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Ear Examination & Otoscopy

From Mediwikis

Ear Examination

The ear examination follows a different structure to some of the others, but it isn't long and doesn't take long to learn. Just try and remember the balance test at the end, it is the one that is more unique and therefore often forgotten!

As with all the examinations, begin with the same opening sequence. Being friendly and rewording questions to make them sound less rehearsed will make your bedside manner appear much more natural and confident.

  • Wash hands
  • Introduce yourself
  • Confirm their name, age and date of birth (try and remember the first 2 for your closing summary!)
  • Consent eg. I've been asked to examine your ear today which will involve having a look in your ear and some simple hearing tests - is that alright with you? - Again, rephrase to what you feel most natural saying.
  • Check for pain or recent problems in hearing


Inspection

Examine both ears, starting with the normal ear. Remember to tuck any hair behind the ear, and look at both the front and back for the following abnormalities.

  • Scars
  • Erythema
  • Swelling
  • Discharge
  • Congenital abnormalities

Palpation

I'm now going to have a quick feel of both your ears, is that alright? Let me know if you feel any pain.

  • Palpate the mastoid tip and the tragus for any tenderness or fluctuance.

Crude Hearing Test

Rinnes and Webers tests

Rinne's Test

Use a 512HZ tuning fork to perform Rinne's Test. Remember to explain to the patient what you're doing. I'm going to place this tuning fork behind your ear, can you please tell me once the ringing has stopped. I will then move the fork to in front of your ear, and will ask you if you can hear the ringing again. Is that alright with you? Air conduction should be louder than bone - this would be a positive Rinne's result and therefore normal.

  • Conductive deafness - the bone test will be louder than air.

Remember to test both ears, not only the 'problem' ear.

Weber's test

place the tuning fork on the patient's forehead and ask them whether the sound is equal in both ears or if they can hear it louder on one side.

  • Conductive deafness - the sound will localise to the same side as the defect.
  • Sensorineural deafness - the sound will be heard louder in the normal side.


Otoscopy

I'm now going to have a look in your ear - is that ok? It may be a little bit uncomfortable, but if you feel any pain or want me to stop then let me know and I'll stop straight away.

  • Tilt the head away by 15-20 degrees.
  • Adults - pull pinna superiorly/posteriorly. Children - pull pinna inferiorly/posteriorly.
  • Hold it like a pen and steady your hand by resting your ring/little fingers on the patient's face.
  • Remember RIGHT ear, RIGHT hand, your RIGHT eye.

Once you've looked in both ears, remember to summarise your findings.

  • Inflamed or not inflamed
  • Intact or perforated
  • Cone of light in the right anatomical position
  • Fluid in the middle ear and if so, is it infective?

Romberg's Test

Can you stand up for me please and close your eyes? I'm going to be testing your balance, but don't worry, my hands will be out to support you if you are unsteady. Swaying, stumbling or falling would be a positive result.

Nystagmus

Ask the patient to follow your finger up and down then side to side while you watch their eyes for any flickering or oscillations.


As always, thank the patient and wash your hands.

SUMMARY - After introducing the patient's name and age, comment briefly on each of the sections and finish with an overall statement such as this was a normal ear examination.

Questions

What are some of the common ear problems in children?
Infection secondary to respiratory tract infection, glue ear (prolonged otitis media with effusion).
What is the difference between infective otitis media and otitis media with effusion?
Infective: most often viral, accompanying URTI. Self-limiting.
Otitis Media w/ Effusion: Collection of pus in middle ear resulting from negative pressure due to altered eustachian tube function.
Looking for bullous myringitis, swollen, inflamed tympanic membrane
Which group of medicine could cause hearing loss?
Aminoglycosides (antibacterial, ie. Gentamicin), diuretics, aspirin
Which occupations that could contribute to hearing loss?
Airports, traffic, construction - anything with high environmental noise.
Could heredity contribute to hearing loss?
Yes, GJB2, Stickler Syndrome, Pendred Syndrome