UNIVERSITY OF CEBU – BANILAD

COLLEGE OF NURSING

ASSESSMENT of the EARS

REVIEW ON THE ANATOMY OF THE EAR:

EXTERNAL EAR
INTERNAL EAR
MIDDLE EAR

General Approaches:
⚫ Greet the patient and explain the assessment.
⚫ Use a quite room that will be free from interruptions.
⚫ Ensure adequate lighting.
⚫ Place the patient in an upright sitting position.
⚫ Always compare the right and left sides of ears, nose, mouth and throat.

Nursing Health History:

• Evaluate the condition of the external ear
• Evaluate the condition and patency of the ear canal
• Evaluate the status of the tympanic membrane
• Evaluate bone and air conduction of sound vibrations
• Evaluate hearing acuity
• Evaluate the patient’s equilibrium

Client Preparation:
• Make sure the client is seated comfortably during the ear examination.
• Explain the tests thoroughly to guarantee accurate results.
• Answer the client’s questions.
• Note how the client responds to explanations during the ear examination process.

Equipment:
▪ Otoscope
▪ Penlight
▪ Tuning fork , 512 Hz
▪ Watch
▪ Clean gloves
▪ Cotton tipped applicator

Points to Remember:
• Recognize the role of hearing in communication and adaptation to the environment
particularly in regard to aging.
• Know how to use the otoscope effectively when performing ear examination.
• Understand the usefulness and significance of basic hearing tests.

Inspection of the External Ear

A. INSPECT THE AURICLE, TRAGUS AND LOBULE

POSITION, SIZE, SHAPE, COLOR

NORMAL:
Ears are equal in size (4 – 10 cm.)
Auricle aligns with the corner of each eye.
Earlobes maybe free, attached or tightly attached to the adjacent skin.

ABNORMAL FINDINGS:
MICROTIA (underdeveloped pinna (external ear)
PERICHONDRITIS (cauliflower ear)
B. OBSERVE FOR LESIONS, DISCOLORATIONS AND DISCHARGES
NORMAL FINDINGS:
INSPECTION
COLOR – ear should match the flesh color of the rest of the patient’s.
POSITION – located centrally and in proportion to the head top of the ear should pass the
imaginary line from the outer canthus of the eye to the occiput.
CERUMEN – moist and does not obscure the TM
No foreign bodies, redness, drainage, deformities, nodules and lesions
BASAL CELL CARCINOMA
BLOODY & PURULENT DRAINAGE
PAROTITIS
BATTLE’S SIGN
TOPHI - Non-tender, hard, cream-colored nodules on the helix containing uric acid crystals.
DARWINIAN TUBERCLE - a benign protrusion on upper part of helix.

PALPATION
a. Palpate using the thumb and index finger.
b. Using the tips of the index and middle fingers, palpate the mastoid tip, noting any
tenderness.
c. Using the tips of the mid and index fingers, press inward on the tragus, noting any
tenderness.
d. Hold the auricle between the thumb and the index finger and gently pull up and down,
noting any tenderness.

NORMAL:
The patient should not complain of pain or tenderness during palpation.
ABNORMAL FINDINGS:
OTITIS EXTERNA
MASTOIDITIS
■ Missing or malformed landmarks: Associated with hearing deficit.
■ Creased earlobe: Associated with heart conditions.
■ Ear pits or sinuses usually located anterior to the tragus: Associated with internal ear
anomalies.
■ Low-set ears or ears rotated posteriorly more than 15 degrees: Associated with mental
retardation.
■ Drainage: Bloody drainage can result from trauma and purulent drainage from an infection.
Clear drainage may be spinal fluid from a head injury.
■ Impacted cerumen.
■ Redness: Inflammation may indicate infection, fever.
■ Lesions: E.g., skin cancer from sun exposure.

OTOSCOPIC EXAMINATION
Procedure:
⚫ Ask the patient to tip the head away from the ear being assessed.
⚫ Select a speculum that would fit comfortably the patient.
⚫ Hold the otoscope securely in the dominant hand, with the handle held like a pencil
between the thumb and the forefinger.
⚫ Rest the back of the dominant hand on the right side of the patient’s head.
⚫ Use the free hand to pull the right ear in a manner that will straighten the canal.
⚫ If hair obstructs visualization, moisten the speculum with water.
⚫ Slowly insert the speculum into the canal, looking as the speculum passes.
⚫ Assess the canal for inflammation, exudates, lesions and foreign bodies.

Visualize the tympanic membrane:

COLOR
LIGHT REFLEX
PERFORATIONS
LESIONS
BULGING OR RETRACTION
DILATION OF BLOOD VESSELS
BUBBLES
FLUIDS
Note the movement of the TM while asking the patient to pinch the nose closed and blow
gently.

NORMAL FINDINGS:
Ear Canal - no redness, swelling, tenderness, lesions, drainage, foreign bodies or
scaly surface areas.
Cerumen - varies in amount, consistency and color.
Cerumen is white, dry, and flaky in patients of Asian and Native American
descent and honeycolored and sticky in whites and African Americans.
TM - is pearly gray with clearly defined landmarks and a distinct cone-shaped
light reflex. Should move when the patient blows against resistance.
Blood Vessels - seen only in the periphery and the membrane do not bulge, retracted or
have any evidence fluid behind it.

