history and examination of ear

1. EXAMINATION
Of
EAR

2.  Otorrhoea (Ear discharge)
 Otalgia (Ear ache)
 Hearing Loss/impairment
 Vertigo
 Tinnitus
 Ear fullness/blockage
 Aural polyp
 Itching in ear
 Swelling and Deformity
 Foreign body/ injury

3.  Discharge from the ear
Etiology
Infection –
• EAC - otitis externa, otomycosis, furunculosis, acute dermatitis, neoplasm, TM
joint disease
• Middle ear – ASOM, CSOM, Mastoiditis, cholesteatoma
• CSF leak
Side – B/L, Right , left
Onset – sudden – ASOM, gradual/insidious –
CSOM, malignancy
Amount – scanty –CSOM -AAD, Otitis externa,
profuse – CSOM –TTD

4. • Duration – long – CSOM-AAD, Otitis externa
intermediate – CSOM-TTD short – ASOM, Furuncle
• Progress – intermittent – CSOM-TTD, continous – CSOM-AAD,
granulations, malignancy
• Nature –
1. purulent – furuncle, mastoiditis, malignant otitis externa, CSOM-AAD
2. Mucoid/mucopurulent – granular myringitis, CSOM-TTD, ASOM
(late stage)
3. Watery – CSF leak, eczematous/viral otitis externa
4. Bloody – ASOM (initial stage), trauma, granulations,
malignancy
5. Pulsatile – ASOM with pin point perforation, glomus tumour, ICA
aneurysm

5.  Colour – green – pseudomonas infection, yellow
black – otomycosis, yellow
 Smell – odourless – allergic otitis externa, CSOM- TTD foul smell – CSOM-
AAD, cholesteatoma
 Aggravating factors – cold, head bath,
pharyngitis, tonsillitis – CSOM-TTD
 Preceding history – trauma – CSF leak, ear surgery, skin disease
 Associated complaints
 Ear ache – Acute otitis externa, pruritus – chronic otitis externa, otomycosis,
eczema of skin – recurrent otitis externa, retro orbital pain
– abscess, hearing loss, vertigo

6.  Pain in and around the ear
Etiology
 Primary otalgia – local causes – inflammation, trauma, neoplasm
affecting external and middle ear, inner ear – no pain
• Auricle – perichondritis, trauma
• EAC – furuncle, impacted wax, acute otitis externa, FB, otomycosis,
neoplasm, myringitis
• Middle ear – ASOM, cholesteatoma, mastoiditis, ET obstruction,
malignancy, CSOM- no pain unless otitis externa, intra cranial
complications of CSOM
• Barotrauma- due to flying or scuba diving
• Referred otalgia.

7.  Secondary otalgia
 Referred pain to ear from other regions of head
and neck – common nerve supply
 V CN – Auriculo temporal branch of mandibular
nerve – anterior part of pinna, TM, EAC –
referred from dental, oral cavity, salivary glands,
nose, PNS, TM joint, face, parotid
 VII CN – branch of facial nerve –skin of concha,
anti helix, lobule, post EAC – referred in bell’s
palsy, herpes zoster infection
 IX CN – Jacobson’s nerve – tympanic branch to
middle ear, tympanic plexus, medial part of TM –
referred from nasopharynx, oropharynx, tonsil,
soft palate, styloid process, ET, mastoid
Referred Otalgia

8.  Duration – short – ASOM, perichondritis long –
malignancy
 Nature – dull – impacted wax, secretory otitis media, eczematous
otitis externa, sharp – furuncle throbbing – ASOM
 Location – front of ear – furuncle, deep in ear – middle ear
pathology, behind ear – mastoiditis, lymphadenitis, below ear – ET
pathology
 Aggravating and relieving factors
 Relieved on discharge from ear – ASOM, increase on swallowing –
ASOM, increase on yawning, chewing – furuncle, increase on pulling
pinna and pressing tragus – acute otitis externa

9.  Associated factors
 Tinnitus present – acoustic neuroma
 Itching present – otomycosis
 Association with ear discharge, hearing loss
 Past history – trauma, ear surgery
 Psychogenic
 More on exertion and left side pain – CAD
 Pain is always more on lying down – increased
blood supply- primary otalgia
 Costen’s syndrome – pain due to TM joint abnormality – defective
bite – associated with tinnitus, vertigo, blocked sensation

