Examination of the Ear

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves

Approach the examination in a systematic way, starting from the outer parts of the ear before moving to the inner parts of the ear; be prepared to be instructed to move on quickly to certain sections by any examiner.

Pinna and Post Auricular Area

Inspect the pinna and the mastoid:

• Obvious deformities or abnormal cartilaginous fragments
• Scars or skin changes
  • Including for skin malignancies
• Signs of inflammation
  • An inflamed mastoid may push the pinna forward

Palpate the lymph nodes and pinna, specifically:

• Pre- and post-auricular lymph nodes
• Tragus
  • Tragal tenderness is a sign of otitis externa

By TeachMeSeries Ltd (2024)

Figure 1 – A basal cell carcinoma located on the posterior aspect of the outer ear

External Ear Canal

Inspect the outer aspect of the external ear canal using the otoscope as a light source

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

Look for signs of:

• Wax or a foreign body
• Skin changes or erythema
• Discharge

Tympanic Membrane

Hold the otoscope like a pen between thumb and index finger, left hand for left ear and right hand for right ear, resting your little finger on the patient’s cheek – this acts as a pivot.

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

For a normal tympanic membrane, you should be able to observe*:

• Lateral process of malleus
• Cone of light
• Pars tensa and pars flaccida

*The cone of light can be used to orientate; it is located in the 5 o’clock position when viewing a normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic membrane.

Adapted from work by Michael Hawke MD [CC BY 4.0], via Wikimedia Commons

Figure 2 – A normal right tympanic membrane

For an abnormal tympanic membrane, common signs may include:

• Perforations
• Tympanosclerosis
• Red and bulging membrane
• Retraction of the membrane

Ensure to check the function of the facial nerve

By Michael Hawke MD / CC BY (https://creativecommons.org/licenses/by/4.0)

Figure 3 – A traumatic perforation of the left tympanic membrane

Assessment of Hearing

Rinne Test

Strike the tuning fork (512Hz) against your elbow and place against the mastoid process (bone conduction), then once patient stops hearing it, hold it near the external ear canal (air conduction)

• For normal hearing or sensorineural hearing loss, air conduction is heard better than bone conduction (Rinne positive)
• For conductive hearing loss, bone conduction is heard better than air conduction (Rinne negative)

Weber Test

Strike the tuning fork (512Hz) against your elbow and place on the patient’s forehead in the midline. Ask the patient whether the sound is heard in the midline or has lateralised

• For normal hearing, the sound is heard in the midline
• For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing deficit
• For sensorineural hearing loss, the sound is loudest on the contralateral side to the hearing deficit

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Tympanogram
• Pure tone audiometry