Physical Assessment: Ears

For patients w/hearing loss ask the following questions:

"Is the hearing loss in one ear?" "For how long have you been aware of a loss of hearing?" "Was the loss sudden?" "Is there a family history of hearing loss?" "What type of work do you do?" "What other work have you done?" "What types of hobbies do you have?" "Have you noticed that you can hear better when it is noisy?" "What kind of medications are you currently taking?" "Do you know if you have ever been given an antibiotic called streptomycin or gentamicin?"

Ottorhea or discharge from ear often indicates acute or chronic infection. Ask patient the following questions:

"Can you describe the discharge?" "Have you had similar episodes?" "Do you experience dizziness?" "Do you have ear pain?" "Have you had a recent ear or throat infection?" "Have you had any change in your hearing?" "Have you used ear drops?" "Have you been swimming recently?" "Have you had any recent head or ear injury?"

Vertigo: Sense of Spinning or turning at rest; often associated w/loss of vestibular function. Ask patient the following questions:

"How long have you had this sensation?" "Have you had repeated attacks?" "How long does an attack last? Seconds? Minutes? Hours? Days?" "Is the onset of an attack abrupt?" "Was the sensation brought on by, or worsened by, changes in position?" "Does the spinning sensation get worse during an attack?" "Are there any positions that make you feel better?" "During an attack, have you had double vision? Loss of strength? Decreased hearing? A disturbance of gait? Nausea? Vomiting? Ringing in your ears?" "What kind of medications are you currently taking?" "Do you know if you have ever been given an antibiotic called streptomycin or gentamicin?"

The ear can be divided into 4 parts: What are they?

1. External ear 2. Middle ear 3. Inner ear 4. Nervous innervation

What is a Rinne test?

Air conduction is compared w/bone conduction. Each ear is tested separately. Strike tuning fork and place its handle on the mastoid tip near the external auditory meatus. Ask the patient whether he or she hears the sound and to indicate when he or she no longer hears it. When the patient can no longer hear the sound, place the tines of the vibrating tuning fork in front of the external auditory meatus of the same ear, and ask the patient whether he or she can still hear the sound.

Otoscope: A Normal Tympanic Membrane

As the speculum is introduced farther into the canal in a downward and forward direction, the tympanic membrane is visualized. Normal tympanic membrane: intact, ovoid, semitransparent, pearly gray membrane Identify: Malleus in center of pars tensa, light reflex is reflected from pars tensa The pars flaccida, the short process of the malleus, and the anterior and posterior folds should be identified.

External Ear Structures

Auricle: Helix, Antehelix, Tragus, Antitragus External auditory canal

What is the Weber test?

BC is compared in both ears, and the examiner determines whether monaural impairment is neural or conductive in origin. Stand in front of the patient and place a vibrating 512-Hz tuning fork firmly against the center of the patient's forehead. Ask the patient to indicate whether he or she hears or feels the sound in the right ear, in the left ear, or in the middle of the forehead.

Hemotympanum

Blood behind drum Associated with middle meningeal artery injury secondary to basilar skull fracture Can also see "battle sign" blood behind ear

Exotosis

Bony Overgrowth of the canal Associated with chronic irritation ie surfing, sand exposure

Hemorrhagic Otitis Media

Bulging of the upper drum where the drum is most flexible Pain, fever, difficulty with hearing Can cause perforation with increased pressure

Inner Ear Functions

Cochlea transmits sound to eighth CN. Semicircular canals are involved in vestibular function.

Bell's Palsy

Define: Inflammation of facial nerve. Result: Pain behind ear (possibly before) decrease in muscle movement.

Review of related hx (Ear): Present Illness

Difficulty hearing Dizziness Discharge Pain Vertigo Trauma

How to test for Auditory Acuity Testing: Tests gross hearing

Examiner should occlude one external canal by pressing inward on the tragus and to speak softly into the other ear of the patient

Otoscope: Technique

Example of examination of right ear: Hold otoscope in right hand like a pencil Straighten canal w/left hand by pulling pinna up, out, back (for child: pull down & back)

Rinne Test: total deafness in one ear

False-negative Rinne test result: the patient may hear the tuning fork even when it is placed on the mastoid process of the deaf ear. This results from the transmission of vibrations by bone across the skull to the opposite side, where they are sensed by the healthy ear.

