The Effect of Auricle Position on Tympanic Thermometry
Condition: Body Temperature Changes
MeSH terms: Body Temperature Changes
Study type: Interventional

Summary: 
      Objective: The aim of this study was to investigate the effect of auricle position on body
      temperature measurements made with tympanic membrane thermometer in adult patients.

      Methods: The study was conducted with a quasi-experimental design with a pre-test and a
      post-test. A total of 143 patients who fit the inclusion criteria of the study were included
      in the sample. The research carried out between 1 November - 31 December 2016 in the
      emergency department. Body temperature measurements were carried out on the patients in the
      study firstly by not changing the position of the auricle and then repeated after a minute,
      this time by changing the position of the auricle.

      Results: The difference between the measurement values found in two different positions was
      0.31 0C, and the Bland Altman plot showed that the differences were distributed
      systematically around the value 0.31. The difference between the lengths of measurements
      performed on two separate positions was detected to be 1.08 second. During body temperature
      measurements performed through giving position to auricle, 59.2 % of the patients never felt
      discomfort.

      Conclusions: It was found in the comparison of two positions that there was a significant
      difference between the tympanic membrane thermometer measurements made by positioning the
      auricle and those without positioning.
    

Detailed description: 
      Introduction One of the most common practices in clinical investigations is the measurement
      of a patient's body temperature (1-2,3). Body temperature measurement has a significant place
      in evaluation of clinical pictures and clinical monitoring (4). The issue at hand is that
      various temperature measurement modalities yield different results (2-4).

      Although the accuracy of temperatures measured by infrared tympanic thermometers is a
      controversial issue among people interested in the subject, these thermometers have many
      advantages; they measure the temperature fast (1-2 s), and they are easy to use and
      non-invasiveness (3). Compared to the armpit or oral temperatures, the tympanic temperature
      reﬂects the core temperature more accurately which was demonstrated by comparing the
      temperature measurements made in the pulmonary artery and esophagus (5-6).

      Methods Aim The aim of this study investigate the effects of auricle position on body
      temperature values in tympanic membrane thermometer measurements performed on adult patients.
      The hypothesis was "Position of the auricle during measurement of tympanic membrane
      temperature will affect the reading".

      Design The study was conducted with a quasi-experimental design with a pre-test and a
      post-test.

      The Study Participants This cross-sectional study surveyed 143 patients from one of emergency
      department in Turkey. The patients who were 18 years old or older, conscious, without
      communication issues, volunteers, not diagnosed with otitis media, who did not have a fever.
      Because otitis media and fever cause to potential sources of bias. A sample of the study with
      143 patients who meeting these criteria and agreed to participate in the study was generated.

      Data collection The data were collected by "a Personal Information Form, a Visual Comparison
      Scale, a tympanic membrane thermometer and a stop watch" by the researcher on 143 patients
      who selected convenience sampling at the Emergency Services of a university hospital in the
      period of 1 November - 31 December 2016.

      Data Collection Tolls The "Personal Information Form" is a form that includes three questions
      based on socio-demographic characteristics (age, sex, presence of otitis media), this form
      was developed by the researchers. "Tympanic membrane thermometer" were used during body
      temperature measurements. The "Visual Comparison Scale" is used in evaluating the discomfort
      the patients feel based on auricle position change during the body temperature measurement,
      and it records the values for the duration of the body temperature measurement process and
      body temperature. This form was developed by the researchers. The score range of the "Visual
      Comparison Scale" is between 0 and 10.

      According to this scale, while "0" means "I do not feel discomforted", "10" means "I feel
      terribly discomforted". "Stop watch" was used to record whether there is a difference between
      the measurement processes in terms of duration.

      To measure the body temperature in all the patients, only the Covidien brand tympanic
      membrane thermometer was used. Before the study was started, the Covidien brand tympanic
      membrane thermometer was calibrated and a pilot study was conducted with 15 people to assure
      the accuracy of the thermometer.

      Intervention Firstly, patients selected with convenience sampling. In the sampling method,
      the order of the patients' enrollment to the emergency room was used. Then, patient's age,
      sex and presence of otitis media were recorded in the Personal Information Form.

      After recording, measurements were carried out on the patients in the study firstly by not
      changing the position of the auricle. The duration was measured by stop watch and the results
      were recorded in the data form. The levels of patients' discomfort were evaluated by the
      "Visual Comparison Scale".

      The measurement was then repeated after a minute, this time by changing the position of the
      auricle. The duration was measured for this position and the results were recorded in the
      data form. The levels of patients' discomfort were evaluated by the "Visual Comparison
      Scale". The auricle on the same side was used during both measurements.

      Sample Size Calculation In order to determine the sample size, a pre-administration was
      conducted on a total of 15 adult patients. The collected data were subjected to a power
      analysis. The effect size was determined as d=0.3645, according to the evaluation that was
      conducted by using these data. To obtain 99% power at a level of α=0.05, it was determined
      that there must be 110 patient in the groups. When considering that there may be a loss of
      data in the study process, it was decided that the study should be conducted on a total of
      143 participants.

