Table of Contents

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The Pinna & Surrounding Structures
Inspection
Palpation & Percussion
The External Auditory Canal
Preparing & Inserting the Otoscope
Inspecting the canal
Inspecting the TM
TM: The 4 quadrants (image)
Testing auditory acuity
Verbal testing
The Rinne
The Weber

Pinna & Surrounding Structures

Inspection

  1. Inspect the external ear for deformities, atrophy, nodules, lesions or signs of trauma or inflammation such as swelling or erythema.

    1. Pitting or dimples anterior to the tragus are usually remnants of the first branchial arch
    2. Cauliflower ear is a deformity usually caused by repetitive trauma (the classic example is in rugby players).
    3. Tophi (hard deposits of uric acid crystals in the auricula) may be suggestive of gout

  2. If discharge is present, describe it (color, consistency, translucency).
  3. Inspect the post-auricular region for signs of trauma or inflammation. Note any scars (indicative of prior surgery).

Palpation & Percussion

  1. Palpate the mastoid process. Tenderness or swelling may be indicative of mastoiditis.

External Auditory Canal

Preparing & Inserting the Otoscope

  1. Choose the largest speculum size that the external auditory meatus will accommodate. Typically, a speculum with a tip diameter of 4mm is used for adults and children and a 2mm speculum is used for infants.
  2. Pick up the otoscope with your anterior-most hand, leaving your forefinger free. Is best to hold the otoscope in the right hand if examining the right ear and in the left hand if examining the left ear.
  3. With the posterior-most hand, gently grasp the pinna by the helix and pull upward, backward and slightly away from the head. This helps to straighten the ear canal (remember, the canal is curved downward and forward).

In children, pull the pinna DOWN and back.

  1. Brace your index finger against the patient's face to prevent damage in the case of sudden unexpected movements (especially common when examining children). Gently introduce the speculum into the ear canal, directing it downward and forward.

Having trouble finding the tympanic membrane? Try aiming the speculum in the direction of the patient's nose.

  1. Gently advance the speculum through any hair found in the canal.

Many early learners fail to advance the speculum far enough into the ear as they are afraid of hurting the patient. If you can't see the ear drum, try pointing the speculum upwards and forwards and continue advancing slowly into the canal.

Inspect the canal

  1. Once your speculum is in place, inspect all 4 quadrants of the wall of the EAC.  You can move your speculum slightly in each direction to facilitate this.  This will also help to orient you.   Inspect the canal for erythema, swelling or tenderness.

    1. Note any otorrhea, blood, wax,  tumors, foreign bodies, osteomas or exostoses (benign bony outhgrowths of the EAC).

If a foreign body is found in the ear canal, make sure to check other orifices such as the opposite ear and the nasal cavities for additional foreign bodies!

  1. Collections of cerumen may obstruct your view. If the canal or TM is not visible due to cerumen impaction, remove the ear wax and try again.

Inspect the TM

  1. Systematically inspect the TM by dividing it into 4 quadrants: posterior-superior, posterior-inferior, anterior-inferior and anterior-superior. The TM is divisible into these 4 quadrants by drawing an imaginary line straight down the handle of the malleus, then by drawing a second line (perpendicular to the first) right through the umbo.

Figure 1: The four quadrants (right TM)

  1. Quadrant by quadrant, begin to familiarize yourself with the pertinent landmarks (umbo, handle of malleus, short process of malleus, pars flaccida, pars tensa). It may be possible to see the incus in the posterior-superior quadrant. Extremely well defined middle ear anatomy is indicative of tympanic retraction/atelectasis.

If you are having orienting yourself with the tympanic membrane, start with the light reflex. It is generally located in the anteroinferior segment of the TM.

  1. For each quadrant, describe the general characteristics of the TM including:
  1. Color:
  1. Transparency
  2. It is retracted or bulging? Is an air-fluid level visible behind the TM?
  3. Perforation? If so, where (what quadrant[s]) and to what extent (pin-holed, ½ or entire TM)?

