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11/13/24, 7\:05 PM Guide | Hearing assessment & otoscopy

Hearing assessment & otoscopy

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
i n v o l v e m e h a v i n g a l o o k i n s i d e y o u r e a r s u s i n g a s p e c i a l p i e c e o f e q u i p m e n t k n o w n a s a n o t o s c o p e . I' d a l s o l i k e t o a s s e s s y o u r
h e a r i n g .
"
Gain consent to proceed with the examination.
Ask the patient to sit on a chair.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Hearing aids\: note if the patient is wearing a hearing aid and ask the patient to remove this when performing otoscopy.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status. The
patient may have vestibulocochlear nerve pathology causing both hearing and balance issues.
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Gross hearing assessment

Preparation

Ask the patient if they have noticed any change in their hearing recently.
Explain that you're going to say 3 words or 3 numbers and you'd like the patient to repeat them back to you (choose two-
syllable words or bi-digit numbers).

Assessment

1. Position yourself approximately 60cm from the patient's ear and then whisper a number or word.
2. Mask the ear not being tested by rubbing the tragus. Do not place your arm across the face of the patient when rubbing the
tragus, it is far nicer to occlude the ear from behind the head. If possible shield the patient's eyes to prevent any visual stimulus.
3. Ask the patient to repeat the number or word back to you. If they get two-thirds or more correct then their hearing level is
12db or better. If there is no response use a conversational voice (48db or worse) or loud voice (76db or worse).
4. If there is no response you can move closer and repeat the test at 15cm. Here the thresholds are 34db for a whisper and 56db
for a conversational voice.
5. Assess the other ear in the same way.
Whisper a number 60cm from the ear

Weber's test

Explain to the patient that you are going to test their hearing using a tuning fork.
1. Tap a 512Hz tuning fork and place in the midline of the forehead. The tuning fork should be set in motion by striking it on your
knee (not the patient’s knee or a table).
2. Ask the patient " W h e r e d o y o u h e a r t h e s o u n d ?"
These results should be assessed in context with the results of Rinne's test before any diagnostic assumptions are made\:
Normal\: sound is heard equally in both ears.
Sensorineural deafness\: sound is heard louder on the side of the intact ear.
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Conductive deafness\: sound is heard louder on the side of the a
A 512Hz tuning fork is used as it gives the best balance between time of decay and tactile vibration. Ideally, you want a tuning
fork that has a long period of decay and cannot be detected by vibration sensation.
Tap a 512Hz tuning fork and place in the midline of the forehead

Rinne's test

1. Place a vibrating 512 Hz tuning fork
sure the contact is
2. Con
3. When the patient can no longer hear the sound, move the tuning fork in front of the external auditory meatus to test air
conduction.
4. Ask the patient if they can now hear the sound again. If they can hear the sound, it suggests air conduction is better than
bone conduction, which is what would be expected in a healthy individual (this is often confusingly referred to as a "Rinne's
positive" result).

Summary of Rinne's test results

These results should be assessed in context with the results of Weber's test before any diagnostic assumptions are made\:
Normal result\: air conduction > bone conduction (Rinne's positive)
Sensorineural deafness\: air conduction > bone conduction (Rinne's positive) - due to both air and bone conduction being
reduced equally
Conductive deafness\: bone conduction > air conduction (Rinne's negative)
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Place a 512 Hz tuning fork on the mastoid process
Conductive vs sensorineural hearing loss
Conductive hearing loss occurs when sound is unable to e
external auditory canal, tympanic membrane and middle ear (ossicles). Causes of conductive hearing loss include
excessive ear wax, otitis externa, otitis media, perforated tympanic membrane and otosclerosis.
Sensorineural hearing loss occurs due to dysfunction of the cochlea and/or vestibulocochlear nerve. Causes of
sensorineural hearing loss include increasing age (presbycusis), excessive noise exposure, genetic mutations, viral
infections (e.g. cytomegalovirus) and ototoxic agents (e.g. gentamicin).

External ear

Inspection

Pinnae
Inspect the pinnae for\:
Asymmetry\: by comparing the pinnae you may identify subtle unilateral pathology.
Deformity of the pinnae\: this may be acquired (e.g. cauli
Ear piercings\: can be a potential source of infection, an allergen and a cause of trauma.
Erythema and oedema\: typically associated with otitis externa.
Scars\: indicative of previous surgery.
Skin lesions\: look for evidence of pre-malignant (actinic keratoses) and malignant (e.g. basal cell carcinoma, squamous cell
carcinoma) skin changes.
Mastoid
Inspect the mastoid region\:
Erythema and swelling\: typically associated with mastoiditis.
Scars\: indicative of previous surgery (e.g. mastoidectomy).
Pre-auricular region
Inspect the pre-auricular region (in front of the ear)\:
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Pre-auricular sinus/pit\: a common congenital deformity that appears as a dimple in the pre-auricular region. These sinuses
can sometimes become infected and require surgical drainage.
Lymphadenopathy\: typically associated with an ear infection (e.g. otitis media, otitis externa).
Conchal bowl
Inspect the conchal bowl for signs of active infection such as erythema and purulent discharge.