10.  Hard of hearing – if hearing loss can improve on
treatment
 Deaf – very severe or profound with little or no residual hearing
 Laterality - Rt/Lt/bilateral
1. Unilateral – CSOM, Acoustic neuroma, mumps
2. Bilateral – presbycusis, meniere’s disease, otosclerosis, noise
induced
 Onset – sudden – wax, viral deafness, ASOM, traumatic perforation,
head injury, blast injury, vascular causes, acoustic trauma, labyrinthitis
 Gradual/insidious – CSOM, OME, otosclerosis, NIHL, presbycusis,
acoustic neuroma

11.  Type – conductive – defect in external and middle ear, SNHL – defect in
inner ear or VIII CN, mixed
 Progress – stable – CSOM TTD (non discharging), perforated TM
 Progressive – CSOM AAD,CSOM TTD discharging, otosclerosis,
meniere’s disease, acoustic neuroma, presbycusis
 Fluctuating – meniere’s disease, secretory otitis
media
 Degree – mild – diseases of EAC like wax, FB, mild to moderate –
diseases of middle ear, mild to profound – inner ear diseases

12.  Duration – since birth – genetic, prenatal drugs, maternal infections,
prolonged labour, infancy infections like mumps, measles, meningitis
 Recent – trauma, inflammation, neoplasm, vascular
 Childhood – ASOM, OME, young adults – otosclerosis, old
age – presbycusis
 Family history – otosclerosis, meniere’s disease
 Drug history – ototoxic drugs like aminoglycoside, quinine,
salicylates, cytotoxic drugs
 Occupational history – noisy enviroment
 Trauma, viral fever, psychogenic

13.  Diplacusis – different pitch in both ears –
meniere’s disease
 Paracusis Willisi – hears better in noisy surroundings –
otosclerosis
 Hears better in quiet place – SNHL
 Autophony – hears own voice louder – serous otitis media, patulous ET
 Hyperacusis/ phonophobia – increased or painful sensitivity to everyday
sound that wont trouble normal person – stapedius muscle paralysis,
congenital syphilis
 Recruitment – cant hear at normal intensity but slight increase in intensity
leads to discomfort – cochlear pathology

14.  Perception of auditory sensation/sound ringing or noise with no
external stimuli
 33% population
 Classification
 Subjective tinnitus – only perceived by patient, Mainly
psychogenic/functional, more common
 Objective tinnitus – perceived by patient as well as examiner. Seen in
chronic contractions of palatal or tympanic muscles, live insects in
ear, intracranial vascular tumours, patulous ET,AV malformations,
clicking TM joint

15.  Pulsatile tinnitus – non continous – idiopathic, non vascular causes
like myoclonus, neoplasm, TM joint disease, vascular causes like
HTN, atherosclerosis, otosclerosis, glomus tumour, anaemia,
pregnancy, exercise
 Non pulsatile tinnitus – continous – with hearing loss seen in wax,
FB, otitis media, otosclerosis, noise exposure, presbycusis,
meniere’s disease, acoustic neuroma
 Without hearing loss – psychogenic, idiopathic, migraine

16.  Site – ear/head
 Unilateral or bilateral
 Duration – short – middle ear disease, long – inner ear
disease like ototoxicity, meniere’s disease
 Severity
 Fluctuant – meniere’s disease
 Past history – head injury, ear surgery, drug intake, noise
exposure
 Aggravated by smoking – inner ear pathology
 Aggravated by yawning, blowing – ET dysfunction
 Relieved by putting pressure on side of neck – vascular cause

17.  Associated with hearing loss – ear disease
 Tinnitus is first symptom of salicylate
poisoning
 Auditory hallucination – in psychiatric patients –
hear voices and sounds like music

18.  Sensation of rotation of surrounding enviroment with respect to
person or person with respect to surrounding. Disturbance of
equilibrium or movements
 Associated with LOC – central cause, not
associated – peripheral cause – inner ear
 Associated with loss of hearing – labyrinthitis, meniere’s disease,
acoustic neuroma (U/L)
 Associated with discharging ear – labyrinthitis
secondary to ASOM, CSOM
 Sudden onset – ear pathology
 Associated with posture – BPPV
 Associated with URTI – viral labyrinthitis