Define: Hearing

Hearing is interpretation of sound waves that travel through the ear to the brain. Sound is also transmitted by bone directly to the inner ear.

Normal Weber response

Hearing the sound, or feeling the vibration, in the middle

Abnormal Weber response: conductive deafness

If the sound is not heard in the middle, the sound is said to be lateralized. Sound is lateralized to the affected side in conductive deafness. AC is decreased. You can try this by occluding your external ear and placing the tuning for in the center of your forehead; result: you will have increased sound on affected side.

Rinne Test: sensorineural deafness

Impaired AC and BC but maintain the normal response (AC > BC). The middle ear amplifies the sound in both positions.

Common causes of tinnitus:

Inner ear disease: Ménière's disease, noise trauma, ototoxic drugs, and otosclerosis.

Physical Examination of Ear includes:

Inspection of external ear Palpation of external ear Assess Auditory acuity Otoscope

Keloid Formation

No intervention other than cosmetic

Middle ear functions

Ossicles transmit sound from tympanic membrane to inner ear. Tympanic membrane separates middle from external ear.

Middle Ear Structures

Ossicles: malleolus, incus, stapes Tympanic membrane

External Otitis

Pain on movement of the Pinna or tragus Swelling of the canal Discharge

Palpate the External Ear Structures

Palpate the pinna for tenderness, swelling, or nodules. If pain is elicited by pulling up and down on the pinna or by pressing in on the tragus, an infection of the external canal is probably present. Inspect the posterior auricular region for scars or swelling. Apply pressure to the mastoid tip, which should be painless. Tenderness may indicate a suppurative process of the mastoid bone.

Perforated Tympanic Membrane

Perforated drum Will impact hearing Increase chance of infection in middle ear Associated with trauma and with otitis media

Polyp

Polyp of the external canal Can be associated with decreased hearing and discharge

Inspection of external ear: what to look for

Position, size, & shape of pinna Postauricular skin Inspect the external ear for deformities, nodules, inflammation, surgical scars, or lesions. Presence of discharge

External Ear Functions

Protective Helps gather and channel sound

Rinne Test: Conductive hearing loss

Rinne negative test result (BC > AC)

Normal Rinne Test result:

Rinne positive test result (AC > BC)

Serous Otitis Media

Serous fluid behind drum If chronic can cause "glue ear" ie decreased movement of the middle ear bones and conductive hearing loss

Otoscope: Areas to note

The presence or absence of the light reflex should not be considered indicative of either normality or disease. Describe the color, integrity, transparency, position, and landmarks of the tympanic membrane. Diseased tympanic membranes may be dull and become red or yellow. The blood vessels should be visible only around the perimeter of the membrane. Dense, white plaques on the tympanic membrane may be caused by tympanosclerosis, which is caused by deposition of hyaline material and calcification within the layers of the tympanic membrane. Is the tympanic membrane bulging or retracted? Bulging of the membrane may indicate fluid or pus in the middle ear. No bubbles or fluid should be seen behind the tympanic membrane in the middle ear. If the tympanic membrane is perforated, describe the characteristics. Perforation of the tympanic membrane can occur after trauma or infection.

Otoscope: Inspection of external canal

There should be no evidence of redness, swelling, or tenderness, which indicates inflammation. The walls of the canal should be free of foreign bodies, scaliness, and discharge. If a foreign body is seen, pay particular attention when inspecting the opposite ear canal, the nose, and other accessible body orifices. Any cerumen should be left as is, unless it interferes with the visualization of the rest of the canal and tympanic membrane. If a discharge is present, look for the site of origin.

Review of related hx (Ear): Past Medical Hx

Trauma Congenital diseases Otosclerosis: Bones of mid ear are fused Meniere's Disease: Endolymph abnormality Ototoxic medications

Inner Ear Structures

Vestibule Semicircular canals Cochlea

Cerumen Impaction

Will cause conductive hearing loss Obstructs ear canal and can cause external otitis Can impact hearing acutely

What is tinnitus?

sensation of hearing sound, such as buzzing or ringing, in the absence of environmental input.

Abnormal Weber response: unilateral sensorineural deafness

the sound is not heard on the affected side but is heard by, or localized to, the unaffected ear.