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Video otoscopy: Bringing otoscopy out of the “black box”
International Journal of Pediatric Otorhinolaryngology (2006) 70, 1875—1883
www.elsevier.com/locate/ijporl
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’§,§§ Woodson Scott Jones * Department of Pediatrics, Uniformed Services University of the Health Sciences (USUHS), San Antonio Military Pediatric Center, 2200 Bergquist Dr. STE1, Lackland AFB, San Antonio, TX 78236, United States Received 31 October 2005; received in revised form 27 June 2006; accepted 27 June 2006
KEYWORDS Indexing: Video otoscopy; Video otoscope; Otoendoscope; Education; Otitis media
Summary Background: Several billion dollars are spent each year on otitis media, a diagnosis for which educational approaches and diagnostic skills are suboptimal. The Center for Disease Control has identified improvement in otoscopy skills as a key intervention to curb inappropriate antibiotic usage. Educators are looking for interventions to both improve and assess otoscopy skills. Video otoscopy (VO) uses endoscopic technology to project the image of the ear onto a monitor for all to see, offering unexplored educational opportunity. The objective of this study is to perform an evaluation of VO systems in medical education from a review of the literature and hands-on experience of available technology. Methods: The evaluation will focus on the technical acceptability (user requirements), clinical appropriateness (validity, reliability, feasibility), operational effectiveness (training requirements and implementation), and equipment selection. Results: The technical requirements in pediatric education exceed those available in some VO systems, specifically pneumatic capability, sophisticated cameras and optics, and pediatric-sized ear speculums. VO images are comparable to the conventional otoscopic and otomicroscopic examinations. VO is feasible in a primary care setting and can be integrated into resident and medical student education. The technology in VO systems is changing rapidly, necessitating comparison of systems before equipment is purchased. Conclusions: VO is technically acceptable, clinically appropriate and can be integrated into the otoscopic education of residents and medical students. VO provides an
§ USUHS Instructional Development Protocol E086EO supported this work. There are no other affiliations, financial agreements, or involvement with any company whose products are mentioned in the article. §§ The opinions or assertions contained herein are the private ones of the author and are not to be construed as official or reflecting the views of the Department of Defense, United States Air Force, or the Uniformed Services University. * Tel.: +1 210 292 5097; fax: +1 210 292 5238. E-mail address: [email protected].
0165-5876/$ — see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.ijporl.2006.06.014
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W.S. Jones opportunity to bring the pediatric ear examination out of the ‘‘black box,’’ potentially improving diagnostic skills, quality of care, and reducing antibiotic overuse. Published by Elsevier Ireland Ltd.
1. Introduction Several recent studies have identified deficiencies in the otoscopic diagnostic skills in some pediatric providers and residents [1—3]. On an end-of-clerkship survey, 45% of our USUHS third-year medical students reported they could not make a ‘‘reasonable’’ otoscopic assessment in young children’s ears more than half of the time [4]. Internationally there is a recognized need to improve diagnostic skills in otoscopy [5—7]. Traditionally, otoscopic skills are taught primarily by repetitive examinations accompanied by didactic sessions [8]. Some educators and investigators have incorporated various other modalities (VHS, CD, web-based), which utilize video images or still images of tympanic membranes [9—13]. While evidence exists to suggest these interventions improve diagnostic interpretive skills [11,12], they fail to adequately address examination and interpretive skills simultaneously in a clinical context. While a learner looking through the preceptor’s otoscope offers a real-time advantage, any movement of the otoscope or the child removes assurances that the learner is seeing what the teacher intends. Dualheaded otoscopes have inadequate magnification and luminance, poor ergonomics, and are often challenging to use in young, uncooperative children. A video otoscopy (VO) system utilizes components of endoscopic technology to acquire and project video images of the tympanic membrane onto a monitor for preceptors, patients, families, and learners. VO is primarily utilized by veterinarians, otolaryngologist, audiologists, otitis researchers, and in telemedicine [14—16]. The components of a VO system have been described along with their integration into audiologists’ practice for patient education, medical documentation, inter-provider communication, as well as augmenting knowledge base and skills enhancement [16]. Kaleida and Hoberman utilized VO to acquire images of tympanic membranes in order to develop the ‘‘video otoendoscopic examinations’’, a compilation of three sets of 50-videotaped tympanic membranes used to both assess and train providers in otoscopic interpretive skills [9]. However, no report has specifically addressed integration of VO into pediatric otoscopy training of medical students and residents. This report elaborates on the potential teaching capabilities and processes of integrating VO into medical education, as well as
provides a usability evaluation of VO systems from a review of the medical literature and 7 years of experience using VO systems for resident and medical student education. The usability evaluation will follow a previously outlined process for assessing telemedical equipment focusing on technical acceptability (user requirements), clinical appropriateness (accuracy, precision, feasibility), operational effectiveness (training requirements and implementation), and equipment selection [17].
2. Methods We performed an OVID Medline review for all articles that used otoscopy, video otoscopy, otoendoscopy, otoscopy/telemedicine, or otoscopy/ videotaping from 1966 to November 2005. The references for each of these articles were also surveyed for applicable literature. Other articles were reviewed specifically regarding reliability of VO known by the author from previously published works in the field. The literature was examined for utility in answering usability questions posed above. The author has experience using seven different VO systems examining children, teaching residents and medical students in a clinical context.
3. Results 3.1. Technical acceptability The major components of a VO system include a camera (camera head, optical coupler), light source, optical system to deliver light to the ear canal (otoendoscope, Hopkins rod telescope, optical cable, etc.), display monitor (TV, computer monitor), and data-capturing device (computer, VHS player, DVD recorder, video printer) (Fig. 1). Technical requirements for quality image acquisition in children are more significant than in adults. In one report, compared with older children and adults, children less than 4 years old had a disproportionate percentage (49 of 59, 83%) of the overall number of images rated as ‘‘poor’’, since this age range represented only 43% (18 of 40) of the subjects [18]. The health care extenders (health aides, nurses, etc.) were able to gain adequate or better
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’
Fig. 1 Components of video otoscope system (VO system) for use in pediatric medical training include camera, light source, pneumatic otoendoscope, DVD player/burner, color printer and monitor.