19.  Duration – 6 weeks or longer – labyrinthitis, 24 minutes to 24 hours
– meniere’s disease, few seconds several times a day – BPPV
 Otological causes – furuncle, wax due to stimulation of vagus nerve,
ET catarrh due to negative pressure in middle ear, surgical trauma to
inner ear due to mastoidectomy, stapedectomy, labyrinthitis, mumps,
measles, meningitis, ototoxic drugs like streptomycin
 Outside ear causes – cervical pathology,CVS – HTN, hypotension,
CNS – tumours, head injury, metabolic – DM, Hypothyroidism,
anaemia
 Functional or idiopathic

20.  Drugs like sedatives, antibiotics, anti hypertensives,
aspirin
 Tullio’s phenomenon – very loud sound causes vertigo – seen
in patients with labyrinthine fistula or those underwent
fenestration operation
 Perilymph fistula- coughing and sneezing causes vertigo – due to
rupture of round window (barotrauma) or at oval window due to
stapedectomy

21.  Fungal infection – otomycosis
 Allergy
 Wax
 Dermatitis
 Wax/ FB
 ET blockage/dysfunction – due to URTI –
aggravated on lying down
 Patulous ET – disappears on lying down or alters with
position of head
 Meniere’s disease – pressure in ear

22.  Pedunculated mass in EAC arising from EAC or middle ear,
associated with ear discharge, hearing loss and pain in ear
 Can bleed
 Etiology
 EAC – furuncle, trauma, FB, granuloma
 CSOM TTD/AAD
 Glomus tumour – red polyp which easily bleeds

23.  Nasal complaints like nasal obstruction, discharge, post nasal
discharge
 Throat complaints like irritation, dysphagia, change in voice
 Allergy and bronchial asthma – ET dysfunction, serous
otitis media
 DM – Malignant otitis externa, sudden SNHL
 HTN – Sudden SNHL
 Radiation – SNHL
 Mumps, measles, chicken pox – SNHL
 Anti thyroid drugs - giddiness

24.  Treatment for the same illness in the past or any other illness
 Diabetes, HTN, TB, Asthma and allergies, HIV, HBV, syphilis, radiation
exposure
 Surgeries - ear, hospital admissions, Trauma
 Deliveries and pregnancies
 Drug history- at present or past- steroids, insulin, ocp, anti
hypertensives, nasal decongestants, ototoxic drugs
 Allergy history – drugs or diet or allergen
 FOR DRUG ALLERGY – WRITE IN RED

25.  Life style – exercise, sedentary, hygiene
 Food habits – regular-irregular, spicy-non spicy,
nonveg- veg, excess tea or coffee
 Work place – noisy enviroment
 Home – dampness, pets, hobbies
 Alcohol, Tobacco – quantity, quality
 Sexual life
 Bladder & Bowel habits
 Menstrual history

26.  Enquire about parents, siblings and children
 h/o similar illness in family
 Familial diseases like Peptic ulcer, cancers,
allergies, diabetes and HTN, otosclerosis, deaf
mutism, meniere’s disease
 Consanguinous marriage
 Infectious diseases- by contact – TB , acute
infections

27.  Children – immunisation schedule
 OBSTETRIC HISTORY – early deafness
 Ototoxic drugs to mother during 1st trimester
 Infections to mother – rubella, mumps
 Birth trauma
 Post natal jaundice

28. Examination of
EAR

29.  External Ear - Auricle/Pinna
- Pre auricular region
- Post auricular/Mastoid region
 EAC
 TM
 Middle ear mucosa
 Eustachian tube
 Facial nerve and other CN
 Neck
 Nose and Throat

30.  INSPECTION
 Size – anotia (absence), microtia (small)
 Shape – cauliflower ear, bat ear (auricle protrudes anteriorly)
 Colour- red (perichondritis)
 Position- displacement of auricle forwards, laterally or inferiorly –
mastoid abscess
 Swelling
 Scar
 Ulcer

32. PALPATION
 Superficial palpation -
Using fingers (digital palpation) of cartilage and soft tissue
Soft tissue – mobility of skin (lost in malignancy), thickening, swelling
Raised temperature, tenderness
Cartilage – defect or loss
 Deep palpation -
Tragal tenderness- inflammation
Painful movement of pinna – acute otitis externa

