Physical Exam: Ears

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I. History

• Presenting problem or injury
• Presence of hearing loss
• Use of hearing assist
• Associated findings
• Onset
• Precipitating factors
• Aggravating and alleviating factors
• Lifestyle factors: swimming, musician
• Medical history
• Family history of allergy or hearing disease
• Medications

II. Inspection - External Ear

• Observe size, shape and symmetry of both ears
• Auricles are normally level with each other, and upper point of attachment is in a straight line with the lateral canthus of the eye
• Inspect ear skin for color, lesions, rash and scaling
• Inspect area behind auricle for tophus (a deposit of sodium biurate in tissues near a joint, in the ear, or in bone in gout)

III. Palpation

• Palpate auricle, tragus and mastoid area for tenderness and elevated local temperature
• Normal findings: auricle is normally smooth without lesions
• Estimate size of external auditory meatus

IV. Otoscopic Examination

• Adult: Grasp auricle and pull UP and BACK to straighten external ear canal before inserting otoscope
• Child: Grasp auricle and pull DOWN and BACK
• Inspect ear canal for redness, swelling, discharge, crusting and foreign bodies
• Expect a small amount of moist, usually orange cerumen (ear wax). Cerumen is usually dry in Asians, Native Americans and the elderly
• Tympanic Membrane: 

1. Normal Finding: translucent, shiny, light gray, taut disk; free from tears or breaks
2. Test its mobility: Ask client to say "ah" or swallow. Intact membrane will vibrate slightly

V. Hearing Acuity: Four Tests

1. Gross hearing is tested by client's response to normal conversation
2. Whispered words or ticking watch test
3. Weber Test: Tuning fork of 512 cps is set to vibrate and placed perpendicularly on the midline vertex of the skull. Client asked to report in which ear sound is heard. If heard in one ear, suspect sensorineural loss in the other
4. Rinne Test: Compares sound conduction - air versus bone 

• Set tuning fork to vibrate
• Place on mastoid process
• Ask client whether the sound is heard and when it can no longer be heard. Note how long the sound can be heard
• When client states that sound  is gone, immediately move the tuning fork to about 2 cm from auditory canal
• Ask the client again whether there is sound and when it stops 
• Normal finding: latter sound should be heard twice as long as that of mastoid sound

VI. Geriatric Alterations

• Ear lobes may appear pendulous
• Presbycusis