Ear examination

Introduction

Wash hands
Introduce self
Ask Patient’s name, DOB and what they like to be called
Explain examination and obtain consent
Explain procedure, asking them to stay completely still when you use the otoscope
Position patient – seat at same level as you with both ears accessible
Note and remove any hearing aids
Prepare otoscope, speculum, 512Hz tuning fork

Inspection

General inspection: symmetry, position (low set = genetic syndromes), shape
Close ear inspection
- Skin in front of and behind ear: skin tags, erythema, scars, preauricular sinuses/pits
- Pinna: any skin changes (e.g. neoplasia), deformities (e.g. accessory auricle), scars, erythema (erysipelas, chondritis),perichondrial haematoma (trauma)
- External auditory meatus: erythema, pus/discharge (otitis externa)
- Mastoid: erythema/swelling (mastoiditis)

Palpation

Pinna: tug gently (tenderness may suggest mastoiditis)
Mastoid: palpate mastoid (tenderness may suggest mastoiditis)
Lymph nodes: feel for pre/postauricular lymphadenopathy (infection)

Otoscopic view of right tympanic membrane

Otoscopy

Apply new speculum to otoscope and turn on light
Hold the otoscope like a pencil (in your right hand for the right ear and vice versa) with the handle pointing anteriorly
Start with non-affected ear
Pull the pinna up and backwards (down and backwards in children) with your other hand to straighten the external auditory canal
Insert the speculum tip into the external auditory meatus
Rest the ulnar border of your hand on their cheek to stabilise it
Gently advance the speculum while looking through the otoscope
Look at:
- Auditory canal: wax, foreign bodies, skin quality (thick white growth = cholesteatoma), erythema/discharge (otitis externa)
- Tympanic membrane
  - Colour: should be pinkish-grey (erythematous = otitis media; scarred = tympanosclerosis)
  - Structure: look for perforation, tympanostomy (‘grommet’), bulging (otitis media), or retraction (Eustachian tube dysfunction)
  - Fluid (effusion, haemotympanum)
- Behind tympanic membrane for any visible features (pars tensa, pars flaccida, handle/lateral process of malleolus, cone of light)
Slowly withdraw the otoscope
Dispose of speculum in clinical waste bin

Hearing tests

Crude hearing test

Ask patient to occlude one ear

Whisper a number, starting peripherally and then moving closer towards their ear

Ask them to tell you the number when they hear it

Repeat on other side

Weber’s test

Use a 512Hz tuning fork

Twang the prongs and place the round base of the fork on the patient’s forehead between their eyes

Ask them if one side is louder than the other (if one side is louder, either that side has a conductive deficit, or the contralateral side has a sensorineural deficit – Rinne’s test can then determine which)

Rinne’s test

Use a 512Hz tuning fork

Twang the prongs and place the round base of the fork on the patient’s mastoid process

Ask them to tell you when the sound stops

Then, place the prongs near the patient’s ear

Ask them if they can then hear it again – air conduction should be louder than bone conduction (if they cannot hear it, there is a conductive deficit in that ear)

Lastly

Test facial nerve function if serious pathology observed

To complete

Thank patient
Summarise and suggest further investigations you would consider after a full history (e.g. audiometry, tympanometry)

Common ear pathology

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Test your knowledge

What is a cholesteatoma?

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What is Ramsay Hunt syndrome?

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What is a Grommet and what are the indications?

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