images were obtained from 34% of 1-year old, 72% of 2 years old and 80% of 3 years old. From our experience and review of the literature, the components of the camera necessary to capture images in young children’s ears of sufficient quality for teaching and/or management include high resolution capability, wide depth of field (ranges at which a well-focused image can be maintained), adequate luminance, wide range of gain control (prevention of blooming), and appropriate field of view (capability of capturing the entire tympanic membrane when positioned appropriately in ear the canal). Resolution is influenced by many components of the VO system, including the lens, optical couplers (if part of the system) and cables, camera, camera output cables (S-video, composite video, etc.), video recording device, and monitor. The best resolution of the final product will be limited by whatever component has the lowest resolution or potentially distorts the image (i.e., couplers). For example, horizontal resolution may be reduced 30— 40% due to use of composite rather than S-video output [19]. The intensity of light through the aperture and the depth of field are inversely related. A wider aperture, while allowing greater luminance,
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reduces the depth of field [19]. Depth of field is the range of distance from the tip of the probe to the tympanic membrane in which a focused image can be maintained. Because of the various sizes (depth and width) of pediatric ear canals, a camera with a wide depth of field is essential. It is difficult to finefocus the image while examining a young, uncooperative child and could be harmful with some VO systems, especially those not equipped to accommodate ear speculums [15]. Optimally, gain control will allow darker images to appear bright and clearer while prohibiting intensely bright images from appearing ‘‘washed-out’’ or to ‘‘bloom.’’ ‘‘Blooming’’ occurs when high intensity bright light reflects off either cerumen or the TM causing a spilling-over of the bright light into the adjacent pixels of the image [19]. This is a commonly encountered problem when examining young children’s ears due to the frequency of debris in the ear canal and the close proximity of the TM. Since all cameras’ gain controls have limitations, the light source (luminance) is of equal importance. Because of the large variance in size of the pediatric ear canal, an important feature is adjustability of light intensity. While halogen light sources are generally less expensive and offer more adjustability of light intensity, a xenon light source (metal halide) is superior [20]. Using the same camera, we gained images with truer color, less blooming, and better resolution when we used a xenon (metal halide) light as opposed to halogen light, however, both are acceptable for a pediatric VO. The optical systems to deliver light and capture images from the ear canal vary widely from otoscopes with built-in fiber-optics to endoscopes placed through an otoscope head fixed with a wax ear plug [20]. For ease of discussion, we will refer to all optical delivery devices as otoendoscopes. Because many otoendoscopes were designed for adult patients in whom static otoscopic examination is considered acceptable, they do not have the capability to perform pneumatic otoscopy, a very important aspect of the pediatric examination [7,21,22]. In order to obtain images in younger children, 3 mm (2.5 mm at times) specula compatibility is essential [19]. The limiting factor for specula size is typically the diameter of the endoscope rod. Some 2.7 mm rods can use 2.5 mm WelchAllyn specula (WelchAllyn, Skaneateles Falls, NY). Due to children’s smaller external auditory canals, largersized specula will prohibit image acquisition of some TMs. Therefore, we do not recommend 4 mm endoscopes because they limit the examination of younger children. An otoendoscope that utilizes WelchAllyn reusable specula (primarily or with adapters) is preferred because of their brighter
1878 plastic (improved luminance), tapered edges (reduced discomfort), and length (better image and seal) [23]. Though reusable specula also extend a couple of millimeters beyond the lens as compared to disposable specula, thus reducing the field of view, there is less associated ‘‘smudging’’ of cerumen on the lens. The cerumen must then be removed from the lens and more often from the ear canal to gain an adequate image, reducing the efficiency of the examination. An otoendoscope with the capability to use rubber-tipped specula is important and frequently essential to gain an adequate seal of the ear canal in order to gain pneumatic images. Recording capabilities (VCR, computer, CD, DVD) are important due to the need for quick acquisition of images in young children and efficient retrieval of the recorded video images for teaching. Video recording is far superior to static imaging because of the added essential element of pneumatic assessment, which in our experience precludes the necessity for complete removal of cerumen from the ear canal before images are useful for both teaching and diagnostic purposes. It is also optimal to have a recording medium that allows for immediate retrieval of recorded video for teaching and education. Because of the exam brevity at times, particularly in uncooperative children, image sequences of adequate quality for teaching and/or printing and ease of repetitive playback with a frame-by-frame viewing option are helpful. Hence, video digital images (CD or DVD) are more practical for quick retrieval and they offer higher quality images than VHS. Images can be captured on a computer with a video capture board or directly on DVDs/CDs with DVD/CD player/recorders. Computer-captured files can be manipulated easier, adding patient information and filing for later retrieval. Video printers add both a teaching and a continuity of care facet to VO, allowing for printing of high-quality static TM images for medical records. Images placed in the medical record are then available for comparison by the next clinician (potential learner or provider) to compare current findings with the past documented findings, which is especially helpful in a TM with chronic changes (i.e., tympanosclerosis).
3.2. Clinical appropriateness Clinical appropriateness of VO refers to the accuracy and precision compared with other diagnostic modalities (otoscope, otomicroscope, etc.) and the feasibility of using in an educational and clinical environment. Video otoscopy has found greater utilization in the last decade, primarily in telemedi-
W.S. Jones cine. Studies demonstrated that VO examination of the tympanic membrane is superior to otoscopy and as accurate and equally precise as the otomicroscopic examination when assessing for middle ear effusions [3,9,17,18,24,25]. Two to eight weeks after performing the in-person otoscopic examination, the same two validated otoscopists compared their previously reported otoscopic findings with their interpretations of middle ear effusion (MEE) from the VO-acquired videotapes done of the same ears [3,9]. There was substantial correlation of effusion status (observer 1, 91%, k-statistic = 0.79 and observer 2, 92%, k-statistic = 0.80) between direct otoscopic and VO findings. Two otolaryngologists performed otomicroscopic examinations of 40 patients’ TMs, recording their physical findings and diagnosis the same day a health care extender (nurse, community-health aide, or nurse practitioner) took static digital images with a VO system [18]. The two otolaryngologists’ intra-provider diagnostic concordance of the in-person otomicroscopic examination with their interpretation of the corresponding VO-acquired static images reviewed 6—12 weeks later ranged from 79 to 85% (k = 0.67—0.76). The inter-provider correlation for the in-person otomicroscopic diagnostic findings (88%, k = 0.81) was similar to the inter-provider correlation of viewing the VO-acquired static images (84%, k = 0.74), increasing to 89% (k = 0.80) when poor quality images were excluded. Videotelescopy, similar to video otoscopy except for use of a longer endoscope probe to get closer to the TM and lack of pneumatic capability, was found to have the highest accuracy (98.0%), sensitivity (97.8%) and specificity (100%) at diagnosing OME compared with pneumatic otoscopy and tympanometry [25]. One study demonstrated the increasing feasibility of VO in a primary care clinic for telemedicine, noting reduction in TM image acquisition time by physicians that initially varied from 5 to 8 min, down to 3 min, when a newer generation of equipment was subsequently tested [22]. Otolaryngologist, experienced with video otoscopy, report a 1—3min image acquisition time [20,25]. Our acquisition and teaching times have been approximately 5— 10 min because we primarily examine young children and subsequently review of the digital images with the resident, medical student and parents. The Alaska Native Health Board report determined that high-quality video pneumatic images of young children’s ears could be obtained by health care extenders utilizing a VO [19]. In Australia, a 1-day VO training seminar resulted in community health workers being able to immediately acquire good images from aboriginal children for telemedicine referrals [26].