Palpation

Palpate the tragus for tenderness which is typically associated with otitis externa.
Palpate the regional lymph nodes\:
Pre-auricular lymph nodes
Post-auricular lymph nodes
Anatomy of the external ear
Cauli
Cauli
bleeding under the perichondrium of the pinna, stripping away the ear's cartilage. This cartilage normally relies on the
perichondrium for its nutrient supply and as a result, once separated it becomes
architecture.
Congenital deformity of the ears
There are several types of congenital ear deformity including\:
Anotia\: a complete absence of the pinna.
Microtia\: underdevelopment of the pinna.
Low-set ears\: the ears are positioned lower on the head than usual. Low-set ears are a feature of several genetic
syndromes including Down's syndrome and Turner's syndrome.
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Otoscopy

To help decide which ear to examine
Check if the patient has any ear discomfort and if so examine the non-painful side
Ask the patient which is their “better” ear and examine this one

Inserting the otoscope

1. Ensure the light is working on the otoscope and apply a sterile speculum (the largest that will comfortably
auditory meatus).
2. Pull the pinna upwards and backwards with your other hand to straighten the external auditory canal.
3. Position the otoscope at the external auditory meatus\:
The otoscope should be held in your right hand for the patient's right ear and vice versa for the left ear.
Hold the otoscope like a pencil and rest your hand against the patient's cheek for stability. This will prevent damage to the
ear if there is sudden movement.
4. Advance the otoscope under direct vision. Be gentle with the otoscope and ensure movements are slow and considered
otherwise you will cause discomfort.

External auditory canal assessment

5. Inspect the external auditory canal for\:
Excessive ear wax\: the most common cause of conductive hearing loss.
Erythema and oedema\: typically associated with otitis externa.
Discharge\: may suggest otitis externa or otitis media with associated tympanic membrane perforation.
Foreign bodies\: these may include cotton buds, insects and other small objects.

Tympanic membrane assessment

6. Systematically inspect the four quadrants of the tympanic membrane (TM) to avoid missing pathology.
Colour
A healthy TM should appear pearly grey and translucent.
Erythema suggests in
Shape
A healthy TM should appear relatively
Bulging of the TM suggests increased middle ear pressure, which is commonly caused by acute otitis media with e
(there is often an associated visible
Retraction of the TM suggests reduced middle ear pressure, which is commonly caused by pharyngotympanic tube
dysfunction secondary to upper respiratory tract infections and allergies.
Light re
The light re
If a TM is healthy, the cone-shaped re
In the left ear, the light re
In the right ear, the light re
Absence or distortion of the light re
Perforation
Note the size and the position of any perforations of the TM.
Causes of TM perforation include infection (e.g. otitis media with e
insertion of tympanostomy tubes (also known as grommets).
Cholesteatoma typically causes perforation in the superior part of the TM and there may be visible granulation tissue and
discharge in this region.
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Scarring
Scarring of the TM is known as tympanosclerosis and can result in signi
Tympanosclerosis often develops secondary to otitis media or after the insertion of a tympanostomy tube.

Final steps

7. Withdraw the otoscope carefully.
8. Repeat your assessment on the other ear, comparing your
change the speculum on the otoscope before examining the other ear.
9. Discard the otoscope speculum into a clinical waste bin.
Prepare the otoscope
Otitis media and otitis externa
Acute otitis media is an in

behind the membrane. There may also be discharge in the auditory canal if the tympanic membrane has perforated.
Otitis externa is an in
surface of the tympanic membrane. The condition is usually caused by a bacterial infection. Typical
examination include erythema of the auricle and external auditory canal with associated pain. Other
oedema of the auditory canal causing narrowing, regional lymphadenopathy and discharge in the ear canal.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
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Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 2 5- y e a r-o l d m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
t h e r e w e r e n o a b n o r m a l i t i e s n o t e d o n i n s p e c t i o n o f t h e e x t e r n a l e a r.
"
" O t o s c o p y r e v e a l e d n o r m a l t y m p a n i c m e m b r a n e s a n d a u d i t o r y c a n a l s . T h e r e w a s n o e v i d e n c e o f h e a r i n g l o s s o n
a s s e s s m e n t .
"
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Cranial nerve examination\: to identify evidence of facial nerve pathology.
Audiometry and tympanometry\: to screen for hearing loss.

Reviewers

Mr Krishan Ramdoo
ENT Registrar
Mr Ben Cosway
ENT Registrar

References

1. CNX OpenStax. Adapted by Geeky Medics. Otitis externa. Licence\: [CC BY 4.0]. Available from\: [LINK].
2. B. Welleschik. Adapted by Geeky Medics. Mastoiditis. Licence\: CC BY-SA. Available from\: [LINK].
3. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Basal cell carcinoma. Licence\: CC BY 3.0 DE. Available
from\: [LINK].
4. Future FamDoc. Adapted by Geeky Medics. Actinic keratosis. Licence\: CC BY-SA. Available from\: [LINK].
5. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Melanoma. Licence\: CC BY 3.0 DE. Available from\: [LINK].
6. MartialArtsNomad.com. Adapted by Geeky Medics. CauliCC BY. Available from\: [LINK].
7. Lisa Leathwood, Maureen Risch. Adapted by Geeky Medics. Low-set ears. Licence\: CC0. Available from\: [LINK].
8. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Microtia. Licence\: CC BY 3.0 DE. Available from\: [LINK].
9. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. Adapted by
Geeky Medics. Anotia. Available from\: [LINK].
10. By Michael Hawke MD. Adapted by Geeky Medics. Normal tympanic membrane. Licence\: [CC BY 4.0]. Available from\: [LINK].
11. By Michael Hawke MD. Adapted by Geeky Medics. Tympanic membrane perforation. Licence\: [CC BY 4.0]. Available from\: [LINK].
12. By Michael Hawke MD. Adapted by Geeky Medics. Cholesteatoma. Licence\: [CC BY 4.0]. Available from\: [LINK].
13. By Michael Hawke MD. Adapted by Geeky Medics. Acute otitis media. Licence\: [CC BY 4.0]. Available from\: [LINK].
Source\: geekymedics.com
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