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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

External ear anatomy

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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)
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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 testAsk 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 testUse 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 testUse 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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