Assessment of ear

Assessment of ear

History:

Family history of hearing problems or loss

Presence of any ear problems

Medication history especially if there are complaints of ringing in the ears

Any hearing difficulty- onset, factors contributing to it, and how it interferes with the ADL.

Use of corrective hearing device: when and from whom it was obtained

Examination of ear

Direct inspection and palpation of the external ear

Inspection of the remaining parts of the ear by an otoscope.

Auditory acuity

Size and shape

·         Microtia

·         Macrotia

Assessment	Normal findings	Deviations
Inspect the auricles for colour, symmetry of size and position.	•      Colour same as facial skin •       symmetrical •      Auricle aligned with outer canthus of the eye.	•      Bluish colour of the ear lobes ( cyanosis) •      Pallor- frost bite •       excessive redness (inflammation or fever)
•      Palpate the auricles for texture elasticity and areas of tenderness •      Gently pull the pinna upward, downward and backward •      Fold the pinna forward( it should recoil) •       Push in on the tragus •      Apply pressure to the mastoid process	•       Mobile, firm and not tender •       Pinna recoils after it is folded.	•      Lesions •       flaky scaly skin •       tenderness when moved or pressed

External ear canal and tympanic membrane

Assessment	Normal findings	Deviations from normal.
Using an otoscope inspect the external ear canal for cerumen, skin lesions, pus and blood.	•      Distal third contains hair follicles and glands. •      Dry cerumen, grayish tan color, or sticky wet cerumen in various shades of brown.	•      Redness and discharge •      Scaling •      Excessive cerumen obstructing canal

Inspecting the ears with an otoscope

·         Attach the speculum to the otoscope

·         Use the largest diameter that will fit the ear canal without causing discomfort.

·         For an adult straighten the ear canal by pulling the pinna up and back for better visualization.

·         For children under 3 years pull the pinna down and back.

Inserting an otoscope

Hold the otoscope either

a) Right side up, with your fingers between the otoscope handle, and the clients head or

b) Upside down with your  fingers and the ulnar  surface of your hand  against the clients head.

This stabilizes the head and protects the ear drum from ear canal injury if a quick head movement occurs.

Gently insert the tip of the otoscope in to the ear canal avoiding pressure by the speculum against either side of the ear canal.  The inner two third of the ear canal is bony, if the speculum is pressed against either side, the client will experience discomfort.

Normal tympanic membrane: pearly gray colour, semi-transparent

Abnormal findings: Pink to red,

·         some opacity

·         yellow amber

·         White

·         Blue or deep red

·         Dull surface

Abnormal
Yellow- amber drum colour occurs with otitis media with effusion (serous).

 Red colour occurs with acute otitis media.

Air/ fluid level or air bubbles behind drum indicate otitis media with effusion

Retracted drum resulting from vacuum in middle ear with obstructed Eustachian tube.

Bulging drum from increased pressure in otitis media.

Drum hyper mobility is an early sign of otitis media.

Perforation shows as a dark oval area as a larger opening on the drum.

Perforation of Tympanic membrane

Fungal infection -otomycosis

Candidial infection

Acute otitis media

Otis media with effusion

Gross hearing acuity tests:

Asses the clients response to normal voice tones.

If the client has difficulty hearing the normal voice proceed with the following tests.

A) Watch tick test

B) Tuning fork tests.

Watch tick test:

Have the client occlude one ear. Out of the client’s sight,   place a ticking watch 2-3 cm from the occluded ear. Ask what the client can hear. Repeat with the other ear

Whispered voice test-

30 to 60 cm from testing ear covering mouth, whisper words.

Tuning fork tests

1)      Perform Weber's test to assess bone conduction.

Normaly sound is heard in both the ears or is localised at the center of the head (weber negative)

Abnormal finding: - (Weber positive)

Sound is heard better in the impaired ear, indicating a bone- conductive hearing loss or

Sound is heard better in an ear without a problem,   indicating a sensorineural hearing loss.

In the Weber test a vibrating tuning fork (either 256 or 512 Hz) is placed in the middle of the forehead equidistant from the patient's ears. The patient is asked to report in which ear the sound is heard louder.  In a normal patient, the sound is heard equally loud in both ears (no lateralization). 

Detection of conductive hearing loss

A patient with a unilateral conductive hearing loss would hear the tuning fork loudest in the affected ear. This is because the conduction problem masks the ambient noise of the room, whilst the well-functioning inner ear picks the sound up via the bones of the skull causing it to be perceived as a louder sound than in the unaffected ear.

Detection of sensorineural hearing loss

A patient with a unilateral sensorineural hearing loss would hear the sound louder in the unaffected ear, because the affected ear is less effective at picking up sound even if it is transmitted directly by conduction into the inner ear.

Incompleteness

This test is most useful in individuals with hearing that is different between the two ears. It cannot confirm normal hearing because it does not measure sound sensitivity in a quantitative manner. Hearing defects affecting both ears equally, as in Presbycusis will produce an apparently normal test result.

 Rinne test

Compares  bone conduction to air conduction.

Ask the client to block the hearing in one ear by moving the fingertip in and out of the ear canal. Hold the handle of the activate tuning fork  on the mastoid process of one ear,  until the client states that vibration can  no longer be heard.

Immediately hold the still vibrating tuning fork   prongs in front of the client’s ear canal. Push aside the client’s hair if necessary. Ask whether client now hears the sound. Sound conducted by air is heard more readily than sound conducted by bone. The tuning fork vibrations conducted by air are normally heard longer.  (Positive Rinne)

If bone conduction time is equal to or longer than the air conduction time (negative Rinne: indicates a conductive hearing loss.)

For example, if the Rinne test shows that air conduction (AC) is greater than bone conduction (BC) in both ears and the Weber test lateralizes to a particular ear, then there is sensorineural hearing loss in the opposite (weaker) ear.

 Conductive hearing loss is confirmed in the weaker ear if bone conduction is greater than air conduction and the Weber test lateralizes to that side.

Combined hearing loss is likely if the Weber test lateralizes to the stronger ear and bone conduction is greater than air conduction in the weaker ear.

	Weber without lateralization	Weber lateralizes left	Weber lateralizes right
Rinne both ears AC > BC	Normal	Sensorineural loss in right	Sensorineural loss in left
Rinne left BC > AC		Conductive loss in left	Combined loss : conductive and sensorineural loss in left
Rinne right BC > AC		Combined loss : conductive and sensorineural loss in right	Conductive loss in right

Inner Ear

To check equilibrium – Romberg   test