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Ear examination


  • Wash hands
  • Introduce self
  • Ask Patientโ€™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 โ€“ 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


  • 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)


  • 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


  • 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 (โ€˜grommetโ€™), 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

Weberโ€™s test

  • Use a 512Hz tuning fork
  • Twang the prongs and place the round base of the fork on the patientโ€™s forehead between their eyes
  • Ask them if one side is louder than the otherย (if one side is louder, either that side has a conductive deficit, or the contralateral side has a sensorineural deficit โ€“ Rinneโ€™s test can then determine which)

Rinneโ€™s test

  • Use a 512Hz tuning fork
  • Twang the prongs and place the round base of the fork on the patientโ€™s mastoid process
  • Ask them to tell you when the sound stops
  • Then, place the prongs near the patientโ€™s ear
  • Ask them if they can then hear it again โ€“ air conduction should be louder than bone conduction (if they cannot hear it, there is a conductive deficit in that ear)


  • 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)  

Test your knowledge

What is a cholesteatoma?

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What is Ramsay Hunt syndrome?

What is a Grommet and what are the indications?

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