- Wash your hands
- Introduce yourself and confirm the patient’s identity
- Explain that the examination of the ear which will include using an otoscope and tuning fork
- Check if there is any pain or discharge from the ear
- Obtain verbal consent
Inspect from the front for any asymmetry of the pinnas.
Inspect each pinna in turn for deformity or swelling eg cauliflower ear. Inspect for erythema or cellulitis, flaky skin, ear discharge, skin lesions, subcutaneous masses and pre-auricular sinuses.
Look carefully for pre- or post-auricular scars - they can be very faint.
Note the use of hearing aids (behind the ear, in the ear, BAHA or cochlear implant) and remember to ask the patient whether they use hearing aids if they are not present.
Gently palpate the tragus and the mastoid for tenderness. Note whether the mastoid is boggy/swollen or firm.
Using the otoscope, examine the -
External auditory canal: look for wax; erythema; swelling; flaky skin; discharge (is it custard-like mucopurulent, full of black Aspergillus spores or watery?); foreign body; masses (furuncle, exotoses, osteoma); vesicles; granulomata.
Tympanic membrane: look at the four quadrants (in particular the pars tensa); look for perforations, retraction pockets, accumulation of keratin, crusts, bulging, grommets and the colour of the tympanic membrane (is it dull, erythematous or bloody or can you see a fluid level?).
You should hold the otoscope correctly: like a pen; your right hand to the patient's right ear and vice versa; using your little finger to balance your hand against their cheek.
In chronic ear disease, you should examine the ear with a binocular microscope, and perform careful microsuction of any wax, keratin or discharge.
'BEDSIDE' HEARING TESTS
- Explain to the patient what you need them to do.
- Strike a 512 Hz tuning fork against your thigh, knee or forearm, then place the base against the mastoid bone until the patient tells you it can no longer be heard.
- Immediately move the tuning fork in front of the ear (2 cm away from the meatus)
- Ask the patient whether they can still hear the tuning fork
- If they can, the test is positive (=normal)
Record whether the result is normal or abnormal. It is normal to have better air conduction than bone conduction. In shorthand: AC>BC.
(For Rinne's test, a normal test is known as a positive test - the opposite of most other medical tests. Since this is confusing, we suggest you use 'normal' and 'abnormal', supplemented with shorthand where appropriate.)
Strike the tuning fork and hold the base on the patient's forehead. Ask the patient where they can hear it loudest - in the middle, left or right.
Record whether the result is central/equivocal, left or right.
Interpretation of tuning fork tests:
- Normal Rinne's bilaterally and Weber's central = normal, or symmetrical sensorineural hearing loss
- Abnormal Rinne's on the left and Weber's lateralising to the left = conductive hearing loss on the left
- Abnormal Rinne's on the left and Weber's lateralising to the right = sensorineural hearing loss on the left. This situation is known as the "false negative" Rinne.
Note that no test is perfect, and tuning forks can occasionally be misleading - if in doubt, request formal audiometry. Despite this, tuning forks are most often useful nowadays to clarify inaccurate or equivocal pure-tone audiograms!
Free field hearing test:
Choose words, each with two balanced syllables (e.g. cowboy, football, mango, pencil, apron).
On the side of the test ear, shield the patient's eyes with one hand, and gently & repetitively press on the tragus of the non-test ear, using your other hand passed behind the patient's head. This masks the non-test ear.
Say the test words, and ask the patient to repeat them back to you at a full arm's length. If the patient correctly identifies 50% or more words at the quietest threshold (whisper at arm's length) they have normal hearing in this ear. You can then move on to test the contralateral ear. If not, increase the volume as follows until the patient correctly identifies 50% or more words.
- Whispered: normal hearing
- Conversational: mild-moderate hearing loss
- Loud voice: severe hearing loss
At a half arm's length:
- Whispered: mild hearing loss
- Conversational: moderate hearing loss
- Loud voice: profound hearing loss
TO COMPLETE YOUR ASSESSMENT
Pure tone audiometry and tympanometry provide you with a wealth of information.
Assess and document facial nerve function.
OTHER TESTS & INVESTIGATIONS
Flexible nasendoscopy: mandatory in unilateral glue ear in an adult, to visualise the post-nasal space for any masses.
Balance-related tests: eye movements (smooth pursuit and saccades), cerebellar tests, Unterberger's, Romberg’s, gait, Dix-Hallpike, head-thrust test.
Neck examination: for any lymphadenopathy or masses.
Fistula test: pump the tragus inwards to change the pressure in the ear canal; if there is a dehiscence of the bony labyrinth, this pressure will be transmitted into the inner ear; observe for nystagmus towards the affected ear.
Consider a CT temporal bones if you want to assess the state of the ossicular chain or any bony labyrinth erosion.
Consider an MRI internal auditory meatus if there is unilateral/asymmetrical sensorineural hearing loss, to exclude a vestibular schwannoma.
Page last reviewed: 24 September 2017