Examination of the Ear

This includes an assessment of hearing as well as the appearance of the ear.

 History

The following issues should be included:

v Classic symptoms of ear disease: deafness, tinnitus discharge (otorrhoea) and vertiyo.

v Previous ear surgery, or head injury.

v Family history of deafness.

v Systemic disease (e.g. stroke, multiple sclerosis, cardiovascular disease).

v Ototoxic drugs (antibiotics (e.g. gentamicin), diuretics, cytotoxics)

v Exposure to noise (e.g. pneumatic drill or shooting)

v History of atopy and allergy in children.

Inspecting the External Ear

Inspect the external ear before examination with an otoscope/auriscope. Swab any discharge and remove any wax. Look for obvious signs of abnormality.

v Size and shape of the pinna.

v Extra cartilage tags/pre-auricular sinuses or pits.

v Signs of trauma to the pinna.

v Suspicious skin lesions on the pinna including neoplasia.

v Skin conditions of the pinna and external canal

v Infection/inflammation of the external ear canal, with discharge.

v Signs/scars of previous surgery.

Inspecting The Ear Canal And Eardrum

A modern electric otoscope/auriscope with its own light source is primarily used. An otoscope also has its own magnification which gives a good view of the tympanic membrane.

Examination Technique

v This involves grasping the pinna and pulling it up and backwards (posteriorly and superiorly) which helps to straighten the ear canal and for inspection of the TM.

v Hold the otoscope near to the eyepiece rather than at the end, this helps to reduce patient’s discomfort due to hand movements. Fit the correct size of speculum to achieve best view; it is tempting to use a small piece for ease of inserting, but this simply restricts the image available.

v NOTE:The condition of the canal skin, and the presence of wax, foreign tissue, or discharge.

Inspecting The Tympanic Membrane

Move the otoscope in order to see several different views of the drum. The drum is roughly circular (~1cm diameter). In a circular drum, the following structures can be identified.

v Handle/Lateral process of the malleus.

v Light reflex/cone of light.

v Pars tensa and pars flaccid (attic).

Occasionally, in a healthy, thin drum, it is possible to see the following:

v Long process of incus

v Chorda tympani

v Eustachian opening

v Promontory of the cochlea.

Common pathological conditions related to the ear include.

v Perforations

v Glue ear/middle ear effusion

v Refractions of the drum

v Blood in the middle ear (haemotympanum)

Basic Hearing Tests

A patient with normal hearing should hear equally as well in both ears.

Turning Fort Tests

This includes weber’s and Rinnes’s test.

Weber’s Test

This is performed in conjunction with Rinne’s test. The vibrating fork is placed in the middle of the forehead and the patient is asked whether any sound is heard, and if so, whether it is equally heard in the better ear. It is more likely to be a sensorineural hearing loss.

Rinne’s Test

Strike a tuning fork and hold it vertically with its nearest prong about 1cm away from the patient’s external L meatus. The patient is asked to repeat on which of the two positions was it louder. Normally, the patient should hear the air conduction better than the bone conduction (i.e. first position better than the second). This is a positive Rinne’s test. If the Rinnes’s test is positive and there is hearing impairment, it is a sensorineural and not a conductive problem. If there is a negative Rinne’s test with hearing loss, then the problem is conductive one.