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’
3.3. Operational effectiveness 3.3.1. Training requirements In our experience, learning to perform VO takes training and practice to acquire acceptable images from young children, although surprisingly little time. If there are otoscopic findings of interest, it is more efficient to bring the patient to the VO system than vice versa. For example, an examination room can be designated as an ‘‘ear room,’’ incorporating a tympanometer, ear irrigation equipment, and VO system. When a learner reports ear examination findings, the preceptor can meet the learner with the family in the ‘‘ear room.’’ Depending upon the child’s age and level of cooperation, parents hold their children in similar positions as during a routine otoscopic examination. We find sitting the parent in a swivel chair while holding the child facilitates rapid, optimal positioning. However, we recommend the examiner position the child in a manner that allows for minimal alteration of the examiner’s head position from insertion of the otoendoscopic specula to viewing the display monitor (Fig. 2). Allowing the child to view the monitor is often placating as well. All VO systems (even those using a traditional otoscope design) require some degree of adaptation in examination technique. Ease of use varies widely by design and preference of examiner [19]. The ergonomics of the otoendoscopes available are not equal with variable configurations. Fig. 3 demonstrates four different otoendoscopes we have experience with along with a rank-ordering from most to least ergonomic in the pediatric evaluation. Different providers will have different preferences, but a well-balanced, light, non-bulky otoendoscope is helpful. It is important to initially examine adults and/or older, cooperative children
Fig. 2 Proper positioning for VO system examination: position to allow both child, parent and examiner to simultaneously view the monitor.
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before attempting examinations in younger, less cooperative children. As one rapidly masters the examination technique and the equipment, image acquisition will come as readily with VO as with a traditional otoscope, if not become the preferred method of evaluation. We typically use the accompanying learner or a family member to start and stop the video recording at the direction of the examiner. After acquisition of an image, we immediately replay it for both the learners and patient/family for teaching. The video images are saved and available to teach other learners who may not have been present during the examination. In our experience, as well as that of others, both learners and parents highly praise the use of this technology [16]. 3.3.2. Implementation Implementation of VO into a training curriculum or program can be a challenge, particularly in a busy ambulatory clinic setting. Though reports allude to the value or potential of VO in allowing demonstration of otoscopic findings to medical students and residents [14,19,20], none have given specifics on their experiences with integration into training. We have experience with VO in teaching residents and medical students during pediatric ear followup clinics and routine ambulatory care clinics for over 5 years. Some staff are reticent to use the equipment, often reluctant to invest time in overcoming the initial skill acquisition curve. Some of the residents skilled in technology are more willing to learn how to perform VO. Residents can choose to acquire images independently, simply reviewing them with precepting staff, potentially avoiding an additional examination of the child. Offering familiarization of the equipment as a part of the residents’ orientation to their ambulatory clinic rotation is one potential method of increasing utilization. Emphasizing the patient benefits and positive response of this technology may help gain advocates. Having a video printer available to generate pictures for the medical record may also increase participation by emphasizing the quality control measures gained by providing helpful documentation of TM findings for comparison at future visits. At times, parents of children previously evaluated with VO request subsequent evaluations at follow-up visits, increasing willingness of the staff to learn the necessary skills. In order to more accurately assess the providers’ diagnostic skills and direct their learning, it is best to have the learner present their ear findings with specificity such as using the COMPT mnemonic (color, other, mobility, position, translucency) [27]. After an image is acquired with VO, we have
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W.S. Jones
Fig. 3 Pneumatic otoendoscopes have various configurations and adaptations influencing ergonomics and image acquisition. The otoendoscopes are listed from most to least ergonomic: (A) JEDMED VO 2002 otoendoscope; (B) AMD-2015 ENT scope; (C) JEDMED EVS otoendoscope; (D) WelchAllyn Compac videoscope.
the same learner again assess the image in a like manner and see if they note discrepancies between their otoscopic findings and the VO findings. Documentation of residents’ participation in this process with improvement of skills (increased concordance with the VO findings) could satisfy components of the competency-based approach to education put forth by the Accreditation Council for Graduate Medical Education [28].
3.4. Equipment selection Published reviews and comparisons of different VO systems were performed primarily for use in telemedicine in remote locations with populations at high risk for ear disease [15,19] and within a family practice clinic [22]. The Alaskan field trial is the most comprehensive published trial to date, comparing four different VO systems [19]. Electronics,
Fig. 4 Video otoscopy (VO) systems with camera, light source and otoendoscope: (A) Storz Tricam SL/Xenon 125; (B) JEDMED Combo/150; (C) JEDMED Combo/50; (D) AMD-300 camera and illumination source.
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’ optics and clinical reviews were all included in the equipment selection process to be used by healthcare extenders in remote parts of the state. Three of the four VO systems, American Medical Development (AMD, St. Lowell, MA), JEDMED Instrument Company (St. Louis, MO), and VCOM Systems (Sausalito, CA) included pneumatic capability. Not all VO systems in this trial had either equal amount of clinical assessment time or underwent the complete battery of tests. A couple of the VO systems tested may not have been optimally functioning according to manufacturers’ specifications, potentially distorting the outcomes. The AMD and JEDMED VO systems tested had the highest resolutions. The AMD system had better ergonomics and electronics (color accuracy, luminance, gain control) of the three with pneumatic capability. While the AMD equipment tested (AMD-300 imaging system/AMD2015 ENT scope, Fig. 4D) is still available, the JEDMED system (JEDMED video scope system) tested is no longer produced. Others who have assessed the AMD and JEDMED systems concluded that both improved over previously tested models and were feasible for telemedicine otoscopy in a family practice clinic, used by nursing personnel with minimal training requirements [22]. However, very few small children were examined and little direct comparison data between the two systems was offered. Only the Storz 3-mm Hopkins Rod Telescope (Karl Storz GMBH and Co. KG, Tuttlingen, Germany) had pneumatic capability in another review of four VO systems [15]. As technology (e.g., the components) of some VO systems are rapidly changing, the usefulness of prior published VO systems direct comparisons diminishes. The VO system analyzed may not be available or the manufacturer has modified components in the VO
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system since the last published trial was performed. That is why we recommend ‘‘field-trials’’ with several different VO systems prior to purchase. The trial should be long enough to gain comfort in examining relatively young children (<2 years old) and assessing the proficiency of each system to gain adequate images for teaching. The expense and utility of different VO systems for training also varies widely. In general, the more expensive systems have better cameras (electronics) and light sources, but may not necessarily be worth the additional cost if you can get a more reasonably priced camera with a more ergonomic otoendoscope. Acquiring an older model camera from the hospital’s endoscopy suite is another economic option once you ensure compatibility with otoendoscope of choice. Some of the VO systems that we have used are pictured in Fig. 4 and listed in Table 1 along with the relative strengths and weaknesses of the subcomponents of each system based upon our clinical experience. Most have the capability to capture highquality video images in young children (4 months), with exception of the WelchAllyn Compac video otoscope. The VO system with which we have the most experience is the JEDMED EVS system ($10,000 USD, Fig. 1). It has a combined 480-line horizontal resolution camera and xenon light source (50 W), 2.7 mm otoendoscope head with adapter compatible with WelchAllyn reusable speculum (includes rubbertipped speculum). The monitor is a high-resolution TV monitor and images are captured on a DVD recorder/player for immediate retrieval. With frame-byframe viewing capabilities, we can pause the DVD recorder on the desired static image for printing on a Sony UP-20 Medical Video Printer ($1500 USD, Sony Medical, Park Ridge, NJ), generating high-quality
Table 1 Features and value of video otoscopy systems (VOS) in young children VOS a
Camera rating b
Light source rating
Pneumatic otoscope ergonomic rating
Cost rating c
WelchAllyn Compac video otoscope (not pneumatic) Storz Telecam DXII/481C Light/ Hopkins II 3 mm tele-otoscope Storz TricamSL/Xenon 125/ HopkinsII 3 mm tele-otoscope AMD-300 camera and illumination source/AMD-2015 ENT scope JEDMED/150 camera and light source/JEDMED VO 2002 otoscope JEDMED Combo 50/JEDMED VO 2002 otoscope JEDMED EVS
+
+
+
$
+++
+++
++
$$$
++++
++++
++
$$$$
++++
+++
+++
$$$$
++
++
++++
$$
+++
+++
++++
$$$
+++
+++
++
$$$$
a b c
All tested VOS used same Panasonic high resolution TV monitor, Sony UP-20 medical video printer, and Panasonic DVD recorder. Range listed highest (++++) to lowest (+) quality of systems evaluated. Range highest ($$$$) to lowest ($) cost of systems evaluated.
