Ear Examination

Question 1

Opening

Answer 1

Hello, I’m a 3rd year medical student An Nakamura.
I’ve been asked to perform an examination of your ear
This will involve me using a otoscope to look in your ears, a tuning fork
Will this be ok?
Do you have any questions?
Are you in any pain?

Question 2

Inspection

Answer 2

Hearing aids - ask patient to remove this before otoscopy

Mobility aids - potential vestibulocochlear nerve issues?

Question 3

Gross hearing test

Answer 3

Have you noticed any changes in your hearing?

Rustle fingers by ear and whisper 3 numbers by their other ear

Ask patient to repeat what they heard

Repeat in other ear

Question 4

Rinnes and Webers test

• how to carry out the test
• result interpretation

Answer 4

Rinne
-512Hz held next to ear vs on mastoid
Positive result - air > bone
Negative result - bone > air

Weber
-tuning fork on forehead
Equal on both sides
Lateralises to one side

Conductive hearing loss

• Negative Rinne and lateralises to affected ear.
• outer or middle ear problem

Sensorineural hearing loss

• Positive Rinne and lateralises to good ear
• cochlea, CN8 issue

Question 5

External ear inspection

Answer 5

Pinna
Asymmetry
Deformity - cauliflower ear, no pinna, underdeveloped pinna, low set ears (Turners, Downs)
Piercings - infection, allergen, trauma?
Erythema, edema - OE
Scars - past surgery
Skin lesions - premalignant, malignant skin changes

Mastoid
Erythema, swelling - mastoiditis
Scars - mastoidectomy?

Pre-auricular region
Sinus - congenital deformity, may become infected => surgical drainage
Lymphadenopathy - ear infection

Conchal bowl
Erythema, purulent discharge - infection?

Question 6

External ear palpation

Answer 6

Tragus tenderness - OE

Regional LN

Question 7

Otoscopy

• order
• insertion
• removal

Answer 7

Ask for any discomfort
Which is the better ear? => start from there

Apply sterile speculum
Pull pinna up and back => straighten ear canal
Hold otoscope in right hand for right ear and vice versa
Rest hand against cheek
Advance otoscope anteriorly with direct supervision

Careful withdrawal
Repeat in other year
Discard speculum

Question 8

Otoscopy inspection

-external auditory canal assessment

Answer 8

Excess ear wax - most common cause of conductive hearing loss

Erythema, edema - OE

Discharge - OE, perforated OM

Foreign body

Question 9

Otoscopy inspection

-tympanic membrane assessment

Answer 9

Systematic assessment of 4 quadrants

Colour

• pearly grey, translucent - healthy
• erythema - inflammation

Shape

• flat - healthy
• bulging - increased middle ear pressure (OME)
• retraction - reduced middle ear pressure (URTI, allergies?)

Light reflex

• L ear => 7-8oclock
• R ear => 4-5oclock
• absent/distorted => OM

Perforation size and position

• infection - (OME)
• trauma - diving related?
• cholesteatoma
• insertion of grommets

Scarring - tympanosclerosis

Question 10

Conclusion

Answer 10

General inspection positive findings
Otoscopy positive findings
Hearing loss findings

Further assessment

• cranial nerve assessment - facial nerve pathology
• audiometry, tympanometry - for a better assessment of hearing loss