The document discusses clinical examination of the ears and hearing. It covers examination of the external ear structures like the pinna and external auditory canal. It also discusses wax production and removal methods. Assessment of hearing is described including free field speech testing and tuning fork tests like Rinne and Weber to distinguish conductive and sensorineural hearing loss. Structured otoscopy of the tympanic membrane is outlined along with normal findings and age-related changes.

1. Clinical examination of the ears &
hearing
Pinna
The external ear or pinna is constructed of cartilage & skin. The cartilage forms an outer helix & an
inner antihelix. These structures surround the conchal bowl that is shielded anteriorly by the tragus.
The pinna collects sound & directs it down the external canal towards the tympanic membrane.
Examination of the external auditory canal
The external canal consists of a cartilaginous outer third & a bony inner two-thirds. It is angled &
needs to be straightened before examination is attempted. This is done by gently pulling the pinna
posterosuperiorly. This aligns the cartilaginous canal with bony canal & should allow visualization of
the entire canal & Tympanic membrane.
The temperomandibular joint creates an anterior bulge in the deep external canal that may obscure
the anterior inferior tympanic membrane.
Wax production
Wax is produced by the hair-bearing skin of the external auditory canal. Wax is a common of
desquamated skin& cerumen formed by glands in the base of the hair follicles.
Most external canals are self cleaning with the desquamated skin migrating up to their hair follicles
where it is separated from the dermis &mixes with the cerumen to form wax. The wax migrates
down the hair & fall out of the ear canal.
Indications for wax removal
1. Indications for wax removal are impaired hearing or discomfort associated with water
getting trapped in the ear after showering or swimming.
2. If the patient has an otological symptoms (pain , vertigo).
3. The deep external canal & tympanic needs to be evaluated to ensure that there is no
pathology present.
Method of removal syringing, Jobson Horne probe or suction under microscopic control.
Wax softening: occlusive wax, especially if adherent to the canal wall, may need to be softened
prior to removal.
To soften the wax, the patient is asked to turn their head on the side to allow the external canal to
allow the external canal to be filled with water & liquid soap(decrease the surface tension) or wax
softener. The tragus is then pushed in & out to aid penetration into wax. The patient should
continue this for about 20 minutes prior to syringing.

2. Ear toilet
1.Syringing
1. The syring is filled with warm water at body temperature.
2. A headlight should be worn to illuminate the external canal adequately, while the ear canal
is straightened by pulling the pinna posterosuperiorly.
3. If the gap is present between the wax & ear canal, the stream of water should be bounced
off the wall at that point. This will allow water pressure to be generated behind the wax
plug& will result in its extrusion.
4. If there is no gap, the stream of water should be directed at the junction of the wax & the
canal & a gap created allowing the water to generate pressure behind the wax plug.
5. Once otoscopy confirms the clearance of the wax plug, the canal needs to be dried with
either a piece of string placed down the ear canal or by mopping the canal.
2.Mopping the canal
A mop can be used to dry the ear canal after syringing or to remove discharge or debris from the ear
canal. This allows visualization of the underlying canal & tympanic membrane.
A mop is made by winding a thinned out piece of cotton wool around the end of orange stick. Care
should be taken to ensure that the stick extends only half way into the cotton wool mop.
3.Microscopic ear toilet
It allows the external canal & tympanic membrane to be magnified while wax, pus or debris is
removed using a suction cannula. It allows the ear to be cleaned with great precision & with minimal
discomfort for the patient.
Otoscopy
The first decision when performing otoscopy is to choose the size of the speculum to be placed on
the otoscope. A narrow speculum limits the visible canal or tympanc membrane. The otoscope then
has to be moved around & all the subsequent images pieced together like pieces of a jigsaw until the
overall picture is established.
Normal external canal
The outer third of the ear external canal has hair-bearing skin which is thick. At the junction of the
cartilaginous & bony canal, the skin thins & covers the underlying bony canal. This allows the bony
prominence formed by the impression of the temperomandibular joint to be clearly seen.
Structured otoscopy
The most recognizable feature in most ears is the handle of malleus & this should be the first
structure sought, the umbo & lateral process should be identified.

3. Foreshorting indicates retraction of the tympanic membrane medially as does lipping around the
annulus.
Loss of light reflex, may be caused by either retraction, inflammation or scarring of the tympanic
membrane.
Tympanic membrane is normally a grey , slight translucent colour.
Deposition of calcium in the fibrous layer occurs as a consequence of previous ear infections. This
increases the whiteness of the tympanic membrane & can be diffuse thickening of the tympanic
membrane or isolated tympanosclerotic plaques. Tympanosclerosis may affect the middle ear ossicle
with consequent conductive deafness, as these plaques reduce the ossicular mobility.
Tympanosclerosis can also be seen after middle ear surgery or repair of the tympanic membrane.
Tympanic membrane lose its translucency & ossicular chain increased in stiffness with age.
Clinical assessment of hearing
Free-field speech testing
1. This test is performed with the subject facing forward & the examiner stationed opposite the
ear to be tested.
2. The patient should not be able to see the examiner’s lips movement.
3. It is necessary to mask the nontest ear by pushing the tragus in or out/ rubbing the paper
between the finger’s over the non-test ear.(this provides mask at a level around 40db).
4. A combination of letters & numbers are going to be wisherpered & spoken into the test ear.
The patient is asked to repeat them.( number-letter combination has mix consonant that
allows a relatively broad range of frequencies to be tested). Full extension of arm should put
the examiner about 1 meter from the test ear. A number of letter-number combinations are
repeated. If the patient repeats more than 50% of the number-letter combinations
accurately, the hearing in the ear is at least better than 40dbHL.
5. The test is then repeated with a whispered voice. A whispered at 1 metre is around 15db.
Tuning fork tests
Tunning fork test are used to distinguish between a conductive & a sensorineural hearing loss. The
most commonly used forks are 256 & 512 Hz fork more reliable response than the 1024Hz.
Tunning forks are activated by striking them lightly against the elbow.
Rinne tuning fork test
The rinne test is designed to compare air conduction with bone conduction. Two methods
1) Loudness comparison method(more reliable).
2) Threshold comparison method.

4. A vibrating tunning fork is placed on the patient’s mastoid (as closely as possible to the
posterosuperior edge of the canal without touching it). When he stops hearing, it is placed
vertically, about 2cm away from the opening of the EAC. If he still hears, AC is greater than
BC.
Loudness comparison method; the patient is asked to compare the loudness of sound heard
through air & bone conduction.
Negative Rinne test for 256, 512& 1024 indicates a minimum AB gap of 15 , 30& 45 db
respectively.
False positive & false negative test again depends on the air-bone gap. The false positive
rate in normal patients is 20%.
Weber tuning fork test
The test is performed by placing an activated tuning fork over the forehead, on the bridge of the
nose or over the incisor teeth, midline over the vertex of the skull.
The patient is asked to identify in which ear the sound is heard or louder.
The principal of this test is to compare bone conduction between the two ears. In conductive
deafness, weber is lateralised to the affected ear or diseased ear. In sensorneural deafness, weber is
lateralised to the opposite ear or healthy ear. If a conductive loss of 10db or exists, the sound should
be heared in the affected ear.
Absolute bone conduction test
The principle of this test is to compare the bone conduction of the patient with that of the examiner
with ear occluded to make the absolute bone conduction.
In sensorineural deafness patient’s bone conduction is shortened than the examiner& in conductive
deafness it is lengthened.