PHYSICAL

EXAMINATION OF THE
EARS
OUTCOMES
 Identify pertinent ear history questions.
 Obtain a history of the ears.
 Perform a physical assessment of the ears.
 Document ear assessment findings.
 Identify actual / potential health problems
stated as nursing diagnoses.
 Differentiate between normal and
abnormal findings.
Anatomy Review Structures
 The ear has three sections:
 External Ear: auricle (pinna) and external
ear canal
 Middle ear: tympanic membrane and
auditory ossicles (malleus,
incus and stapes), eustachian tube
 Inner ear: labyrinth, cochlea, organ of
Corti, and CN VIII
The external ear
Functions
What are the functions of:

Auricle and external ear canal:

Collect and transmit sound waves
Tympanic membrane (TM):
Divides external ear from middle ear;
transmits sound waves
Ossicles:
Three smallest bones in body; transmit
sound waves
Functions
What are the functions of:

Eustachian tube:
Equalizes pressure on both sides of TM

Structures of inner ear:

Transmit sound waves to CN VIII and
affect equilibrium
Developmental
Variations
What developmental variations of the ears
might be seen with:
 Children
 Adolescents
 Pregnant clients
 Older adults
Cultural Variations

What cultural variations of the ears

might be seen with:
 Asians and Native Americans
 Whites and blacks
Symptoms
What symptoms would signal a problem with the ears?

 Hearing loss
 Vertigo
 Ringing in the ears (tinnitus)
 Ear drainage (otorrhea)
 Earache (otalgia)
Physical Assessment

Anatomical landmarks: angle of

attachment of the ears
Approach: inspection and palpation ,
otoscopy
Position: sitting
Tools: tuning fork, otoscope with
earpieces of different sizes,
thermometer, clean gloves.
Assessment of the ear

 Consists of three parts

1. Auditory screening (CN VIII)
2. Inspection and palpation of the external ear
3. Otoscopic assessments
Auditory screening
 Voice-whisper test
 E: instruct the patient to occlude one ear with a finger
 Stand 2 feet behind the patient’s other ear and whisper a two-
syllable word or phrase.
 Ask the patient to repeat it
 Repeat the test with other ear.
 N: patient able to repeat the words whispered from a distance of
2 feet.
 A: patient unable to repeat the words correctly or states that she
did not hear anything.
 P: indicates hearing loss in the high –frequency range that may
be caused by excessive exposure to loud music.
 Tuning fork test
 Weber and Rinne tests help to determine whether
the type of hearing loss the patient is experiencing
whether conductive or sensorineural.
 This involves conduction of sound through air and
bone.
 Air conduction is transmission of sound through
the ear canal, tympanic membrane and ossicular
chain to the cochlea and auditory nerve.
 Bone conduction is transmission of sound through
the bones of the skull to the cochlea and auditory
nerve.
Weber test
 E: hold the handle of a 512-Hz tuning fork and strike
the tines in the ulnar border of the palm to activate
it.
 Place the stem of the fork firmly against the middle
of the patient’s forehead, on top of the head at the
midline.
 Ask the patient if the sound is heard centrally of
towards one side.
 N: the patient should perceive the sound equally in
both ears or ‘in the middle’
 Negative Weber test- no lateralization of sound.
Cont’d
 A: sound lateralizes to the affected ear.
 P: occurs in unilateral conductive hearing loss
because the sound is being conducted directly
through the bone to the ear. Can be due to external
or middle ear disorders e.g. impacted cerumen,
perforation of the tympanic membrane, serum or
pus in the middle ear, or a fusion of the ossicles.
 A: sound lateralizes to the unaffected ear.
 P: occurs in sensorineural loss related to nerve
damage in the impaired ear. This loss occurs in a
disorder in the inner ear, auditory nerve or brain e.g.
in congenital defects, ototoxic drugs, repeated or
prolonged exposure to loud noise.
Rinne test