ABNORMAL FINDINGS:
External auditory canal foreign body
HARD, DARK CERUMEN
FURUNCULOSIS – deep infection of the hair follicle leading to abscess formation with
accumulation of pus and necrotic tissue.
EXOSTOSIS - “surfer’s ear”
SEROUS OTITIS - yellowish membrane with fluid and air bubbles visible behind TM.
OTITIS EXTERNA
OTITIS MEDIA - reddish TM with absent or distorted light reflex.
ACUTE OTITIS MEDIA
ACUTE PURULENT OTITIS MEDIA
PERFORATED EARDRUM
PERFORATED TM - round/oval dark area
HEMOTYMPANUM - blue to black TM from bleeding
BLACK OR BROWN SPORES
AIR BUBBLES IN THE TYMPANIC MEMBRANE

HEARING & EQUILIBRIUM TESTS

Points to Remember:
• Recognize the role of hearing in communication and adaptation to the environment
particularly in regard to aging
• Know how to use the otoscope effectively when performing ear examination
• Understand the usefulness and significance of basic hearing tests

General Approaches:
Greet the patient and explain the assessment.
Use a quite room that will be free from interruptions.
Ensure adequate lighting
Place the patient in an upright sitting position.
Always compare the right and left sides of ears, nose, mouth and throat.

WEBER TEST
a. Hold the handle of a 512 Hz tuning fork and strike the tine on the ulnar border of the
palm to activate it.
b. Place the stem of the fork firmly against the middle of the patient’s forehead, on the top
of the head at the midline, or on the front of the teeth.
c. Ask the patient if the sound is heard centrally or toward one side.
NORMAL:
The patient should perceive the sound equally in both ears or in the middle and there is no
lateralization of sound.

IN CONDUCTIVE HEARING LOSS:

The patient reports lateralization of sound to the poor ear – the client “hears” the sound in the
poor ear.
The good ear is distracted by background noise, conducted air, which the poor ear has trouble
hearing.
So, the poor ear receives most of the sound conducted by bone vibration.

IN SENSORINEURAL HEARING LOSS:

THE CLIENT REPORTS LATERALIZATION OF SOUND TO THE GOOD EAR.
THIS IS DUE TO LIMITED PERCEPTION OF SOUND DUE TO NERVE DAMAGE IN THE BAD EAR,
MAKING SOUND SEEMLOUDER IN THE UNAFFECTED EAR.

RINNE TEST
a. Stand behind or to the side of the patient the patient and strike the tuning fork.
b. Place the stem of the tuning fork against the patient’s right mastoid process to test
bone conduction.
c. Instruct the patient to indicate if the sound is heard.
d. Ask the patient to tell you when the sound stops.
e. When the patient says the sound has stopped, move the tuning fork, with the tines
facing forward, in front of the right auditory meatus, and ask the patient is the sound is
still heard. Note the length of time the patient hears the sound (AIR CONDUCTION)
f. Repeat the test on the left ear.
NORMAL: Air conduction is heard twice as long as bone conduction. This is noted as
AC>BC or + Rinne

IN CONDUCTIVE HEARING LOSS:

BONE CONDUCTION SOUND IS HEARD LONGER THAN OR EQUALLY AS LONG AS AIR
CONDUCTION SOUND BC > AC

IN SENSORINEURAL HEARING LOSS:

AIR CONDUCTION SOUND IS HEARD LONGER THAN BONE CONDUCTION AC > BC

HELPS TO DETERMINE WHETHER THE TYPE OF HEARING LOSS IS CONDUCTIVE OR

SENSORINEURAL
AIR CONDUCTION:
SOUND ------ EAR CANAL ------ TYMPANIC MEMBRANE ------ OSSICULAR CHAIN ------ COCHLEA ---
--- AUDITORY NERVE
BONE CONDUCTION:
SOUND ---- BONES OF THE SKULL ---- COCHLEA ---- AUDITORY NERVE

IF THE SOUND LATERALIZES IN THE AFFECTED EAR

CONDUCTIVE HEARING LOSS
This is the term which is used when there are problems which the flow of ear pressure waves
down the ear canal, across the ear drum or through the ossicles.
Impacted cerumen
Perforated eardrum

VOICE-WHISPER TEST
a. Instruct the patient to occlude one ear with a finger.
b. Stand 2 feet behind the patient’s other ear and whisper a 2-syllable word or phrase that
is evenly accented.
c. Ask the patient to repeat the word or phrase.
d. Repeat the test with the other ear.
NORMAL:
The patient should be able to repeat the words correctly or states that he or she is unable to
hear anything.
Watch Tick Test
■ Have patient cover opposite ear being tested.
■ Hold ticking watch within 5 inches from ear.
■ Note patient’s ability to hear sound.
Normal: Patient hears tick of a watch in each ear at a distance of 5 inches.

IF THE SOUND LATERALIZES IN THE UNAFFECTED EAR

SENSORINEURAL HEARING LOSS:
This is the term use when there is a problem in the cochlea, the auditory nerve
or any other of the nerves linking the cochlea to the auditory cortex of the brain.
Drug induced damage to the cochlea (antibiotics, certain diuretics, chemotherapy drugs).
Traumatic damage to the cochlea (noise, blow to the head, penetrating injury to the inner ear.
Age related to the cochlea (presbycusis).
Tumor on the auditory nerve.
Certain infections, like meningitis.

ROMBERG’S TEST
NORMAL:
Client maintains position without swaying or with minimal swaying.
ABNORMAL FINDING:
If the client moves feet apart to prevent fall or starts to fall from loss of balance may indicate a
VESTIBULAR disorder.

Prepared by:
Jegs C. Pornia RN, MN, LPT