Expert Review Examination of the Ear Tom GH Bowden* and Martin J Burton# ……………………………………………………………………………………………………………………………………..

The Journal of Clinical Examination 2007; 2: 1-3

Abstract Examination of the ear is an essential part of the clinical examination, and a comprehensive approach to it is useful for doctors in all environments. This article provides a routine for examination of the ears in adults, and follows the principles of clinical examination [1]. It should provide a useful resource for both the novice medical student and the more experienced clinician. Word count: 1,490. Key words: clinical examination, ear, otoscopy. Address for correspondence: [email protected] Authors’ Affiliations * Final Year Medical Student, The University of Oxford. Otolaryngology, University of Oxford and John Radcliffe Hospital Oxford, UK.

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Consultant, Department of

…………………………………………………………………………………………………………………………………….. Introduction Examination of the ear is an essential part of the clinical examination. Medical Students do not spend as much time in Otolaryngology as other surgical specialities and so there is less scope for this part of the examination to be performed during a doctor’s training. A comprehensive approach to the examination of the ear is essential for doctors in all environments. This is often without the benefit of the more advanced type of equipment found in an ENT department. Here we set out a routine for the examination of the adult ear. Examination Examination of the ear should follow the criteria set out in The Principles of Clinical Examination [1] and follow a logical pattern as with other clinical examinations. An otoscope with pneumatic attachment and a 512 Hz tuning fork are essential pieces of equipment that you will need. Begin by introducing yourself to the patient, explain what you are going to do and ask them if they have any pain and to let you know if you cause them discomfort at any point. Ask the patient to sit down in front of you. If you are examining a patient at home or in hospital, look around for any items that may give you a clue to that they have any diseases of the ear. INSPECTION Start by inspecting from the front for any asymmetry or abnormally protruding ears. Then inspect each ear in turn starting on the normal side if the patient presents with unilateral symptoms. If the patient is wearing a hearing aid ask them to remove it. Start with inspection of the pinna. Note its size, shape, position, colour and look for any congenital defects

or scars. A normal pinna and its landmarks are shown in Figure 1. Abnormality in any of these may be a familial trait or may indicate an underlying disease process. ‘Cauliflower ears’ may result from repeated blunt trauma (e.g. from contact sports). Look also for tophi (a sign of gout), sebaceous cysts, or any abnormalities such as extra pinnae, skin tags or a pre-auricular sinus. Common surgical scars around the ear include a post auricular scar in or just behind the post auricular sulcus and an endaural scar between the root of the helix and the tragus which result from middle ear or mastoid surgery.

Figure 1 The external ear. After inspection of the pinnae you should look for any wax or otorrhoea (discharge from the external auditory meatus [EAM]). Wax (cerumen) is a normal finding but may be present in variable quantities. In the cases of head trauma a bloody or serous 1

discharge may indicate a fracture of the base of the skull. Foul smelling or purulent discharge may be associated with otitis, a foreign body or a cholesteatoma. Closer visual inspection of the EAM itself should follow to see if there is any obvious obstruction to the lumen. An especially large EAM may indicate that the patient has had a meatoplasty – a surgical procedure to widen the EAM, often performed as part of a mastoidectomy operation. To complete the inspection of the ear, the pinna should be gently bent forward to allow a good view of the post auricular area. This may reveal surgical scars, inflammation or ulceration.

Therefore, use the largest speculum that is comfortable for the patient. Insert it slowly into the canal to a depth of around 1 – 1.5cm. You are trying to reach a point just past the hairs of the lateral canal. Take care not to insert it too far as the bony section of the canal is very sensitive. If you ‘jam’ the end of the speculum into the bony canal you have gone too far. Even with a large speculum you will not be able to see the whole tympanic membrane or canal without moving the speculum (and your head with it).

PALPATION After inspecting the post auricular area, palpate the pinnae and post auricular region for any tenderness, swelling or nodules. Proceed to palpate the mastoid area, tenderness here may indicate mastoiditis. Finally gently pull on the pinna. This should be painless. Pain indicates that there may be inflammation of the external ear canal. Palpate the area in front of the tragus and ask the patient to open and close their mouth. Tenderness with or without crepitus may indicate tempero-mandibular joint dysfunction. OTOSCOPY Visualisation of the EAM and the tympanic membrane is often thought to be difficult. However, with adequate illumination from an appropriate otoscope the view of the external canal and tympanic membrane can be excellent. The otoscope should be held like a pen between the thumb and index finger, using your right hand for examination of the right ear and left hand for examination of the left ear. Rest the ulnar side of your hand on the patients head as shown in Figure 2. The rationale for this method is that your hand is ‘fixed’ relative to the patients head. If you slip or someone bumps your arm, the otoscope will not suddenly stab into the EAM causing pain and distress. With your free hand gently pull the pinna upwards, backwards and outwards. Remember to watch for the patient’s reaction when doing this as it is easy to cause discomfort if they have inflammation in their EAM. This manoeuvre straightens the cartilaginous external ear canal allowing a good view of the tympanic membrane. The amount of light passing down the ear canal onto the drum is dictated by the size of the speculum used on the otoscope. Also, the bigger the speculum, the larger the fraction of tympanic membrane that can be seen at any one time.

Figure 2 How to hold an otoscope. Inspect the canal for discharge, scaling, inflammation, foreign bodies, stenoses, cerumen and exostoses. Exostoses are areas of localised bony hypertrophy often found in those with a history of aquatic sports. If your view is obscured by cerumen it may be appropriate to remove it. This can be done with a wax hook or by syringing in the primary care setting. Microsuction in an ENT department may be needed if removal is difficult. After looking at the canal, inspect the tympanic membrane. You need to be able to recognise a normal tympanic membrane in order to identify pathology. A normal tympanic membrane is shown in Figure 3. Practice is necessary due to the wide variety of normal appearances. Be systematic, look at each quadrant in turn and identify the normal landmarks shown in Fig. 3 (pars tensa, pars flaccida, handle of malleus and the light reflex). The light reflex should be seen as a cone of light in the 2

anterio-inferior quadrant as the membrane reflects light from your otoscope back towards you. Note the colour and translucency of the drum. It should not be bulging out or retracted and should have no perforations. A bulging tympanic membrane may lose its bony landmarks and usually is a sign of pus in the middle ear. A retracted membrane will have accentuated bony landmarks and may signify a dysfunctional Eustachian tube. Small white areas on the drum are most likely to be ‘plaques’ of tympanosclerosis.

You should now have completed you examination of the ear. To conclude, thank the patient and make sure they are comfortable. References [1] Jopling, H. The principles of clinical examination The Journal of Clinical Examination (2006) 1: 3-6 [2] Bagai A, Thavendiranathan P, Detsky AS. Does this patient have hearing impairment? JAMA 2006;295:416–28. [3] TGH Bowden and MJ Burton Examination of the ear using the tuning fork tests The Journal of Clinical Examination (2007) 2: 4-6 [4] Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination, 3rd Edition. Mosby; 1995 [5] Munro JF, MacLeod J, Campbell CR.Macleod’s Clinical Examination, 11th Edition. Churchill Livingstone; 2005 [6] O’Donoghue GM, Narula AA, Bates GJ. Clinical ENT, 2nd Edition. Singular Publihing; 2000.

Figure 3 View of the tympanic membrane. To complete the examination you should assess the patient’s hearing. Ask the patient if they have any hearing loss and observe their ability to hear you during the examination. Controversy exists as to the role of the voice whisper tests as a screening test for hearing loss [2. However, if hearing loss is suspected then the tuning fork tests [3 – Rinne and Weber’s tests – may be useful.

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