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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Tutor notes – This session is linked to the first PBL case – George Marshall is a 55 year old
wood machinist who is suffering from a hearing deficit caused by the high levels of noise in
his work environment.
SESSION PLAN:
12.00pm-12.30pm Briefing in Lecture Theatre B For Peer Tutors
12.30pm-13.30pm – Lecture Theatre B, Otoscopy lecture demonstration by ENT
registrar/teaching fellow
13.30/15.30pm– Move to clinical cubicles –recap on anything that the students have queries about
then spend the rest of the time observing the students and helping them develop their ear
examination and hearing tests skills.
45mins
Students need to practice the steps of ear examination (including otoscopy) on the manikin head
first and show competent handling of the otoscope before they examine each other.
The students can then practice on each other – ensure that they practice consenting each other for
this procedure and that they use a new speculum each time. Please ensure that speculums are
disposed of in the clinical waste.
The students need to be familiar with both the wall mounted and the portable otoscopes.
45mins
Students should then practice whispered voice test, Rinne’s and Weber’s on each other
If there is time at the end – get the students to carry out a full examination (ear exam and hearing
tests)
Learning outcomes
By the end of the session, students should be able to:
 Demonstrate competent handling of an otoscope and otoscopy technique
 Describe the anatomy of the outer and middle ear, identifying structures that can be seen
using the otoscope
 Perform whispered voice and tuning fork hearing tests on a colleague
Clinical relevance
Otoscopy is a vital skill in many specialties but is often not practised by students as much as other
skills. Consider the following scenarios:
 a 4 year old on the paediatric ward with a high fever, pulling at their ear
 a 75 year old attending his GP practice because his wife says he is deaf
 an anxious mother in A&E with her 2 year old child, concerned that they might have put a
bead in their ear
 a patient admitted to the neurosurgical unit with a head injury and possible basal skull
fracture;
 a patient in ENT outpatients, referred with possible cholesteatoma
Otoscopy is an essential component in the examination of these patients.
As well as being able to look in the ear, you should be able to perform the bedside hearing tests to
differentiate between sensory and conductive hearing problems. These tests are not difficult, but
tend to confuse and worry students – again, as with most things, if you practise, you will improve.
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Links with other learning
As you can see from the paragraph above, otoscopy and hearing tests feature in many specialties.
You also need to be aware of the issues that may arise in communicating with a patient with a
hearing difficulty. This is significant both in gathering information during history taking, introducing
yourself and explaining the examination in order to gain consent, explaining what you are doing as
you go along and giving clear instructions when performing any hearing tests.
What might you need to do to aid communication? Consider:
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background noise,
your position- sit directly in front of the patient, so that they can see your lip movement
clearly
volume, clarity and speed of speech
tone and manner
non-verbal communication skills
Later in the academic year during life control we will be revisiting hearing tests when you learn how
to examine the cranial nerves
Related Basic Sciences:
Please prepare for this session. You need to know the anatomy and physiology of the ear.
Where are the structures listed below located?
How do they function in hearing and balance?
Outer ear
 Helix
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Pinna
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Antihelix
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Tragus
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Concha
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Lobe
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External auditory meatus
Middle ear
 Tympanic membrane (pars tensa, pars flaccida, attic, handle of malleus)

Ossicles (malleus, incus, stapes)

Mastoid air cells

Eustachian tube
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Inner ear
 Vestibule
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Semicircular canals