 E: stand behind or at the side of the patient

and strike the tuning fork.
 Place the stem of the tuning fork against the
patient’s right mastoid process to test bone
conduction
 Instruct the patient to indicate if the sound is
heard.
 Ask the patient to tell you when the sound
stops
Cont’d
 When the patient says that the sound has stopped,
move the tuning fork, with the tines facing forward,
in front of the right auditory meatus, and ask the
patient if the sound is still heard. Note the length of
time the patient hears the sound (testing air
conduction)
 N: air conduction is heard twice as long as bone
conduction when the patient hears the sound
through the auditory canal (air) after it is no longer
heard at the mastoid process (bone). Its denoted
AC>BC
Cont’d
 A: patient reports hearing the sound longer
through bone conduction i.e. BC greater or
equal to AC.
 P: conductive hearing loss due to disease,
obstruction or damage to the outer or middle
ear.
 A: bone conduction is prolonged in the
context of a normal TM, patent Eustachian
tube, and middle ear disease.
 P: otosclerosis
Conductive hearing loss
Inspection/Palpation of the External
Ear
 Angle of attachment and position
 Size, shape, and symmetry
 Drainage: clear, bloody, or purulent
 Consistency and tenderness
 Palpate tragus, mastoid, and helix for
tenderness
External ear: inspection
 E: inspect the ears and note their position, color,
size and shape
 Note any deformities, nodules, inflammation, or
lesions.
 Note the color, consistency, and amount of
cerumen.
 N: ear should match the flesh of the rest of the
patient’s skin and should be positioned centrally and
in proportion to the head. The top of the ear should
cross an imaginary line drawn from the outer
canthus of the eye to the occiput.
Cont’d
 The cerumen should be moist and not obscure the
Tympanic Membrane.
 There should be no foreign bodies, redness,
drainage, deformities, nodules or lesions.
 A: ears are pale, red or cyanotic
 P: vasomotor disorders, fevers, hypoxemia, and
cold weather.
 A: ears are abnormally large or small
 P: congenital abnormalities or due to trauma.
 Microtia- unusually small external ear frequently
accompanied by an absent external ear canal and
mid-ear, but an intact inner ear.
Low set ears
Cont’d

 A: an ear that is grossly misshapen,

damaged or mutilated
 P: auricular hematoma. Blunt trauma e.g.
contact sports or human biting
 A: external ear is erythematous, edematous,
warm to the touch, and painful.
 P: perichondritis- an inflammation of the
fibrous connective tissue that overlies the
cartilage of the ear.
Cont’d
 A: a tumor on the external ear.
 P: basal cell and squamous cell carcinoma.
Prolonged exposure to sunlight is a predisposing
factor for the tumor.
 A: purulent drainage
 P: infection
 A: clear or bloody drainage
 P: may be CSF leaking as a result of head trauma
or surgery
 A: hematoma behind the ear over the mastoid bone
 P: Battle’s sign indicating head trauma to the
temporal bone of the skull.
Cont’d
 A: a hard, painless, irregular-shaped nodule on the
pinna.
 P: tophi are uric acid nodules and may indicate
gout.
 A: sebaceous cysts
 P: blockage of sebaceous gland
 A: lymph nodes anterior to the tragus or overlying
the mastoid
 P: enlarged due to malignancy or infection e.g
external otitis.
Palpation
 E: palpate the auricle between the thumb and the
index finger, noting any tenderness or lesions. If the
patient has ear pain, asses the unaffected ear first,
then cautiously assess the affected ear.
 Using the tips of the index and middle fingers,
palpate the mastoid tip, noting any tenderness
 Hold the auricle between the thumb and the index
finger and gently pull it up and down, noting any
tenderness.
 N: patient should not complain of pain or tenderness
during palpation
Cont’d

 A: auricle pain or tenderness

 P: Auricle pain is a common finding in
external ear infection and is called acute otitis
externa.
 A: tenderness over the mastoid process
 P: middle ear inflammation or mastoiditis
 A: tragus is edematous of sensitive
 P: inflammation of the external or middle ear.
Otoscopic Exam

