Hearing Assessment & Otoscopy Flashcards
Give the overall steps of a hearing assessment & otoscopy station
- General inspection
- Gross hearing assessment
- Weber’s test
- Rinne’s test
- External ear - inspection, palpation
- Otoscopy
Describe how the gross hearing assessment is carried out
- Ask the patient if they have noticed any change in their hearing recently.
- Explain that you are going to say 3 words or numbers and you’d like them to repeat them back to you (choose two-syllable words or bi-digit numbers).
- Stand behind patient (approx. 60cm from patients’ ear) and mask the ear not being tested by rubbing the tragus
- Whisper a number or word and ask patient to repeat back to you
- Repeat this on same ear with another two different numbers
- Repeat on other ear
if the patient gets two thirds or more correct in the gross hearing assessment, what is their hearing level?
their hearing level is 12db or better
If there is no response in the gross hearing assessment, what can you do?
move closer and repeat test at 15cm
What type of tuning fork is used in a hearing assessment?
512 Hz
Describe how Weber’s test is carried out
Tap a 512Hz tuning fork (on knee NOT table) and place in the midline of their forehead
Ask them which ear it is heard loudest in
Describe results of Weber’s test in normal hearing
sound heard equally in both ears (i.e. middle)
Describe results of Weber’s test in sensorineural deafness
Sound heard loudest on side of intact ear
Describe results of Weber’s test in conductive deafness
sound is heard louder on the side of the affected ear
Describe results of Rinne’s test in normal hearing
air conduction > bone conduction (Rinne’s test positive)
Describe results of Rinne’s test in sensorineural deafness
air conduction > bone conduction (Rinne’s test positive)
Describe results of Rinne’s test in conductive deafness
bone conduction > air conduction (Rinne’s negative)
What occurs in conductive hearing loss?
Occurs when sound is unable to effectively transfer at any point between the outer ear, external auditory canal, tympanic membrane, and middle ear (ossicles)
What type of hearing loss does excessive ear wax cause?
Conductive
What type of hearing loss does otitis externa cause?
Conductive
What type of hearing loss does otitis media cause?
Conductive
What type of hearing loss does otosclerosis cause?
Conductive
What type of hearing loss does a perforated tympanic membrane cause?
Conductive
What happens in sensorineural hearing loss?
Occurs due to dysfunction of the cochlea and/or vestibulocochlear nerve
What type of hearing loss does presbycusis cause?
Sensorineural
What type of hearing loss does excessive noise exposure cause?
Sensorineural
What type of hearing loss do viral infections (e.g. CMV) cause?
Sensorineural
What type of hearing loss do ototoxic medications (e.g. gentamicin) cause?
Sensorineural
What aspects of the external ear should you inspect?
- Pinnae
- Mastoid
- Pre-auricular region (in front of ear)
- Conchal bowl
What are you inspecting the pinnae for?
- Asymmetry
- Deformity
- Ear piercings
- Erythema & oedema
- Scars
- Skin lesions e.g. actinic keratoses, BCC, SCC
What condition is erythema & oedema typically associated with?
otitis externa
What deformities of the pinna are you inspecting for?
Acquired (e.g. cauliflower ear) or congenital (e.g. anotia, microtia, low-set ears)
What are you inspecting the mastoid for?
- Erythema & swelling – mastoiditis
- Scars – previous surgery e.g. mastoidectomy
What are you inspecting the pre-auricular region for?
- Pre-auricular sinus/pit
- Lymphadenopathy
What is a pre-auricular sinus/pit?
a common congenital deformity that appears as a dimple in the pre-auricular region which can sometimes get infected and require surgical drainage
What can lymphadenopathy of the pre-auricular region indicate?
Ear infection e.g. otitis media, otitis externa
Areas of ear:
What are you inspecting the concha bowl for?
Inspect for signs of active infection e.g. erythema and purulent discharge
What areas of the external ear are you palpating?
- Tragus
- Regional lymph nodes - pre-auricular & post-auricular
What are you palpate the tragus for?
Palpate the tragus for tenderness which is typically associated with otitis externa.
What is cauliflower ear?
An irreversible condition that develops as a result of repeated blunt ear trauma.
What is anotia?
complete absence of the pinna
What is microtia?
underdevelopment of the pinna
What conditions are low set ears commonly seen in?
feature of genetic syndromes e.g. Down’s syndrome, Turner’s syndrome
Which ear should you examine first in otoscopy?
- Check if patient has any ear discomfort and if so, examine the non-painful side first
- Ask the patient which is their ‘better’ ear and examine this one first (can be useful for comparison)
Describe how to insert the otoscope
- Ensure light is working and apply a sterile speculum (the largest that will fit comfortably into ear)
- Pull pinna upwards and backwards with your other hand to straighten external auditory canal
- Position otoscope at external auditory meatus
- Advance otoscope under direct vision – be gentle and slow
Why do you pull the pinna upwards and backwards in otoscopy?
To straighten external auditory canal
What hand should you hold the otoscope in?
Otoscope should be held in right hand for patients’ right ear (and vice versa)
How should you hold the otoscope?
Hold otoscope like a pencil and rest your hand against patients’ cheek for stability – prevents damage to ear if sudden movement
After inserting the otoscope, what should you inspect the external auditory canal for?
- Excessive ear wax
- Erythema & oedema – e.g. otitis media
- Discharge – otitis externa or otitis media with associated tympanic membrane perforation
- Foreign bodies – cotton buds, insects etc
What is the most common cause of conductive hearing loss?
Excessive ear wax
How should you assess the tympanic membrane?
Systematically inspect the 4 quadrants of the TM
What are you inspecting the tympanic membrane for?
- Colour
- Shape
- Light reflex
- Perforation
- Scarring
- Grommets (children)
What is the colour of a healthy tympanic membrane?
pearly grey & translucent
What is the shape of a healthy tympanic membrane?
relatively flat
What would a bulging TM indicate?
increased middle ear pressure (commonly caused by acute otitis media with effusion – often an associated visible fluid level)
What would retraction of the TM indicate?
reduced middle ear pressure (commonly caused by pharyngotympanic tube dysfunction 2ary to URTIs and allergies)
What is reduced middle ear pressure commonly caused by?
pharyngotympanic tube dysfunction 2ary to URTIs and allergies
What is the light reflex of the TM?
The cone of light, or light reflex, is a visible phenomenon which occurs upon examination of the tympanic membrane with an otoscope. Shining light on the tympanic membrane causes a cone-shaped reflection of light to appear in the anterior inferior quadrant.
In healthy individuals, where should the cone of light appear?
Cone-shaped reflection of light should appear in the anterior inferior quadrant
What condition is absence or distortion of the light reflex associated with?
Absence or distortion of light reflex is associate with otitis media (due to bulging of TM
Give some causes of a perforated TM
- Infection (e.g. OM with effusion)
- Trauma (e.g. diving related)
- Cholesteatoma
- Insertion of grommets
Which aspect of the TM does a cholesteatoma typically cause a perforation?
superior aspect
What condition causes scarring of the TM?
Tympanosclerosis
What type of hearing loss can tympanosclerosis cause if extensive?
Conductive
What does scarring of the TM typically develop 2ary to?
2ary to otitis media or after insertion of grommets
Where should you discard the otoscope speculum?
into a clinical waste bin
Give some further investigations following a hearing assessment/otoscopy
- Cranial nerve exam – identify evidence of facial nerve pathology
- Audiometry & tympanometry – screen for hearing loss
- Swab discharge if present
