Examination of the Ear

The following list represents a relatively comprehensive examination, portions of which may be omitted during a focused clinic visit, based on patient complaint.

External Inspection:

Examine the auricle for presence of all anatomic subunits. Note any congenital malformations.
In a trauma setting, examine the auricle for evidence of auricular hematoma, which requires emergent drainage.
Examine the skin of the ear and the periauricular region for masses or lesions.
Examine the preauricular region for presence of pits or sinuses. Note any evidence of infection, drainage, or scarring.
Examine for presence of any scars indicating prior otologic surgery; endaural scars are preauricular, postaural are postauricular.
In a trauma setting, examine the postauricular region for ecchymosis, which may indicate a temporal bone fracture.
Examine the mastoid region for tenderness or fluctuance.
Examine the external auditory meatus. Note any discharge, crusting, or visible foreign object.

Facial Nerve Assessment

Ask the patient to raise his eyebrows. Note any weakness or asymmetry.
Ask the patient to shut his eyes tightly. Note incomplete eye closure, as this necessitates precautionary measures to prevent corneal abrasion.
Ask the patient to wrinkle his nose. Note any weakness or asymmetry. Note the presence of diminished nasolabial fold.
Ask the patient to show you his teeth (grimace). Note any weakness or asymmetry at the corners of the mouth.

Pneumatic Otoscopy:

Examine the external auditory canal for any discharge, edema, erythema, skin lesion, mass, or foreign body. If discharge is present, note its color and consistency.
In a trauma setting, note whether bloody otorrhea is present, as this may be a sign of temporal bone fracture.
Note any obstructive cerumen impaction and debride if necessary.
Note whether traction on the auricle during otoscopy is painful for the patient.
In immunocompromised patients, note whether granulation tissue is present at the bony-cartilaginous junction, as this is suggestive of malignant otitis externa.
Visualize the tympanic membrane. Note whether it appears inflamed or retracted.
Examine the tympanic membrane for retraction pockets and cholesteatoma, which typically appears as a white, pearly mass, frequently in the anterior-superior quadrant.
Note the size and position of any perforation, as well as whether it appears wet or dry.
If the patient has had tympanostomy tubes placed, note whether they are in position and if they appear to be patent.
Note whether there appears to be any fluid behind the tympanic membrane, which may be evidenced by the presence of air bubbles.
Obtain a good seal of the ear canal by using an appropriately sized speculum and inserting it sufficiently into the canal. Apply pressure to the pneumatic bulb of the otoscope and observe whether movement of the tympanic membrane is normal, diminished, or absent.

Tuning Fork Testing

A 512-Hz fork may be used for basic testing.
To perform the Weber test, strike the tuning fork and place it on the patient’s forehead in the midline. Ask the patient whether the sound is louder on the left or right side, or if it is equally loud in both ears.
In a normal-hearing patient, the sound will be equally loud in both ears. This is termed a negative Weber test.
A Weber test that lateralizes to the right (i.e., the sound is louder in the right ear) may be caused by right-sided conductive hearing loss or left-sided sensorineural hearing loss.
A Weber test that lateralizes to the left (i.e., the sound is louder in the left ear) may be caused by left-sided conductive hearing loss or right-sided sensorineural hearing loss.
In order to determine the type of hearing loss, perform the Rinne test. Strike the tuning fork and place it approximately 5 cm from the ear canal, with the tines of the tuning fork in line with the ear. Then move the fork so that its base is pressed firmly on to the mastoid process, behind the ear. Ask the patient whether the sound is louder in front of the ear (air conduction) or on the bone (bone conduction).
If the patient states that the sound is louder in front of the ear, this indicates that air conduction is greater than bone conduction. This is termed a positive Rinne test and is a normal result.
If the patient states that the sound is louder on the bone, this indicates that bone conduction is greater than air conduction. This is termed a negative Rinne test and usually signifies a conductive hearing loss when the Weber test lateralizes to that ear.