No one way

Dr. Roy Halpern suggested, in the January AAP News (Second Opinons, Speculum positioning), an alternative positioning of the otoscopic speculum-upright, rather than upside-down, as discussed by Dr. Fred Weinberg in a previous article. Dr. Halpern finds the traditional upside-down position clumsy for otoscopic exam. In fact, both physicians are probably correct, since the position and method of holding depend on the age and cooperation of the patient. In order to perform a diagnostic pneumatic otoscopy, I find the upside-down position preferable for infants and small toddlers, since this allows me to use the side of the examining hand to stabilize the head, and the other hand to manipulate the insufflator bulb. Older children are typically more cooperative, do not tend to pull away, and can hold their heads upright to allow a similarly upright otoscope position.