1882 images for the medical record. While we have been able to generate high-quality video images in very young (4-month-old), uncooperative children, there are a couple of drawbacks to this system. The expense of this complete VO system ($12,000 USD) is of primary concern. The 50-W short arc xenon light source only has two intensity settings. One is generally too bright for otoscopy in children and the other is not bright enough at times. Additionally, the white balance must be reset each time the camera is turned on. The JEDMED EVS otoendoscope is not compatible with other VO systems and the ergonomics are not as favorable as other JEDMED or AMD otoendoscopes evaluated (Fig. 3A and B). Among the more expensive (>$10,000 USD) VO systems tested, the refurbished Storz Tricam SL/Xenon 125 (Fig. 4A) gained the highest quality images. The otoendoscope (Hopkins II 3 mm tele-otoscope) we tested with this VO system required multiple adapters to attach specula and to deliver insufflations making it less ergonomic than other otoendoscopes available.
4. Conclusions Accurate examination of the tympanic membrane is a core competency for otoscopy training, yet evidence exists that current otoscopy training practices are inadequate. Improving otoscopy skills should be a training priority and reduce inappropriate use of antibiotics. We have integrated VO into medical student and resident education. VO offers training programs an opportunity to improve otoscopy skills, provide competency-based assessment of these skills, and improve the quality of medical care given to children. In our experience, learners, practitioners and families have high regard for VO when used in a clinical setting. VO examinations have been shown to correlate highly with direct otoscopy and otomicroscopy. More research needs to be performed to assess if integration of VO into medical school and resident training actually improves diagnostic skills. While most systems being utilized in telemedicine are expensive, more economic VO systems that are feasible both in examining young children and facilitating medical education are now available for a reasonable cost, approaching the cost of a quality tympanometer. Given the staggering sum spent annually on ear disease, the cost of a VO system is relatively inexpensive compared to the potential cost savings of reducing inappropriate diagnoses, antibiotic usage (and associated bacteria resistance rates), and medical visits. Bringing otoscopy diagnostics and teaching of otoscopy out of the ‘‘black
W.S. Jones box’’ with VO is a prudent step for medical training programs in order to best address these challenges.
References [1] W.J. Steinbach, T.C. Sectish, D.K. Benjamin, K.W. Chang, A.H. Messner, Pediatric residents’ clinical diagnostic accuracy of otitis media, Pediatrics 109 (2002) 993—997. [2] M.E. Pichichero, M.D. Poole, Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media, Arch. Pediatr. Adolesc. Med. 155 (2001) 1137—1142. [3] W.S. Jones, P.H. Kaleida, J.O. Lopreiato, Assessment of pediatric residents’ otoscopic interpretive skills using videotaped examinations, Ambul. Pediatr. 4 (2004) 162—165. [4] W.S. Jones, C.H. Johnson, J.L. Longacre, How well are we teaching otoscopy: medical students’ perspectives, Pediatr. Res. 53 (4) (2003) 544A. [5] E.W. Fisher, A.G. Pfleiderer, Assessment of the otoscopic skills of general practitioners and medical students: is there room for improvement? Brit. J. Gen. Pract. 42 (1992) 65—67. [6] S.F. Dowell, S.M. Marcy, W.R. Phillips, et al., Otitis media–— principles for judicious use of antimicrobial agents, Pediatrics 101 (1998) 5165—5171. [7] Subcommittee on Management of Acute Otitis Media, Diagnosis and management of acute otitis media, Pediatrics 113 (2004) 1451—1465. [8] W.J. Steinbach, T.C. Sectish, Pediatric resident training in the diagnosis and treatment of acute otitis media, Pediatrics 109 (2002) 404—408. [9] P.H. Kaleida, A. Hoberman, C.G. Smith, Videotaped otoendoscopic examinations in clinical education and research: 1995 update, Arch. Pediatr. Adolesc. Med. 149 (Suppl) (1995) 117. [10] P.J. Wormald, G.G. Browning, K. Robinson, Is otoscopy reliable? A structured teaching method, Clin. Otolarygol. 20 (1995) 63—67. [11] P. Burke, W. Jones, Pneumatic otoscopy in the diagnosis of middle ear effusion: the use of video as a teaching aid, J. Audiovis. Media. Med. 12 (1989) 26—28. [12] D.J. Bain, Training for general practice: clinical behaviour in trainers and trainees, BMJ 288 (1984) 762—764. [13] American Academy of Pediatrics Online Learning in Otitis Media. Available at http://www.aap.org/otitismedia/ www/. Last accessed June 26, 2006. [14] V.J. Jaisinghanin, L.L. Hunter, Y. Li, R.H. Margolis, Quantitative analysis of tympanic membrane disease using videootoscopy, Laryngoscope 110 (2000) 1726—1730. [15] M.N. Mbao, R.H. Eikelbroom, M.D. Atlas, M.A. Gallop, Evaluation of video-otoscopes suitable for tele-otoscopy, Telemed. J. E. Health 9 (2003) 325—330. [16] R.F. Sullivan, Video otoscopy in audiologic practice, J. Am. Acad. Audiol. 8 (1997) 447—467. [17] D.P. Birkmire-Peters, L.J. Peters, L.A. Whitaker, A usability evaluation for telemedicine medical equipment, Telemed. J. 5 (1999) 209—212. [18] C. Patricoski, J. Kokesh, A.S. Ferguson, K. Koller, et al., A comparison of in-person examination and video otoscope imaging for tympanometry tube follow-up, Telemed. J. E. Health 9 (2003) 331—344. [19] Ferguson AS [Alaska Native Health Board]. Video otoscope testing, final report. Anchorage, AK: University of Alaska Anchorage, April 22, 1998. Available as html document at: http://64.233.161.104/search?q=cache:95yGnV4MYikJ:appliedsci.uaa.alaska.edu/nlm/otoscope.pdf+alaska+field+trial+video+otoscopy&hl=en&gl=us&ct=clnk&cd=4. Accessed June 26, 2006.
