- 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 both 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.
Note any pre- or post-auricular scars.
Note the use of hearing aids and remember to ask the patient whether they use hearing aids.
OTOSCOPY & OTOMICROSCOPY
Gently palpate the tragus and the mastoid for tenderness. Note whether the mastoid is boggy/swollen or firm.
Using the otoscope or microscope, 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 attic, handle of malleus and light reflex); look for perforations, retraction pockets, 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.
'BEDSIDE' HEARING TESTS
- Strike a 512 Hz tuning fork against your thigh or forearm, then place the base against the mastoid bone until it can no longer be heard and then in front of the ear
- 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.)
Do not place tuning forks against teeth, eyes or anything else silly.
Strike the tuning fork and hold the base on the patient's forehead. Ask the patient where they can hear it loudest - both ears, left or right.
Record whether the result is central/equivocal, left or right.
Rinne's vs Weber's
- Normal Rinne's bilaterally and Weber's central = normal
- Abnormal Rinne's on the left and Weber's lateralising to the left = conductive hearing loss on the left (and vice versa)
- Abnormal Rinne's on the left and Weber's lateralising away to the right = sensorineural hearing loss on the left (and vice versa)
Note that Rinne's and Weber's tests are not very sensitive and can occasionally be misleading - if in doubt, request formal audiometry
Free field hearing test:
Choose any three words, each with two syllables (i.e. mango, pencil, apron).
On the side of the test ear, shield the patient's eyes and gently & repetitively press on the tragus of the non-test ear (to ‘mask’ it from inadvertently hearing).
Say all three words and ask the patient to repeat them back to you at a full arm's length (60cm)
- Whispered: normal hearing
- Conversational: mild-moderate hearing loss
- Loud voice: severe hearing loss
Repeat at a half arm's length (15cm)
- 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 nasoendoscopy: mandatory in unilateral otitis media with effusion in an adult, to visualise the post-nasal space for any masses.
Balance-related tests: cerebellar, Unterberger's, Romberg’s, gait, Dix-Hallpike, doll's eyes 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 (finer slices than a general CT head) if you want to visualise the bony anatomy of the ear.
Consider an MRI internal auditory meatus if you want to visualise the labyrinth and associated cranial nerves.
Page last reviewed: 23 September 2016