Examination of the ears
This includes an assessment of hearing as well as the appearance of the ear.
Inspecting the external ear
Inspect the external ear before examination with an otoscope/auriscope. Swab any discharge and remove any wax. Look for obvious signs of abnormality.
- Size and shape of the pinna.
- Extra cartilage tags/pre-auricular sinuses or pits.
- Signs of trauma to the pinna.
- Suspicious skin lesions on the pinna, including neoplasia.
- Skin conditions of the pinna and external canal.
- Infection/inflammation of the external ear canal, with discharge.
- Signs/scars of previous surgery.
Inspecting the ear canal and eardrum
A modern electric otoscope/auriscope with its own light source is primarily used to examine the ear. An otoscope also has its own magnification, which gives a good view of the tympanic membrane (TM). Batteries need to be fully operational to allow optimal light during the examination. The examination technique involves grasping the pinna and pulling it up and backward (posteriorly and superiorly), which helps to straighten the ear canal and for inspection of the TM. (In infants, only pull the pinna posteriorly not superiorly for examination.)
Hold the otoscope near to the eyepiece rather than at the end; this helps to reduce the patient’s discomfort due to hand movements, which are exaggerated in the ear. Modern otoscopes are designed to use a disposable speculum. It is necessary to fit the correct size of the speculum to achieve the best view; it is tempting to use a small piece for ease of insertion, but this simply restricts the image available.
Note the condition of the canal skin, and the presence of wax, foreign tissue, or discharge. The mobility of the eardrum can be evaluated using a pneumatic speculum, which attaches to the otoscope. The drum should move on squeezing the balloon.
- Size and shape.
- Obvious bend or deformity: a deviated nose is often best looked at from above.
- Scars or abnormal creases.
- Redness (evidence of skin disease).
- Discharge or crusting.
- Offensive smell.
Inspecting the tympanic membrane
Move the otoscope in order to see several different views of the drum; it is not always possible to see the whole drum in one single view using an otoscope. The drum is roughly circular (~ 1 cm in diameter). In a normal drum the following structures can be identified:
- Handle/lateral process of the malleus.
- Light reflex/cone of light.
- Pars tensa and pars flaccida (attic).
Occasionally, in a healthy, thin drum, it is possible to see the following:
- Long process of incus.
- Chorda tympani.
- Eustachian opening.
- Promontory of the cochlea.
Common pathological conditions related to the ear include:
- Perforations (note size, site, and position).
- Glue ear/middle-ear effusion.
- Retractions of the drum.
- Haemotympanum (blood in the middle ear).
Check facial nerve function if ear pathology is serious.
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