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’ [20] E. Yanagisawa, The use of video ENT endoscopy: its value in teaching, ENT J. 73 (1994) 754—763. [21] W.S. Jones, P.H. Kaleida, How helpful is pneumatic otoscopy in improving diagnostic accuracy? Pediatrics 112 (2003) 510—513. [22] W.J. Crump, R. Kumar, G. Orsak, P. Thom, A field trial of two telemedicine camera systems in a family practice, Arch. Fam. Med. 7 (1998) 174—176. [23] S.L. Block, Dispose of the disposables, Pediatr. Infect. Dis. J. 17 (1998) 1179—1180. [24] L. Burgess, M.R. Holtel, M.J. Syms, D.P. Birkmire-Peters, L.J. Peters, P.A. Mashima, Overview of telemedicine applications for otolaryngology, Laryngoscope 109 (1999) 1433—1437.
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[25] A. Shiao, G. Yaun-Ching, A comparison assessment of videotelescopy for diagnosis of pediatric otitis media with effusion, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1496—1502. [26] R.H. Eikelbroom, S. Weber, M.D. Atlas, Q. Dinh, M. Mbao, M.A. Gallop, A tele-otology course for primary care providers, J. Telemed. Telecare. 9 (Suppl. 2) (2003) 19— 22, S2. [27] P.H. Kaleida, The COMPLETES exam for otitis, Contemp. Pediatr. 14 (1997) 93—101. [28] ACGME outcome project [accreditation council for Graduate Medical Education web site]. Available at http://www. acgme.org/Outcome/Accessed June 26, 2005.
www.elsevier.com/locate/ijporl
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’§,§§ Woodson Scott Jones * Department of Pediatrics, Uniformed Services University of the Health Sciences (USUHS), San Antonio Military Pediatric Center, 2200 Bergquist Dr. STE1, Lackland AFB, San Antonio, TX 78236, United States Received 31 October 2005; received in revised form 27 June 2006; accepted 27 June 2006
KEYWORDS Indexing: Video otoscopy; Video otoscope; Otoendoscope; Education; Otitis media
Summary Background: Several billion dollars are spent each year on otitis media, a diagnosis for which educational approaches and diagnostic skills are suboptimal. The Center for Disease Control has identified improvement in otoscopy skills as a key intervention to curb inappropriate antibiotic usage. Educators are looking for interventions to both improve and assess otoscopy skills. Video otoscopy (VO) uses endoscopic technology to project the image of the ear onto a monitor for all to see, offering unexplored educational opportunity. The objective of this study is to perform an evaluation of VO systems in medical education from a review of the literature and hands-on experience of available technology. Methods: The evaluation will focus on the technical acceptability (user requirements), clinical appropriateness (validity, reliability, feasibility), operational effectiveness (training requirements and implementation), and equipment selection. Results: The technical requirements in pediatric education exceed those available in some VO systems, specifically pneumatic capability, sophisticated cameras and optics, and pediatric-sized ear speculums. VO images are comparable to the conventional otoscopic and otomicroscopic examinations. VO is feasible in a primary care setting and can be integrated into resident and medical student education. The technology in VO systems is changing rapidly, necessitating comparison of systems before equipment is purchased. Conclusions: VO is technically acceptable, clinically appropriate and can be integrated into the otoscopic education of residents and medical students. VO provides an
§ USUHS Instructional Development Protocol E086EO supported this work. There are no other affiliations, financial agreements, or involvement with any company whose products are mentioned in the article. §§ The opinions or assertions contained herein are the private ones of the author and are not to be construed as official or reflecting the views of the Department of Defense, United States Air Force, or the Uniformed Services University. * Tel.: +1 210 292 5097; fax: +1 210 292 5238. E-mail address: [email protected].
0165-5876/$ — see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.ijporl.2006.06.014
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W.S. Jones opportunity to bring the pediatric ear examination out of the ‘‘black box,’’ potentially improving diagnostic skills, quality of care, and reducing antibiotic overuse. Published by Elsevier Ireland Ltd.
1. Introduction Several recent studies have identified deficiencies in the otoscopic diagnostic skills in some pediatric providers and residents [1—3]. On an end-of-clerkship survey, 45% of our USUHS third-year medical students reported they could not make a ‘‘reasonable’’ otoscopic assessment in young children’s ears more than half of the time [4]. Internationally there is a recognized need to improve diagnostic skills in otoscopy [5—7]. Traditionally, otoscopic skills are taught primarily by repetitive examinations accompanied by didactic sessions [8]. Some educators and investigators have incorporated various other modalities (VHS, CD, web-based), which utilize video images or still images of tympanic membranes [9—13]. While evidence exists to suggest these interventions improve diagnostic interpretive skills [11,12], they fail to adequately address examination and interpretive skills simultaneously in a clinical context. While a learner looking through the preceptor’s otoscope offers a real-time advantage, any movement of the otoscope or the child removes assurances that the learner is seeing what the teacher intends. Dualheaded otoscopes have inadequate magnification and luminance, poor ergonomics, and are often challenging to use in young, uncooperative children. A video otoscopy (VO) system utilizes components of endoscopic technology to acquire and project video images of the tympanic membrane onto a monitor for preceptors, patients, families, and learners. VO is primarily utilized by veterinarians, otolaryngologist, audiologists, otitis researchers, and in telemedicine [14—16]. The components of a VO system have been described along with their integration into audiologists’ practice for patient education, medical documentation, inter-provider communication, as well as augmenting knowledge base and skills enhancement [16]. Kaleida and Hoberman utilized VO to acquire images of tympanic membranes in order to develop the ‘‘video otoendoscopic examinations’’, a compilation of three sets of 50-videotaped tympanic membranes used to both assess and train providers in otoscopic interpretive skills [9]. However, no report has specifically addressed integration of VO into pediatric otoscopy training of medical students and residents. This report elaborates on the potential teaching capabilities and processes of integrating VO into medical education, as well as
provides a usability evaluation of VO systems from a review of the medical literature and 7 years of experience using VO systems for resident and medical student education. The usability evaluation will follow a previously outlined process for assessing telemedical equipment focusing on technical acceptability (user requirements), clinical appropriateness (accuracy, precision, feasibility), operational effectiveness (training requirements and implementation), and equipment selection [17].
