!!!!

Member Instructions

“You and I are going to measure the softest sounds that you can hear. Every time you hear beeping tones, push the response button. Respond no matter how soft or far away the tones become. There will be a pause or break, then the beeping tones will start new again. Push the button each time you hear the beeping tones start new again. We’ll start with your right (or left) ear. Do you have any questions?”

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AC Threshold Determination1. Follow appropriate equipment sanitizing and infection control guidelines.

2. Instruct the member

3. Place the AC transducer in the ear canal (over the pinna if headphones) and check for proper placement

4. Present 1000 Hz tone at 40 dB. If no response, increase in 20 dB steps until there is a response. Each tone should be presented about 2 seconds. Vary your timing.

5. Once there is a response, descend in 10 dB steps until there is no longer a response.

6. Increase intensity level in 5 dB steps until there is a response (ascending technique)

7. Continue ascending/descending technique until the member responds to 2 out of 4 opportunities to respond at the lowest presentation level on the ascending runs.

8. Record the threshold on the audiogram using the appropriate symbol

9. Test all frequencies using this technique

10. Repeat procedure for the other ear.

*It is important to vary the time between presentations*

Obtaining Threshold - Example #1

Start the presentation level at 40 dB.

If client does not respond, increase to 60 dB and present again.

When client responds, decrease the presentation level by 10 dB

Continue this until the client does not respond.

At the point that the client does not respond, increase the presentation level in 5 dB steps until they respond again.

Once they respond again repeat the ascend 5 dB/ descend 10 dB “bracketing” until they get 2 out of 4 responses at the same lowest intensity level.

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Obtaining Threshold - Example #2

Start the presentation level at 40 dB.

If client does not respond, increase to 60 dB and present again.

When client responds, decrease the presentation level by 10 dB

Continue this until the client does not respond.

At the point that the client does not respond, increase the presentation level in 5 dB steps until they respond again.

Once they respond again repeat the ascend 5 dB/ descend 10 dB “bracketing” until they get 2 out of 4 responses at the lowest intensity level on the ascending runs

What if they never respond?

Is the equipment working??? Do they understand the task?

If there is no response (NR) at the intensity limit of the equipment for that frequency use the appropriate symbol with a downward-pointing arrow to indicate that you tested this intensity but the tone was not heard.

Lines are used to connect thresholds (that are heard). Do not connect symbols that indicate no response (NR).

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Test Frequencies

Always start with 1000 Hz first, then remaining test frequencies.

1000, 1500, 2000, 3000, 4000, 6000, 8000, 1000, 500, 250 Hz

Best Practice & Costco: 250, 500, (750), 1000, 1500, 2000, 3000, 4000, 6000, 8000 Hz

Inter-octaves must be tested when there is a difference of 20 dB or greater between adjacent octaves.

Retesting 1K Hz is essential to establishing response consistency and threshold reliability. The threshold must be +/-5 dB of the initial threshold at 1K Hz.

If not, stop testing, re-instruct the member, and restart the test (retest everything that’s been tested).

May need to also verify transducer placement.

Lesson 16Pure Tone Bone Conduction Audiometry

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AC Testing vs. BC testing

The difference is the mode of transmission of the stimuli to the inner ear and the transducer used.

Threshold determination is the SAME!

BC Testing

Bypasses the outer and middle ears and tests the cochlea directly by vibrating the skull.

There is no detectable difference in the sound quality or clarity for stimuli delivered by AC or by BC.

Presentation Order:

Same as for AC

1K, 2K, 3K, 4K, 500 Hz

Audiometer limits for BC testing will be lower than for AC

Output level produced by the bone oscillator may result in a tactile sensation (vibrotactile response) at high intensity levels.

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Placement of BC Oscillator

The BC Oscillator is slightly concave or has a raised circle on the side lying against the skull.

The headband applies pressure to the oscillator holding it firmly against the most prominent point on the mastoid, the raised bone behind the ear.

A loose headband results in inaccurate thresholds.

The member must not hold the oscillator in place

Must NOT touch the pinna

Vibrations will be set up in the ear canal that will result in invalid threshold measurements.

Member must remove glasses prior to oscillator placement.