 External ear canal: patency, color,

drainage, lesions, and foreign objects

 Tympanic membrane: color, intactness,

landmarks (malleus, light spot and
occasionally the incus may be visible) and
mobility
Otoscopic assessment
 E: ask patient to tip the head away form the
ear being assessed.
 Select the largest speculum that will
comfortably fit the patient
 Hold the otoscope securely in the dominant
hand, with the head held downward and the
handle held like a pencil between the thumb
and the forefingers.
 Rest the back of the dominant hand on the
right side of the patient’s head
Cont’d
 Use the ulnar side of the free hand to pull the right
ear in a manner that will straighten the canal.
<3years:- down and out, 3year-adult:- up and
back.
 If hair obstructs visualization, moisten the speculum
with water or a water-soluble lubricant.
 If wax obstructs visualization, it should be removed
only by a skilled practitioner either by currettement
or irrigation
 Slowly insert the speculum into the canal, looking at
the canal as the speculum passes
Cont’d
 Assess the canal for inflammation, exudates, lesions
and foreign bodies
 Continue to insert the speculum into the canal,
following the path of the canal until the TM is
visualized
 If the TM is not visible, gently pull the pinna slightly
farther in order to straighten the canal to allow
adequate visualization.
 Identify the color, light reflex, umbo, the short
process, and the long handle of the malleus. Note
the presence of the tympanic membrane, dilatation
of blood vessels, bubbles, or fluid
Cont’d
 Ask the patient to close the mouth, pinch the
nose closed, and blow gently while you
observe for movement of the TM.
 Gently withdraw the speculum and repeat the
process with the left ear.
 N: ear canals have no redness, swelling,
tenderness, lesions, drainage, foreign bodies,
or scaly surface areas.
 Cerumen varies in amount, consistency and
color.
Cont’d
 The Tympanic Membrane should be pearly gray
with defined landmarks and a distinct cone-shaped
light reflex extending from the umbo towards the
anterioinferior aspect of the membrane.
 This light reflex is seen at 5 o’clock in the right ear
and 7 o’clock in the left ear.
 Blood vessels should be visible only one the
periphery and the membrane should not bulge, be
retracted, or have any evidence of fluid behind it.
 The TM should move when the patient blows
against resistance.
Abnormal findings
 A: a foreign body in the external auditory canal
(EAC)
 P: both adults and children can have foreign bodies
in EAC. Some object
 P: tympanostomy tubes are surgically placed for
prolonged otitis media with effusion (OME).
 The tubes allow drainage of the effusion, normal
vibration of the ossicles, and equalization of the
pressure across the tympanic membrane.
 When the myringotomy has been performed with
tympanostomy tube placement, the presence of the
tubes needs to be documented.
Cont’d
 A: a painful, boil-like pustule in the EAC.
 P: furunculosis is an infection of a hair follicle. EAC
edema and otorrhea may also be present.
 A: black or brown spores, yellow/orange spores or
white fluffy hyphae in the EAC.
 P: prolonged use of aural antibiotics can cause
otomycosis, or a fungal infection in the ear. Different
strains of fungi cause the variations in appearance.
 A: exostoses- bony, hard lesions in the deep EAC.
Cont’d
 P: Patients who frequently participate in cold-
water activities are at risk for developing
them. If they become large enough, it can
block the EAC and trap debris between it and
the TM. This can lead to infection.
 A: exquisite pain accompanied by erythema
deep into the EAC and on the TM along with
serous-filled blebs
 P: viral bullous myringitis that can easily be
mistaken for acute otitis media.
Cont’d
 A: appearance of ‘chalk patches’ on the TM
 P: are calcifications found on tympanosclerosis
which occurs after TM surgery of inflammation. This
can be associated with a gradual hearing loss.
 A: air bubbles on the TM
 P: conditions such as coryza and influenza and
changes in extra-tympanic pressure can lead to
Eustachian tube failure.
 A: severely retracted TM that has exaggerated
landmarks. Mobility of the TM is decreased.
Cont’d
 P: retraction of the tympanic membrane can occur
when the intratympanic membrane pressures
(ITMP) are reduced as in Eustachian tube blockage
caused by otitis media with effusion or allergies.
 Repeated negative pressure in the middle ear sucks
in the TM leading to retractions.
 With time, keratinized epithelial deposits itself in
these retraction pockets leading to ossicle fixation.
This leads to cholesteatoma that can be
accompanied by a foul smelling discharge and
deafness.
Cont’d
 A: redness, swelling, narrowing and pain of the
external ear. Drainage may be present
 P: acute otitis externa (AOE) caused by infectious
organisms or allergic reactions. Predisposing factors
include excessive moisture in the ear related to
swimming, trauma from cleaning the ears with sharp
instruments or allergies to substances e.g.
hairspray.
 A: hard, dry and very dark yellow-brown cerumen
 P: old cerumen that may become imparted if not
removed.
Cont’d
 A: TM is red with decreased mobility and possible
bulging
 P: acute otitis media (AOM) or inflammation of the
middle ear. Pain and fever can accompany the ear
infection. Otalgia, fever, decreased hearing,
irritability, disturbed sleep and otorrhea may also be
present.
 A: along the bulging eardrum and decreased
mobility, the landmarks are diffuse, displaced or
absent.
 P: the late stage of AOM causes landmarks to
become progressively obscured.
Cont’d
 A: Amber-yellow fluid on the tympanic membrane.
Bulging may present and mobility of the eardrum
may be decreased.
 P: otitis media with effusion caused by allergies,
infections, and a blocked Eustachian tube.
 A: TM is pearly gray and has dark patches.
 P: old perforations in the TM
 A: TM is pearly gray and has dense white plaques
 P: plaques represent calcific deposits of scarring of
the TM from frequent past episodes of otitis media.
Acute Otitis Media (AOM)
Bulging, hyperemic tympanic membrane
with
indistinct landmarks.
Serous Otitis Media
Air bubbles and serous fluid behind
retracted
amber tympanic membrane
Tympanostomy Tube
Plastic tube placed in inferior portion of
tympanic
membrane. (Courtesy Dr. M. Hawke)
Perforated Tympanic Membrane