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)

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)  

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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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