Ear Examination and Hearing Tests

Ear Examination Cheatsheet

Ear examination involves a systematic approach, from initial inspection to specialized hearing tests. Always prioritize patient comfort and safety.

1. Pre-Examination & Patient Setup (Before starting)

• Hand Hygiene: Gel/wash hands.

• Introduction: Introduce yourself, ensure patient comfort.

• Pain Assessment: Ask about any pain or tenderness before touching.

• Patient Positioning:

  • Adults: Seated on a chair, examiner to the side.

  • Children: Seated across parent/nurse's lap; carer secures head to chest and controls flailing arms. Utilize play and opportunistic examination.

2. Inspection (From the front, Pre-auricular, Post-auricular)

• Overall Appearance:

  • Assess size and symmetry of the pinna.

  • Note any abnormal protrusion or obvious abnormalities.

• Rule: Inspect each ear individually, starting with the "normal" ear (if known).

• Pre-auricular Area:

  • Look for scars (parotidectomy, middle ear surgery).

  • Check for swelling (infection, parotid tumour), erythema, sinuses, pits, fistulae.

• Post-auricular Area:

  • Gently move the pinna anteriorly to inspect the area behind it.

  • Note any post-auricular scars.

  • Acute and/or painful swelling suggests infection (mastoiditis or lymphadenitis).

  • Compare with the other ear.

3. Otoscopy (EAC, Tympanic Membrane, Ossicles)

• Equipment: Ensure otoscope has good magnification and illumination.

• Speculum Size: Use the largest speculum that fits comfortably in the EAC.

• Rule: Start with the "normal" ear.

• Pinna Manipulation:

  • Adults: Gently pull the pinna upwards and backwards.

  • Children: Pull the pinna downwards and backwards for better visualization.

• Otoscope Handling: Hold like a pencil, use little finger as a fulcrum against the cheek to prevent injury from sudden patient movement.

• External Auditory Canal (EAC): Check for wax, discharge, erythema, swelling (infection, trauma).

• Tympanic Membrane (TM):

  • Light Reflex: Is there a normal light reflex in the anteroinferior quadrant?

  • Colour:

    • Normal: Greyish and translucent.

    • Pink/Red: Suggests infection/inflammation.

    • White Plaques: May indicate tympanosclerosis.

  • Position:

    • Retracted: Cholesteatoma, infection.

    • Bulging: Infection.

    • Perforation: Presence of a hole.

• Ossicles: Malleus, incus, and stapes may be visible, sometimes through a perforation.

• Pneumatic Otoscopy: Assesses TM mobility by varying pressure in the ear canal using a rubber bulb.

4. Hearing Tests (Gross, Free Field, Weber's, Rinne's)

These tests help identify and categorize hearing loss (sensorineural vs. conductive).

4.1 Gross Hearing Assessment

• Observation: Observe patient's response to your greeting. Are they using a hearing aid?

4.2 Free Field Testing (Screening Tool)

• Masking: Rub the tragus of the contralateral ear to prevent sound from being heard in the non-test ear, improving accuracy.

• Procedure:

  • Use polysyllabic phrases (numbers/letters, e.g., 'C5', '37') or motivational words for children.

  • Test the normal ear first.

  • Perform tests at arm's length (approx. 60cm) and 15cm.

  • Order of intensity: Whisper, Conversational Speech, Loud Voice.

  • Patient should repeat >50% correctly.

• Interpretations:

  • Whisper at 60cm: Hearing better than 30dB

  • Whisper at 15cm: Hearing better than 35dB

  • Conversational voice at 15cm: Hearing better than 55dB

  • Loud voice at 60cm: Hearing worse than 75-90dB

4.3 Weber's Test (Midline Localization)

• Purpose: Differentiates conductive from sensorineural hearing loss.

• Procedure: Apply vibrating 512Hz tuning fork firmly to the midline of the forehead (or apex of skull).

• Patient Report: Ask if tone is heard in right ear, left ear, or center.

• Interpretation:

  • Lateralization: If tone is louder in one ear, it could be:

    • Conductive Hearing Loss (CHL) in the louder ear (sound bypasses external/middle ear block).

    • Sensorineural Hearing Loss (SNHL) in the quieter ear (cochlea/nerve damage).

  • Use Rinne's test to clarify.

4.4 Rinne's Test (Bone vs. Air Conduction)

• Purpose: Compares air conduction (AC) to bone conduction (BC).

• Procedure:

  1. Position 1 (BC): Place vibrating tuning fork base on the mastoid process until sound fades.

  2. Position 2 (AC): Move the vibrating prongs adjacent to (not touching) the external auditory meatus.

  3. Patient Report: Ask the patient which position was louder.

• Interpretations:

  • Positive Rinne (Normal): AC > BC (Position 2 is louder than Position 1). Indicates normal hearing or SNHL.

  • Negative Rinne (Abnormal): BC > AC (Position 1 is louder than Position 2). Indicates external or middle ear disease affecting air conduction (CHL).