Table of Contents
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)
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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