33.  Sinus – pre auricular sinus
 Fistula
 Scar
 Swelling – cystic, lymphadenitis

34.  INSPECTION
Scar, dermatitis, swelling, fistula
Change in mastoid contour
Normally – uneven bone, skin over it mobile
 PALPATION
Superficial palpation
Skin – mobile
Raised temperature
Swelling – margins, cystic (sebaceous cyst)
Iron out mastoid – smooth surface – coalescent
mastoiditis

36.  Deep palpation
Tenderness – mastoiditis
1. Cymba concha – bony landmark for mastoid antrum
2. Midpoint of posterior border of mastoid
3. Tip of mastoid
 NECK EXAMINATION
1. Bezold’s abscess – pus track along SCM inferiorly
2. Citelli’s abscess – pus track along digastric into submandibular
triangle
3. Luc’s abscess – pus around zygoma
4. IJV as hard cord on palpation along SCM – IJV thrombosis

37. Direct examination
 Without speculum
• Size of meatus – atresia/wide/narrow
• Wide – post op, syphilis, otosclerosis
• Narrow – congenital atresia, scar due to trauma, burns, tumour - osteoma
• Content of meatus – wax, discharge, FB, Polyp
 Digital examination –
 Adults – pinna pulled upwards, backwards and laterally, tragus pulled
forwards
 Children – pinna pulled downwards and laterally

38.  Look for furuncle, swelling
 Fungal infection (otomycosis) – black – aspergillus niger, yellow –
candida albicans
 Polyp – probe test – if probe all around – arise from middle ear
 Impacted wax – whole EAC occluded
 Tumours
 With speculum examination – deep meatus to straighten the canal
 Largest speculum which can enter
 Black coated
 Introduce in slow rotatory fashion upto cartilage only

39.  Cough – vagal irritation
 Sagging of posterior superior EAC – cholesteatoma,
mastoid abscess, mastoiditis
 Absence of sensation in post sup EAC –
Hitselberger’s sign – mass lesion in CP angle

40. Figure : Showing method of holding ear speculum during ear examination

41.  Normal – pearly white colour, obliquely set,
anterior and posterior malleolar fold (longer)
 Handle of malleus – whitish bony landmark
 Umbo
 Cone of light/light relex – triangular in shape
anterio inferiorly – unreliable landmark
 Short or lateral process of malleus – small yellowish prominence – at 12 o
clock position - always present – last landmark to be destroyed in disease
 Quadrants – 4 – imaginary line through tip of umbo, 2 nd vertically along
handle of malleus – ant sup/inf, post sup/inf

43.  Colour of TM – normal pearly white/greyish white, red in ASOM, acute
myringitis
 Congestion with yellowish tint – ASOM
 Diffuse congestion/ localised at handle of malleus – ASOM
 Dark grey colour/dull appearance – tubal occlusion
 Dull white/thickened cotton like drum – senile sclerosis, scarring
 Chalky white appearance – tympanosclerosis
after otitis media
 Dull lusterless/bulging – secretory otitis media
 Blue drum – transudative otitis media
 Dark blue drum - haemotympanum

44.  TM normally inclined downwards and medially
 Protrude outwards – bulging drum – acute otitis media
(pus),Haemotympanum (blood),OME with good ET function (air) –
increase length of handle of malleus, less prominent short process and
malleolar folds, absence of cone of light
 Pulled inwards – retracted TM- OME with poor ET function, ET
obstruction, atelectasis – shortening of handle of malleus, more
prominent short process, anterior and post malleolar folds, distorted
cone of light
 Retraction – attic region (retraction pocket) if deepens –
cholesteatoma sac

46.  Siegle’s pneumatic speculum/ Valsalva
maneuvre
 Normal – change in shape of triangular light
reflex/ handle of malleus movement
 Decreased/absent – ET dysfunction, adhesive
otitis media (fixed), ankylosis of ossicular
chain, SOM
 Hypermobility – Patulous ET, atrophy of TM