      Ethical Considerations Approval (number: 2015-106) was received for the study from the
      Scientific Ethics Board of University, Faculty of Nursing. Written permission was taken from
      the Chief Physician of the Hospital of University, Faculty of Medicine for conducting the
      study in the emergency department of the hospital, while written consent was received from
      patients themselves after information was provided about the purpose of the study.

      Analysis The statistical analysis of the data obtained in the study was achieved using the
      Statistical Package for the Social Sciences (SPSS) 22.0. For analysis of the data,
      frequencies, percentages, means and standard deviations were calculated, and the significance
      of the difference between paired values was tested in order to investigate the effects of
      auricle position on measurement values. Additionally, systematic distributions of the data
      were examined with a Bland Altman plot which is used in repeated measurements based on
      positions. The results were interpreted in a 95% confidence interval and a level of
      significance of p<0.05.

      The mean value taken from the measurements with the tympanic membrane thermometer was
      36.99±0.48 in measurements by positioning the auricle, and 36.68±0.47 in measurements without
      positioning. The difference between the measurements obtained in two different positions was
      found as 0.31 0C. Accordingly, it was found that the difference between the values in two
      different measurement positions was noteworthy (t=15.12; p< 0.05).

      While one of the researchers measured the temperature with the tympanic membrane thermometer,
      the other researcher measured the amount of time elapsed with a stopwatch and recorded it.
      The mean duration of measurement was 5.51 seconds (min: 3.5 max: 7.3) in the measurements
      made by positioning the auricle, and 4.42 seconds (min: 2.9 max: 7.6) in the measurements
      without positioning. Considering the difference between the durations of measurements made in
      two different positions ( =1.08±0.07) it was found that the difference was significant
      between the measurements with positioning and those without positioning (t=15.16; p< 0.05).

      Table II. Measurement results according to pinna position and durations of the measurements
      taken in the comparison of the two positions.

      Conclusion This article contributes the main finding that nurses should be change the
      position of the pinna while measuring the temperature with tympanic membrane thermometers.
      Placing the sensor tip of the thermometer into the ear canal and pulling the auricle allows
      easy access to the tympanic membrane by straightening the external canal and it reflected the
      core temperature accurately.

      Utilization of tympanic membrane thermometers in measurement of body temperature is highly
      important and technique should be applied properly to obtain correct values in emergency
      department. In the light of the results we obtained in this study, in order to achieve
      accurate and reliable measurement values the auricle should be positioned correctly, and the
      ear canal should be straightened. This way, the tympanic membrane that receives blood via the
      external cerebral artery is placed straight ahead the infrared rays. This method of body
      temperature measurement should be included in the in-service training or nurses, as it is one
      of the jobs of nurses to measure body temperature.

      The information in user manuals in Turkish about tympanic membrane thermometers should be
      updated to include the steps in the process of body temperature measurement, and nurses
      should use this method effectively. The information in the literature relative to nursing
      practices on measurements made with tympanic membrane thermometers should be updated. It was
      found that the measurements made by positioning the auricle did not require an extra
      application time and this application would not be an additional workload for the nurses. It
      was determined that body temperature measurement by placing auricle in position did not cause
      discomfort in patients. Studies about the accuracy and reliability of measurements made with
      tympanic membrane thermometers should be repeated on different samples and the results should
      be shared.

      References

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           Graphene-Inked Infrared Thermopile. Sensor 2018;18:3315-23. Doi: 10.3390/s18103315.

        2. Arslan GG, Eşer İ, Khorshıd L. Analysis of the effect of lying on the ear on body
           temperature measurement using a tympanic thermometer. Journal of Pakistan Medical
           Association 2011; 61:1065. Retrieved from http://jpma.org.pk/PdfDownload/3100.pdf.

        3. Erickson RS, Kirklin SK. Comparison of ear-based, bladder, oral, and axillary methods
           for core temperature measurement. Critical care medicine, 1993;21(10): 1528-1534.

        4. Yeoh WK, Lee JKW, Lim HY, Gan CW, Liang W, Tan KK. Re-visiting the tympanic membrane
           vicinity as core body temperature measurement site. PLoS ONE 2017; 2 (4): 1-21. Doi:
           10.1371/journal.pone.0174120.

        5. Stavem, Saxholm, Smith-Erichsen, 1997

        6. Yaron M, Lowenstain SR, Koziol McLain J. Measuring the accuracy of the infrared tympanic
           thermometer. Journal of Emergency Medicine 1995;13:617-621. Doi:
           10.1016/0736-4679(95)00065-i
    

Intervention name(s): Body Temperature Measurements
Intervention type(s): Procedure
Intervention description(s): measurements were carried out on the patients in the study firstly by not changing the position of the auricle. The duration was measured by stop watch and the results were recorded in the data form. The levels of patients' discomfort were evaluated by the "Visual Comparison Scale".
The measurement was then repeated after a minute, this time by changing the position of the auricle. The duration was measured for this position and the results were recorded in the data form.
Intervention model: Single Group Assignment
Intervention model description: a quasi-experimental design with a pre-test and a post-test.
Masking: None (Open Label)
Primary purpose: Other
Keywords: body temperature,; adult patients,; tympanic membrane thermometer,; auricle position,; nursing practice.