• Wash your hands and don PPE if appropriate.

• Introduce yourself to the pa ent including your name and role.

• Con rm the pa ent’s name and date of birth.
• Brie y explain what the examina on will involve using pa ent-friendly language
• Gain consent to proceed with the examina on.
• Ask the pa ent to sit on a chair.
• Ask the pa ent if they have any pain before proceeding with the clinical examina on.
Inspec on:
• Inspect the pinnae for:
o Asymmetry: by comparing the pinnae you may iden fy subtle unilateral
pathology.
o Deformity of the pinnae: this may be acquired (e.g. cauli ower ear) or
congenital (e.g. ano a, micro a, low-set ears).
o Ear piercings: can be a poten al source of infec on, an allergen and a cause of
trauma.
o Erythema and oedema: typically associated with o s externa.
o Scars: indica ve of previous surgery.
o Skin lesions: look for evidence of pre-malignant (ac nic keratoses) and
malignant (e.g. basal cell carcinoma, squamous cell carcinoma) skin changes.
• Inspect the mastoid region:
o Erythema and swelling: typically associated with mastoidi s.
o Scars: indica ve of previous surgery (e.g. mastoidectomy).
• Pre-auricular region
o Inspect the pre-auricular region (in front of the ear):
o Pre-auricular sinus/pit: a common congenital deformity that appears as a dimple
in the pre-auricular region. These sinuses can some mes become infected and
require surgical drainage.
o Lymphadenopathy: typically associated with an ear infec on (e.g. o s media,
o s externa).
• Conchal bowl
o Inspect the conchal bowl for signs of ac ve infec on such as erythema and
purulent discharge.
Palpa on:
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• Palpate the tragus for tenderness which is typically associated with o s externa.
• Palpate the regional lymph nodes:
o Pre-auricular lymph nodes
o Post-auricular lymph nodes

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 Otoscopy
• To help decide which ear to examine rst: Check if the pa ent has any ear discomfort
and if so examine the non-painful side rst. Ask the pa ent which is their “be er” ear
and examine this one rst (this can be useful for comparison).
• Inser ng the otoscope:
o Ensure the light is working on the otoscope and apply a sterile speculum (the
largest that will comfortably t in the external auditory meatus).
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 o Pull the pinna upwards and backwards with your other hand to straighten the
external auditory canal.
o Posi on the otoscope at the external auditory meatus:

▪ The otoscope should be held in your right hand for the pa ent’s right
ear and vice versa for the le ear.

▪ Hold the otoscope like a pencil and rest your hand against the pa ent’s
cheek for stability. This will prevent damage to the ear if there is sudden
movement.
o Advance the otoscope under direct vision. Be gentle with the otoscope and
ensure movements are slow and considered otherwise you will cause
discomfort.

• Inspect the external auditory canal for:

o Excessive ear wax: the most common cause of conduc ve hearing loss.
o Erythema and oedema: typically associated with o s externa.
o Discharge: may suggest o s externa or o s media with associated tympanic
membrane perfora on.
o Foreign bodies: these may include co on buds, insects and other small objects.
• Systema cally inspect the four quadrants of the tympanic membrane (TM) to avoid
missing pathology.
o Color

▪ A healthy TM should appear pearly grey and translucent.

▪ Erythema suggests in amma on of the TM which can occur in
condi ons such as acute o s media.
o Shape

▪ A healthy TM should appear rela vely at.

▪ Bulging of the TM suggests increased middle ear pressure, which is
commonly caused by acute o s media with e usion (there is o en an
associated visible uid level).
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 ▪ Retrac on of the TM suggests reduced middle ear pressure, which is

commonly caused by pharyngotympanic tube dysfunc on secondary to
upper respiratory tract infec ons and allergies.
o Light re ex

▪ The light re ex (also known as the “cone of light”) is visible when a light
is shone onto the TM.

▪ If a TM is healthy, the cone-shaped re ec on of light should appear in

the anterior inferior quadrant.

▪ In the le ear, the light re ex should be posi oned at approximately 7

o’clock to 8 o’clock.

▪ In the right ear, the light re ex should be posi oned at approximately 4

o’clock to 5 o’clock.

▪ Absence or distor on of the light re ex is associated with o s media

(due to bulging of the TM).
o Perfora on

▪ Note the size and the posi on of any perfora ons of the TM.
▪ Causes of TM perfora on include infec on (e.g. o s media with
e usion), trauma (e.g. diving-related), cholesteatoma and inser on of
tympanostomy tubes (also known as grommets).

▪ Cholesteatoma typically causes perfora on in the superior part of the

TM and there may be visible granula on ssue and discharge in this
region.

▪ Scarring
▪ Scarring of the TM is known as tympanosclerosis and can result in
signi cant conduc ve hearing loss if it is extensive.

▪ Tympanosclerosis o en develops secondary to o s media or a er the

inser on of a tympanostomy tube.
• Withdraw the otoscope carefully.
• Repeat your assessment on the other ear, comparing your ndings. If the pa ent has an
infec on in one ear, you should change the speculum on the otoscope before examining
the other ear.
• Discard the otoscope speculum into a clinical waste bin.
• Explain to the pa ent that the examina on is now nished. Thank the pa ent for their
me.
Note: the otoscope head has a port that can be used for pneuma c otoscopy; a rubber
pneuma c squeeze bulb is a ached to the head of the otoscope, and squeezing the bulb
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 produces a gentle air pressure in the external canal which allows for the assessment of the
movement of the tympanic membrane. The port can also be used for suc on and administering
medica ons (??).
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