Placement of BC Oscillator

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Member Instructions

Instructions Matter!!!!!

Member Instructions

“You and I are going to repeat the hearing measurement using a different device, but you’ll still be hearing beeping tones. As before, push the button every time you hear the beeping tones. No matter how soft or far away the beeping tones sound. We’ll start with your right (or left) ear. Do you have any questions?”

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BC Threshold Determination1. Follow appropriate equipment sanitizing and infection control guidelines

2. Instruct the member

3. Place the BC oscillator on the most prominent area of the mastoid bone behind the pinna and check for proper placement

4. Present a 1000 Hz tone at a level 20 dB (10 dB ok too) louder than the AC threshold of the better hearing ear (explained further in Lesson 18). If NR increase in 20 dB increments until there is a response.

5. Once there is a response, descend in 10 dB steps until there is no longer a response.

6. Increase intensity level in 5 dB steps until there is a response (ascending technique)

7. Continue ascending/descending technique until the member responds to 2 out of 4 opportunities to respond at the lowest presentation level on the ascending runs.

8. Record the threshold on the audiogram using the appropriate symbol with the open side close to but not in contact with the vertical frequency line

9. Test all frequencies using this technique

10. Repeat procedure for the other ear.

More about BC thresholds Physiologically BC thresholds cannot be worse than AC thresholds...but it

happens.

Check placement of BC oscillator

Additional ambient noise in room

Might be due to thickness of skull, damage to part of skull that restricts proper vibration, or excess fat covering the bones of the skull

What to do? ALWAYS record the measured threshold - don’t assume they are identical to AC thresholds.

Masking is needed if the BC is better than the AC threshold by 15 dB or more (Lesson 18)

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Bone Conduction:Do I Need to Test the Second Ear?

When is testing of the second ear needed?

When there is a difference of 15 dB or more between the measured BC thresholds of the TE and the measured AC thresholds of the Non-TE.

Only the freq. with the gap must be tested.

All second ear BC scores must be masked (Lesson 18).


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Resources ADC Diagnostix 5111N 2.5v Pocket Otoscope. (n.d.). Retrieved October 24, 2017, from

https://www.floridamedicalequipment.com/products/adc-diagnostix-5111n-2-5v-pocket-otoscope

Anatomy Atlases: Anatomy of First Aid: A Case Study Approach: The External Ear. (n.d.). Retrieved October 30, 2017, from http://www.anatomyatlases.org/firstaid/Otoscopy.shtml

Bankaitis, A. U. (2011, May 9). Otoscopes A. U. Bankaitis. Retrieved October 24, 2017, from https://www.audiologyonline.com/articles/otoscopes-833https://www.merriam-webster.com/medical/otoscopy

Cholesteatoma and mastoid surgery JW Fairley Consultant ENT Surgeon Kent UK. (n.d.). Retrieved October 30, 2017, from http://entkent.com/cholesteatoma-and-mastoid-surgery/

Clinical Practice Guideline Bridge-and-Brace Technique for Patient Safety. (2015). Retrieved October 30, 2017, from https://www.ihsinfo.org/IhsV2/professional-development/pdf/2017/IHS%20Clinical%20Practice%20Guideline%20on%20Bridge-and-Brace%20Technique.pdf

Degrees of Hearing Loss. (n.d.). Retrieved October 30, 2017, from http://hearinghealthcare.ie/degrees-hearing-loss/

Lockhart, MA, CCC-A, S. (Ed.). (2016, February). Hearing (audiometry) test. Retrieved October 30, 2017, from http://www.mayfieldclinic.com/PE-hearing.htm

Oaktree Products. (n.d.). Retrieved October 24, 2017, from https://www.oaktreeproducts.com/welch-allyn-3-5v-halogen-diagnostic-otoscope-complete-set-25020c

Otoscopy Medical Definition. (n.d.). Retrieved October 24, 2017, from https://www.merriam-webster.com/medical/otoscopy

Video otoscope for quality counseling and care. (n.d.). Retrieved October 24, 2017, from http://www.otometrics.com/solutions/hearing-aid-fitting-system-aurical/video-otoscope-aurical-otocam

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