Otoscopic

Ostoscipic Examination

Briefly explain what the examination will involve using patient-friendly language: “Today I’d like to examine your ears, this will involve me having a look inside your ears using a special piece of equipment known as an otoscope after which I'm going also like to assess your hearing using an audiometer, this involves you wearing a set of headphones and pressing a response button whenever you hear a sound.”

Ask the patient if they have any pain before proceeding with the clinical examination.

Gain consent to proceed with the examination.

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

Hearing aids: note if the patient is wearing a hearing aid and ask the patient to remove this when performing otoscopy.
Mobility aids: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status. The patient may have vestibulocochlear nerve pathology causing both hearing and balance issues.

Pinnae

Inspect the pinnae for:

Asymmetry: by comparing the pinnae you may identify subtle unilateral pathology.
Deformity of the pinnae: this may be acquired (e.g. cauliflower ear) or congenital (e.g. anotia, microtia, low-set ears).
Ear piercings: can be a potential source of infection, an allergen and a cause of trauma.
Erythema and oedema: typically associated with otitis externa.
Scars: indicative of previous surgery.
Skin lesions: look for evidence of pre-malignant (actinic keratoses) and malignant (e.g. basal cell carcinoma, squamous cell carcinoma) skin changes.

Mastoid

Inspect the mastoid region:

Erythema and swelling: typically associated with mastoiditis.
Scars: indicative of previous surgery (e.g. mastoidectomy).

Pre-auricular region

Inspect the pre-auricular region (in front of the ear):

Pre-auricular sinus/pit: a common congenital deformity that appears as a dimple in the pre-auricular region. These sinuses can sometimes become infected and require surgical drainage.
Lymphadenopathy: typically associated with an ear infection (e.g. otitis media, otitis externa).

Conchal bowl

Inspect the conchal bowl for signs of active infection such as erythema and purulent discharge.

Palpation

Palpate the tragus for tenderness which is typically associated with otitis externa.

Palpate the regional lymph nodes:

Pre-auricular lymph nodes
Post-auricular lymph nodes

Cauliflower ear

Cauliflower ear is an irreversible condition that develops as a result of repeated blunt ear trauma. Blunt trauma causes bleeding under the perichondrium of the pinna, stripping away the ear’s cartilage. This cartilage normally relies on the perichondrium for its nutrient supply and as a result, once separated it becomes fibrotic, causing distortion of the ear’s architecture.

Congenital deformity of the ears

There are several types of congenital ear deformity including:

Anotia: a complete absence of the pinna.
Microtia: underdevelopment of the pinna.
Low-set ears: the ears are positioned lower on the head than usual. Low-set ears are a feature of several genetic syndromes including Down’s syndrome and Turner’s syndrome.

To help decide which ear to examine first:

Check if the patient has any ear discomfort and if so examine the non-painful side first.
Ask the patient which is their “better” ear and examine this one first (this can be useful for comparison).

Inserting the otoscope

1. Ensure the light is working on the otoscope and apply a sterile speculum (the largest that will comfortably fit in the external auditory meatus).

2. Pull the pinna upwards and backwards with your other hand to straighten the external auditory canal.

3. Position the otoscope at the external auditory meatus:

The otoscope should be held in your right hand for the patient’s right ear and vice versa for the left ear.
Hold the otoscope like a pencil and rest your hand against the patient’s cheek for stability. This will prevent damage to the ear if there is sudden movement.

4. Advance the otoscope under direct vision. Be gentle with the otoscope and ensure movements are slow and considered otherwise you will cause discomfort.

External auditory canal assessment

5. Inspect the external auditory canal for:

Excessive ear wax: the most common cause of conductive hearing loss.
Erythema and oedema: typically associated with otitis externa.
Discharge: may suggest otitis externa or otitis media with associated tympanic membrane perforation.
Foreign bodies: these may include cotton buds, insects and other small objects.

Tympanic membrane assessment

6. Systematically inspect the four quadrants of the tympanic membrane (TM) to avoid missing pathology.

Please see below for further inspection information.

Final steps

7. Withdraw the otoscope carefully.
8. Repeat your assessment on the other ear, comparing your findings. If the patient has an infection in one ear, you should change the speculum on the otoscope before examining the other ear.
9. Discard the otoscope speculum into a clinical waste bin.

Colour

A healthy TM should appear pearly grey and translucent.

Erythema suggests inflammation of the TM which can occur in conditions such as acute otitis media.

Scarring

Scarring of the TM is known as tympanosclerosis and can result in significant conductive hearing loss if it is extensive.

Tympanosclerosis often develops secondary to otitis media or after the insertion of a tympanostomy tube.

Shape

A healthy TM should appear relatively flat.

Bulging of the TM suggests increased middle ear pressure, which is commonly caused by acute otitis media with effusion (there is often an associated visible fluid level).

Retraction of the TM suggests reduced middle ear pressure, which is commonly caused by pharyngotympanic tube dysfunction secondary to upper respiratory tract infections and allergies.

Light reflex

The light reflex (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 reflection of light should appear in the anterior inferior quadrant.

In the left ear, the light reflex should be positioned at approximately 7 o’clock to 8 o’clock.

In the right ear, the light reflex should be positioned at approximately 4 o’clock to 5 o’clock.

Absence or distortion of the light reflex is associated with otitis media (due to bulging of the TM).

Perforation

Note the size and the position of any perforations of the TM.

Causes of TM perforation include infection (e.g. otitis media with effusion), trauma (e.g. diving-related), cholesteatoma and insertion of tympanostomy tubes (also known as grommets).

Cholesteatoma typically causes perforation in the superior part of the TM and there may be visible granulation tissue and discharge in this region.

Ear Wax

Ear Infection

To complete the examination…

Explain to the patient that the first part of the examination is now finished.

Thank the patient and explain the next part.

Dispose of PPE appropriately and wash your hands.

Summarise your findings.

On general inspection, the patient appeared comfortable at rest and there were no abnormalities noted on inspection of the external ear.”

Otoscopy revealed normal tympanic membranes and auditory canals. There was no evidence of hearing loss on assessment.”

In summary, these findings are consistent with a normal examination of the ears.”

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