2. Methods We performed an OVID Medline review for all articles that used otoscopy, video otoscopy, otoendoscopy, otoscopy/telemedicine, or otoscopy/ videotaping from 1966 to November 2005. The references for each of these articles were also surveyed for applicable literature. Other articles were reviewed specifically regarding reliability of VO known by the author from previously published works in the field. The literature was examined for utility in answering usability questions posed above. The author has experience using seven different VO systems examining children, teaching residents and medical students in a clinical context.
3. Results 3.1. Technical acceptability The major components of a VO system include a camera (camera head, optical coupler), light source, optical system to deliver light to the ear canal (otoendoscope, Hopkins rod telescope, optical cable, etc.), display monitor (TV, computer monitor), and data-capturing device (computer, VHS player, DVD recorder, video printer) (Fig. 1). Technical requirements for quality image acquisition in children are more significant than in adults. In one report, compared with older children and adults, children less than 4 years old had a disproportionate percentage (49 of 59, 83%) of the overall number of images rated as ‘‘poor’’, since this age range represented only 43% (18 of 40) of the subjects [18]. The health care extenders (health aides, nurses, etc.) were able to gain adequate or better
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’
Fig. 1 Components of video otoscope system (VO system) for use in pediatric medical training include camera, light source, pneumatic otoendoscope, DVD player/burner, color printer and monitor.
images were obtained from 34% of 1-year old, 72% of 2 years old and 80% of 3 years old. From our experience and review of the literature, the components of the camera necessary to capture images in young children’s ears of sufficient quality for teaching and/or management include high resolution capability, wide depth of field (ranges at which a well-focused image can be maintained), adequate luminance, wide range of gain control (prevention of blooming), and appropriate field of view (capability of capturing the entire tympanic membrane when positioned appropriately in ear the canal). Resolution is influenced by many components of the VO system, including the lens, optical couplers (if part of the system) and cables, camera, camera output cables (S-video, composite video, etc.), video recording device, and monitor. The best resolution of the final product will be limited by whatever component has the lowest resolution or potentially distorts the image (i.e., couplers). For example, horizontal resolution may be reduced 30— 40% due to use of composite rather than S-video output [19]. The intensity of light through the aperture and the depth of field are inversely related. A wider aperture, while allowing greater luminance,
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reduces the depth of field [19]. Depth of field is the range of distance from the tip of the probe to the tympanic membrane in which a focused image can be maintained. Because of the various sizes (depth and width) of pediatric ear canals, a camera with a wide depth of field is essential. It is difficult to finefocus the image while examining a young, uncooperative child and could be harmful with some VO systems, especially those not equipped to accommodate ear speculums [15]. Optimally, gain control will allow darker images to appear bright and clearer while prohibiting intensely bright images from appearing ‘‘washed-out’’ or to ‘‘bloom.’’ ‘‘Blooming’’ occurs when high intensity bright light reflects off either cerumen or the TM causing a spilling-over of the bright light into the adjacent pixels of the image [19]. This is a commonly encountered problem when examining young children’s ears due to the frequency of debris in the ear canal and the close proximity of the TM. Since all cameras’ gain controls have limitations, the light source (luminance) is of equal importance. Because of the large variance in size of the pediatric ear canal, an important feature is adjustability of light intensity. While halogen light sources are generally less expensive and offer more adjustability of light intensity, a xenon light source (metal halide) is superior [20]. Using the same camera, we gained images with truer color, less blooming, and better resolution when we used a xenon (metal halide) light as opposed to halogen light, however, both are acceptable for a pediatric VO. The optical systems to deliver light and capture images from the ear canal vary widely from otoscopes with built-in fiber-optics to endoscopes placed through an otoscope head fixed with a wax ear plug [20]. For ease of discussion, we will refer to all optical delivery devices as otoendoscopes. Because many otoendoscopes were designed for adult patients in whom static otoscopic examination is considered acceptable, they do not have the capability to perform pneumatic otoscopy, a very important aspect of the pediatric examination [7,21,22]. In order to obtain images in younger children, 3 mm (2.5 mm at times) specula compatibility is essential [19]. The limiting factor for specula size is typically the diameter of the endoscope rod. Some 2.7 mm rods can use 2.5 mm WelchAllyn specula (WelchAllyn, Skaneateles Falls, NY). Due to children’s smaller external auditory canals, largersized specula will prohibit image acquisition of some TMs. Therefore, we do not recommend 4 mm endoscopes because they limit the examination of younger children. An otoendoscope that utilizes WelchAllyn reusable specula (primarily or with adapters) is preferred because of their brighter
1878 plastic (improved luminance), tapered edges (reduced discomfort), and length (better image and seal) [23]. Though reusable specula also extend a couple of millimeters beyond the lens as compared to disposable specula, thus reducing the field of view, there is less associated ‘‘smudging’’ of cerumen on the lens. The cerumen must then be removed from the lens and more often from the ear canal to gain an adequate image, reducing the efficiency of the examination. An otoendoscope with the capability to use rubber-tipped specula is important and frequently essential to gain an adequate seal of the ear canal in order to gain pneumatic images. Recording capabilities (VCR, computer, CD, DVD) are important due to the need for quick acquisition of images in young children and efficient retrieval of the recorded video images for teaching. Video recording is far superior to static imaging because of the added essential element of pneumatic assessment, which in our experience precludes the necessity for complete removal of cerumen from the ear canal before images are useful for both teaching and diagnostic purposes. It is also optimal to have a recording medium that allows for immediate retrieval of recorded video for teaching and education. Because of the exam brevity at times, particularly in uncooperative children, image sequences of adequate quality for teaching and/or printing and ease of repetitive playback with a frame-by-frame viewing option are helpful. Hence, video digital images (CD or DVD) are more practical for quick retrieval and they offer higher quality images than VHS. Images can be captured on a computer with a video capture board or directly on DVDs/CDs with DVD/CD player/recorders. Computer-captured files can be manipulated easier, adding patient information and filing for later retrieval. Video printers add both a teaching and a continuity of care facet to VO, allowing for printing of high-quality static TM images for medical records. Images placed in the medical record are then available for comparison by the next clinician (potential learner or provider) to compare current findings with the past documented findings, which is especially helpful in a TM with chronic changes (i.e., tympanosclerosis).