48.  Perforation – ovoid/ kidney shaped/ round, small,
medium, large, sub total, total, central/marginal, pars
tensa/attic, dry/wet, single/multiple (TB, measles,
wegner’s granulomatosis), margins – regular/irregular,
edge of perforation – thick (CSOM)/ thin (ASOM)
 Scars
 Bulla – grey/red/bluish pearls like structures attached to
surface of TM
 Chalky white patch - tympanosclerosis

50. Tympanic membrane in OM
13–50

51.  Only through perforation/ if TM thinned out/
semitransparent
 Middle ear mucosa – oedema/ polyp
 Granulation tissue
 Ossicles, ET, round window, oval window
 FB
 Fistula

52.  Posterior rhinoscopy/ Nasopharyngoscopy/ DNE/
Through perforation
 Valsalva Maneuvre
 ET catheterisation – check patency of ET
 Few drops in ear if perforation and bitter taste in
mouth

53. Three tests that are in common use:
•Rinnie’s Test
•Weber’s Test
•Absolute Bone Conduction Test [ABC Test].
Tunning forks of 256, 512 and 1024 hertz are used.

54. Rinnie’s Test -
In a normal individual air conduction is better
than a bone conduction and the ratio of air: bone
is 2:1.
Test details Result Interpretation
AC > BC Rinnie +ve Normal or SN loss
BC > AC Rinnie –ve Conductive deafness
AC = BC Rinnie = Mild conductive deafness
BC > AC? Rinnie false negative This is seen when a patient has severe SN deafness on test
side and normal hearing on non-test side. On application of
vibrating tuning fork to deaf side the sound is trans- mitted
to the non-test ear by bone and patient perceives this bone
conduction and presumes that it is perceived by test ear,
thus inter- preting it as BC > AC. Bone conduction level
should be confirmed by Weber test.
256 hertz 512 hertz 1024 hertz Interpretation
- +
- -
- -
+
+
-
Mild conductive deafness
Moderate conductive deafness Severe conductive
deafness
Quantification of HL using Rinnie’s test

55. Weber Test

56. Absolute Bone Conduction (ABC) Test -
In this test the bone conduction level of the
patient is compared to that of clinician. During
test ambient noise in the surrounding is
reduced by pressing the tragus of the EAC. This
is a modification of ‘ Swabach’s Test’
Test details Result Interpretation
Clinician listens longer than patient
Clinician listens equal to that of patient
Patient listens longer than clinician.
ABC reduced
ABC normal ABC
lengthened
SN deafness
Normal
Conductive deafness

57.  FISTULATEST
Apply intermittent pressure on tragus/
siegle’s pneumatic speculum – ask patient to look
straight – check for vertigo/ nystagmus towards opposite
side
Fallacy
False -ve test: There can be a fistula without fistula test positive. This happens
in dead labyrinth, or when fistula is temporarily blocked by cholesteatoma
flakes.
False + test: There can be fistula test positive without actually having a fistula.
This happens when thinning of bony labyrinth occurs. This may happen in
syphilis, cholesteatoma.

58.  FACIAL NERVE EXAMINATION
• Paralysis in ASOM, CSOM, Malignant otitis externa, herpes zoster, tumours and
trauma
• Wrinking of forehead/ closure of eyes/ loss of naso labial folds/ deviation of
angle of mouth/ cant whistle or blow
 NOSE AND THROATEXAMINATION
 EYE EXAMINATION
• Nystagmus
• Corneal relex – absent in acoustic neuroma
• Blue sclera – osteogenesis imperfecta
• Papilloedema – CP angle tumours/ otitic hydrocephalus/ temporal abscess
• Interstitial keratitis – congenital syphilis

59. The investigations commonly needed for ear diseases are:
• Microbiology of pus discharge
• Radiology of mastoid and PNS
• Pure tone audiometry
• Impedance audiometry
• Caloric testing.
• Other investigations that may be needed in specific case are:
– High resolution CT scan
– Fundoscopy when you suspect intracranial extension of disease
– Evoked response audiometry
– Electro nystagmography
– Cranio corpography.

60. RADIOLOGICAL EXAMINATION OF THE EAR
Views advised for temporal bone study are:
• Laws position
• Schuller’s position
• Mayer’s position
• Stenver’s position
• Chausse III position.
Out of these Schuller’s view is most com- monly advised view.