It is NOT normal to see any bubbles or fluid behind the tympanic membrane.

  1. Note any other lesions such as cholesteatomas, tumors, or vesicles on the tympanic membrane

Painful hemorrhagic vesicles on the TM are highly suggestive of bullous myringitis but may also be indicative of other pathologies such as Ramsay-Hunt syndrome (a.k.a. herpes zoster oticus)

Test Auditory Acuity

Verbal testing

  1. Occlude one of the patient’s ear canals by pushing down on the tragus. Alternatively, you may occlude the canal directly with your finger while moving your finger quickly but gently within the canal. Both approaches allow us to more reliably test the opposite ear.
  2. In the unoccluded ear, softly whisper words such as “baseball” or “daydream” into the patient’s ear and ask them to repeat. It is best to choose two syllable words that have equal emphasis on each syllable.
  3. Repeat the test in the opposite ear.

To prevent the patient from lip-reading, make sure they are unable to see your face while whispering in their ear.

Rinne

  1. Strike a 512-Hz tuning fork against either the palm of your hand or against your knuckle to set it into vibration.

Never strike the fork against a hard surface like wood or metal.

  1. Holding the fork (by the stem) between you thumb and index finger, place the tip of the stem on the mastoid process. Confirm with the patient that they can hear the sound. This tests bone conduction.
  2. If the patient can hear the sound, ask them to notify you as soon as the sound is no longer audible. When they signal that the sound is no longer audible, remove the stem from the mastoid and place the prongs of the fork (aka: the “U” shaped part) beside the external auditory canal. Ask the patient if they can hear the sound. This tests air conduction.
  3. In patients with normal hearing, air conduction (AC) should always be greater than bone conduction (BC) (meaning the patient can still hear the sound with the fork at the external auditory canal after they could no longer hear it with the stem on the mastoid). A normal result (ie: AC > BC) is known as a positive Rinne test.

If the Rinne Test is negative (ie: BC greater or equal to AC), the patient likely has conductive hearing loss in that ear. In sensorineural hearing loss, the Rinne Test will be positive unless there is complete hearing loss in that ear.


In the case of unilateral total sensorineural hearing loss, the patient may be able to hear the vibration of the tuning fork even when it is placed on the mastoid process of the deaf ear. This is due to the vibration propagating through the skull bone and being perceived by the healthy ear. This misleading result is known as a false-negative Rinne test.

Weber

  1. Strike a 512-Hz tuning fork against either the palm of your hand or against your knuckle to set it into vibration.
  2. Holding the fork (by the stem) between you thumb and index finger, place the tip of the stem against the top of the skull. Alternatively you may press the vibrating fork against the middle of the foreheador nasal bridge.
  3. Ask the patient where they hear the sound. In patients with normal hearing, the sound should be heard equally on both sides. In patients with abnormal hearing, the sound will lateralize to one side.

In the Weber test, sound lateralizes away from sensorineural hearing loss and towards conductive hearing loss. It is impossible to properly interpret the result of the Weber test without a corresponding Rinne test (see table below).


References

Bickley, L. Bates' Guide to Physical Examination and History Taking. 10th Edition. Chapter 7.

Drake, R., et al. Gray's Anatomy for Students. 1st edition.

Gray, H. Gray's Anatomy. 20th Ed. Available online: www.bartleby.com/107

Martini, F., et al. Human Anatomy. 5th Edition.

Schwartz, M. Textbook of Physical Diagnosis. 6th Edition. Chapter 11.

Section Author

Scott Kohlert
Medical Student (MS-4)
University of Ottawa

Section Editors

Laurie McLean, MD1,2
Nita Scherer, MD1,2
Safeena Kherani, MD1,2

1The Ottawa Hospital, Deptartment of Otolaryngology

2Faculty of Medicine, University of Ottawa