3.2. Clinical appropriateness Clinical appropriateness of VO refers to the accuracy and precision compared with other diagnostic modalities (otoscope, otomicroscope, etc.) and the feasibility of using in an educational and clinical environment. Video otoscopy has found greater utilization in the last decade, primarily in telemedi-
W.S. Jones cine. Studies demonstrated that VO examination of the tympanic membrane is superior to otoscopy and as accurate and equally precise as the otomicroscopic examination when assessing for middle ear effusions [3,9,17,18,24,25]. Two to eight weeks after performing the in-person otoscopic examination, the same two validated otoscopists compared their previously reported otoscopic findings with their interpretations of middle ear effusion (MEE) from the VO-acquired videotapes done of the same ears [3,9]. There was substantial correlation of effusion status (observer 1, 91%, k-statistic = 0.79 and observer 2, 92%, k-statistic = 0.80) between direct otoscopic and VO findings. Two otolaryngologists performed otomicroscopic examinations of 40 patients’ TMs, recording their physical findings and diagnosis the same day a health care extender (nurse, community-health aide, or nurse practitioner) took static digital images with a VO system [18]. The two otolaryngologists’ intra-provider diagnostic concordance of the in-person otomicroscopic examination with their interpretation of the corresponding VO-acquired static images reviewed 6—12 weeks later ranged from 79 to 85% (k = 0.67—0.76). The inter-provider correlation for the in-person otomicroscopic diagnostic findings (88%, k = 0.81) was similar to the inter-provider correlation of viewing the VO-acquired static images (84%, k = 0.74), increasing to 89% (k = 0.80) when poor quality images were excluded. Videotelescopy, similar to video otoscopy except for use of a longer endoscope probe to get closer to the TM and lack of pneumatic capability, was found to have the highest accuracy (98.0%), sensitivity (97.8%) and specificity (100%) at diagnosing OME compared with pneumatic otoscopy and tympanometry [25]. One study demonstrated the increasing feasibility of VO in a primary care clinic for telemedicine, noting reduction in TM image acquisition time by physicians that initially varied from 5 to 8 min, down to 3 min, when a newer generation of equipment was subsequently tested [22]. Otolaryngologist, experienced with video otoscopy, report a 1—3min image acquisition time [20,25]. Our acquisition and teaching times have been approximately 5— 10 min because we primarily examine young children and subsequently review of the digital images with the resident, medical student and parents. The Alaska Native Health Board report determined that high-quality video pneumatic images of young children’s ears could be obtained by health care extenders utilizing a VO [19]. In Australia, a 1-day VO training seminar resulted in community health workers being able to immediately acquire good images from aboriginal children for telemedicine referrals [26].
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’
3.3. Operational effectiveness 3.3.1. Training requirements In our experience, learning to perform VO takes training and practice to acquire acceptable images from young children, although surprisingly little time. If there are otoscopic findings of interest, it is more efficient to bring the patient to the VO system than vice versa. For example, an examination room can be designated as an ‘‘ear room,’’ incorporating a tympanometer, ear irrigation equipment, and VO system. When a learner reports ear examination findings, the preceptor can meet the learner with the family in the ‘‘ear room.’’ Depending upon the child’s age and level of cooperation, parents hold their children in similar positions as during a routine otoscopic examination. We find sitting the parent in a swivel chair while holding the child facilitates rapid, optimal positioning. However, we recommend the examiner position the child in a manner that allows for minimal alteration of the examiner’s head position from insertion of the otoendoscopic specula to viewing the display monitor (Fig. 2). Allowing the child to view the monitor is often placating as well. All VO systems (even those using a traditional otoscope design) require some degree of adaptation in examination technique. Ease of use varies widely by design and preference of examiner [19]. The ergonomics of the otoendoscopes available are not equal with variable configurations. Fig. 3 demonstrates four different otoendoscopes we have experience with along with a rank-ordering from most to least ergonomic in the pediatric evaluation. Different providers will have different preferences, but a well-balanced, light, non-bulky otoendoscope is helpful. It is important to initially examine adults and/or older, cooperative children
Fig. 2 Proper positioning for VO system examination: position to allow both child, parent and examiner to simultaneously view the monitor.
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before attempting examinations in younger, less cooperative children. As one rapidly masters the examination technique and the equipment, image acquisition will come as readily with VO as with a traditional otoscope, if not become the preferred method of evaluation. We typically use the accompanying learner or a family member to start and stop the video recording at the direction of the examiner. After acquisition of an image, we immediately replay it for both the learners and patient/family for teaching. The video images are saved and available to teach other learners who may not have been present during the examination. In our experience, as well as that of others, both learners and parents highly praise the use of this technology [16]. 3.3.2. Implementation Implementation of VO into a training curriculum or program can be a challenge, particularly in a busy ambulatory clinic setting. Though reports allude to the value or potential of VO in allowing demonstration of otoscopic findings to medical students and residents [14,19,20], none have given specifics on their experiences with integration into training. We have experience with VO in teaching residents and medical students during pediatric ear followup clinics and routine ambulatory care clinics for over 5 years. Some staff are reticent to use the equipment, often reluctant to invest time in overcoming the initial skill acquisition curve. Some of the residents skilled in technology are more willing to learn how to perform VO. Residents can choose to acquire images independently, simply reviewing them with precepting staff, potentially avoiding an additional examination of the child. Offering familiarization of the equipment as a part of the residents’ orientation to their ambulatory clinic rotation is one potential method of increasing utilization. Emphasizing the patient benefits and positive response of this technology may help gain advocates. Having a video printer available to generate pictures for the medical record may also increase participation by emphasizing the quality control measures gained by providing helpful documentation of TM findings for comparison at future visits. At times, parents of children previously evaluated with VO request subsequent evaluations at follow-up visits, increasing willingness of the staff to learn the necessary skills. In order to more accurately assess the providers’ diagnostic skills and direct their learning, it is best to have the learner present their ear findings with specificity such as using the COMPT mnemonic (color, other, mobility, position, translucency) [27]. After an image is acquired with VO, we have
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Fig. 3 Pneumatic otoendoscopes have various configurations and adaptations influencing ergonomics and image acquisition. The otoendoscopes are listed from most to least ergonomic: (A) JEDMED VO 2002 otoendoscope; (B) AMD-2015 ENT scope; (C) JEDMED EVS otoendoscope; (D) WelchAllyn Compac videoscope.
the same learner again assess the image in a like manner and see if they note discrepancies between their otoscopic findings and the VO findings. Documentation of residents’ participation in this process with improvement of skills (increased concordance with the VO findings) could satisfy components of the competency-based approach to education put forth by the Accreditation Council for Graduate Medical Education [28].
3.4. Equipment selection Published reviews and comparisons of different VO systems were performed primarily for use in telemedicine in remote locations with populations at high risk for ear disease [15,19] and within a family practice clinic [22]. The Alaskan field trial is the most comprehensive published trial to date, comparing four different VO systems [19]. Electronics,
Fig. 4 Video otoscopy (VO) systems with camera, light source and otoendoscope: (A) Storz Tricam SL/Xenon 125; (B) JEDMED Combo/150; (C) JEDMED Combo/50; (D) AMD-300 camera and illumination source.
Video otoscopy: Bringing otoscopy out of the ‘‘black box’’ optics and clinical reviews were all included in the equipment selection process to be used by healthcare extenders in remote parts of the state. Three of the four VO systems, American Medical Development (AMD, St. Lowell, MA), JEDMED Instrument Company (St. Louis, MO), and VCOM Systems (Sausalito, CA) included pneumatic capability. Not all VO systems in this trial had either equal amount of clinical assessment time or underwent the complete battery of tests. A couple of the VO systems tested may not have been optimally functioning according to manufacturers’ specifications, potentially distorting the outcomes. The AMD and JEDMED VO systems tested had the highest resolutions. The AMD system had better ergonomics and electronics (color accuracy, luminance, gain control) of the three with pneumatic capability. While the AMD equipment tested (AMD-300 imaging system/AMD2015 ENT scope, Fig. 4D) is still available, the JEDMED system (JEDMED video scope system) tested is no longer produced. Others who have assessed the AMD and JEDMED systems concluded that both improved over previously tested models and were feasible for telemedicine otoscopy in a family practice clinic, used by nursing personnel with minimal training requirements [22]. However, very few small children were examined and little direct comparison data between the two systems was offered. Only the Storz 3-mm Hopkins Rod Telescope (Karl Storz GMBH and Co. KG, Tuttlingen, Germany) had pneumatic capability in another review of four VO systems [15]. As technology (e.g., the components) of some VO systems are rapidly changing, the usefulness of prior published VO systems direct comparisons diminishes. The VO system analyzed may not be available or the manufacturer has modified components in the VO
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system since the last published trial was performed. That is why we recommend ‘‘field-trials’’ with several different VO systems prior to purchase. The trial should be long enough to gain comfort in examining relatively young children (<2 years old) and assessing the proficiency of each system to gain adequate images for teaching. The expense and utility of different VO systems for training also varies widely. In general, the more expensive systems have better cameras (electronics) and light sources, but may not necessarily be worth the additional cost if you can get a more reasonably priced camera with a more ergonomic otoendoscope. Acquiring an older model camera from the hospital’s endoscopy suite is another economic option once you ensure compatibility with otoendoscope of choice. Some of the VO systems that we have used are pictured in Fig. 4 and listed in Table 1 along with the relative strengths and weaknesses of the subcomponents of each system based upon our clinical experience. Most have the capability to capture highquality video images in young children (4 months), with exception of the WelchAllyn Compac video otoscope. The VO system with which we have the most experience is the JEDMED EVS system ($10,000 USD, Fig. 1). It has a combined 480-line horizontal resolution camera and xenon light source (50 W), 2.7 mm otoendoscope head with adapter compatible with WelchAllyn reusable speculum (includes rubbertipped speculum). The monitor is a high-resolution TV monitor and images are captured on a DVD recorder/player for immediate retrieval. With frame-byframe viewing capabilities, we can pause the DVD recorder on the desired static image for printing on a Sony UP-20 Medical Video Printer ($1500 USD, Sony Medical, Park Ridge, NJ), generating high-quality
Table 1 Features and value of video otoscopy systems (VOS) in young children VOS a
Camera rating b
Light source rating
Pneumatic otoscope ergonomic rating
Cost rating c
WelchAllyn Compac video otoscope (not pneumatic) Storz Telecam DXII/481C Light/ Hopkins II 3 mm tele-otoscope Storz TricamSL/Xenon 125/ HopkinsII 3 mm tele-otoscope AMD-300 camera and illumination source/AMD-2015 ENT scope JEDMED/150 camera and light source/JEDMED VO 2002 otoscope JEDMED Combo 50/JEDMED VO 2002 otoscope JEDMED EVS
+
+
+
$
+++
+++
++
$$$
++++
++++
++
$$$$
++++
+++
+++
$$$$
++
++
++++
$$
+++
+++
++++
$$$
+++
+++
++
$$$$
a b c
All tested VOS used same Panasonic high resolution TV monitor, Sony UP-20 medical video printer, and Panasonic DVD recorder. Range listed highest (++++) to lowest (+) quality of systems evaluated. Range highest ($$$$) to lowest ($) cost of systems evaluated.
1882 images for the medical record. While we have been able to generate high-quality video images in very young (4-month-old), uncooperative children, there are a couple of drawbacks to this system. The expense of this complete VO system ($12,000 USD) is of primary concern. The 50-W short arc xenon light source only has two intensity settings. One is generally too bright for otoscopy in children and the other is not bright enough at times. Additionally, the white balance must be reset each time the camera is turned on. The JEDMED EVS otoendoscope is not compatible with other VO systems and the ergonomics are not as favorable as other JEDMED or AMD otoendoscopes evaluated (Fig. 3A and B). Among the more expensive (>$10,000 USD) VO systems tested, the refurbished Storz Tricam SL/Xenon 125 (Fig. 4A) gained the highest quality images. The otoendoscope (Hopkins II 3 mm tele-otoscope) we tested with this VO system required multiple adapters to attach specula and to deliver insufflations making it less ergonomic than other otoendoscopes available.
4. Conclusions Accurate examination of the tympanic membrane is a core competency for otoscopy training, yet evidence exists that current otoscopy training practices are inadequate. Improving otoscopy skills should be a training priority and reduce inappropriate use of antibiotics. We have integrated VO into medical student and resident education. VO offers training programs an opportunity to improve otoscopy skills, provide competency-based assessment of these skills, and improve the quality of medical care given to children. In our experience, learners, practitioners and families have high regard for VO when used in a clinical setting. VO examinations have been shown to correlate highly with direct otoscopy and otomicroscopy. More research needs to be performed to assess if integration of VO into medical school and resident training actually improves diagnostic skills. While most systems being utilized in telemedicine are expensive, more economic VO systems that are feasible both in examining young children and facilitating medical education are now available for a reasonable cost, approaching the cost of a quality tympanometer. Given the staggering sum spent annually on ear disease, the cost of a VO system is relatively inexpensive compared to the potential cost savings of reducing inappropriate diagnoses, antibiotic usage (and associated bacteria resistance rates), and medical visits. Bringing otoscopy diagnostics and teaching of otoscopy out of the ‘‘black
W.S. Jones box’’ with VO is a prudent step for medical training programs in order to best address these challenges.
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[25] A. Shiao, G. Yaun-Ching, A comparison assessment of videotelescopy for diagnosis of pediatric otitis media with effusion, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1496—1502. [26] R.H. Eikelbroom, S. Weber, M.D. Atlas, Q. Dinh, M. Mbao, M.A. Gallop, A tele-otology course for primary care providers, J. Telemed. Telecare. 9 (Suppl. 2) (2003) 19— 22, S2. [27] P.H. Kaleida, The COMPLETES exam for otitis, Contemp. Pediatr. 14 (1997) 93—101. [28] ACGME outcome project [accreditation council for Graduate Medical Education web site]. Available at http://www. acgme.org/Outcome/Accessed June 26, 2005.