Utricle
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Saccules
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Cochlea
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Vestibular nerve
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Cochlear nerve
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Endolymph
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Perilymph
General notes
Remember that you will have taken a history during which it is important to establish which is the
symptomatic ear and which is the “normal” ear.
When talking, look at your patient and avoid looking down or covering your face.
Use a normal rhythm of speech but slow down slightly, speak clearly but avoid raising your voice. It
may be necessary to clarify by rephrasing or just repeating.
Avoid a patronising tone or manner.
During the examination it is important to remember the anatomy but note that when you look in the
ear at the tympanic membrane you will not be able to see the head of the malleus and the body of
the incus as these structures are normally hidden in the temporal bone. See diagrams below
(reproduced with kind permission of Professor Prescott).
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Examination of the ear- STEPS
Introduction & Preparation
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Introduce yourself fully
Check the patient’s name
Explain the nature and purpose of the assessment using non-technical language
Offer chaperone
Obtain consent
Ask if the patient has any pain and if so, where it is.
Clean your hands
Ensure you have your patient at the correct height so you can easily examine their ears
Ensure you have the correct equipment assembled and working
 otoscope and clean speculum
 512 Hz tuning fork.
Examination
Start by examining the “normal” ear first. This allows you to look at the patient’s normal anatomy,
compare sides, and limits risk of any infection being spread from one ear to the other. Follow the
same steps for each ear:
Inspect the outer ear
Use the otoscope as a torch to help illuminate the outer ear.
Look both in front and behind the pinna for:
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Scars from injury or previous surgery (a large meatus can also indicate previous surgery)
Swellings or lumps
Deformity
Inflammation
Skin condition e.g. evidence of eczema, skin lesions
Hearing aids - small digital hearing aids can be very discreet
Evidence of discharge
Palpation
Gently palpate the:
 Mastoid process - mastoiditis can complicate untreated otitis media
 Tragus
 Temporomandibular joint - pain from the TMJ often radiates to the ear
 Ask if there is any pain before gently pulling the pinna outward, back and up - pain may
suggest otitis externa
Otoscopy
 Use your right hand for their right ear and left hand for the patient’s left ear and hold the
otoscope in a pen grip between your index finger and thumb. Some students (and doctors)
hold the otoscope with a hammer-style grip. This is incorrect. It may feel easier initially, but
gives less control, with more risk of causing pain to the patient. For this reason, it is should not
be held in this manner.
 Gently grip the pinna and pull outward, back and up to straighten the ear canal and allow a
good view of the tympanic membrane,
 Insert the speculum of the otoscope, resting the ulnar border of your hand on the patient’s face
to help steady your hand, and to ensure that if the patient moves, then you move with them. This
helps prevent trauma to the ear from unexpected movement.
 Use your right eye to look in the right ear and your left eye to look in the left ear.
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
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Inspect the external auditory meatus for
- Inflammation
- Eczema
- Furuncles
- Vesicles
- Wax or debris (sometimes may completely occlude the canal. In severe otitis externa,
this may require removal with microsuction)
- Foreign bodies
- Discharge
Look at the tympanic membrane and identify the handle of the malleus and the lateral process
of the malleus (a pyramidal piece of bone that lies superiorly between the handle and the head
of the malleus) for orientation.
Look at the colour and look for the presence of a light reflex
Work your way around the pars tensa (this is the area below the lateral process of the malleus)
systematically, looking for any abnormalities
Then look at the pars flaccida and attic (the area above the head of the malleus. Abnormalities
here are easily missed unless you actively examine this area
Remove the otoscope and inspect the speculum for debris, wax, blood, or discharge
Examine the other ear (use a clean speculum if necessary)
Dispose of speculum in clinical waste
Hearing tests
Whispered voice test
Use this as a quick screening test if the hearing is reported as normal
 First of all you need to check that the patient understands the test.
 Ask the patient “Can you repeat the numbers I am going to say to you?”
 From behind and to the side of the ear to be examined (so they cannot see your face) mask
the sound in the other ear by rubbing your fingers next to the tragus and say a number at
about 15cm away. Repeat with a few different numbers.
 Now do the test
 Tell the patient that you are now going to whisper some numbers and ask them to repeat
them
 From behind and to the side of the ear to be examined (so they cannot see your face) mask
the sound in the other ear by rubbing your fingers next to the tragus and whisper a number
at about 60cm away (arms length).
 Repeat with a few different numbers
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If they can hear a whispered voice at this distance, their hearing is not significantly impaired
Test both ears.
Tuning fork tests
If you identify hearing difficulty with the whispered voice test, or if the patient is complaining of
hearing difficulty, you need to do the Rinne’s and Weber’s tests.
The tests are based on two physiological facts:
 The inner ear is normally twice as sensitive to sound conducted by air as to sound conducted by
bone.
 In the presence of a purely conductive loss the ear is subject to less environmental noise and
this makes it more sensitive to bone conducted sound
The principle of these tests is to compare the loudness of sound perceived purely by bone
conduction with the sound perceived by air conduction. This can be used to determine whether
hearing impairment is sensorineural or conductive in origin.
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
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Always use a 512 fork
Always explain before doing the tests that you are going to use a tuning fork held in different
positions in order to test their hearing and that you will be asking them to tell you where they
hear the sound the loudest
Always strike the prongs against a resistant but elastic object such as your elbow. This requires
some practice as it can be painful!
Rinne’s test
 Explain that you would will be holding the tuning fork in front of their ear and that you will be
placing it on the bone behind the ear and that you need to know whether they can hear it
loudest in front or behind.
 Strike the prongs of the fork and position them about 5cm from the external canal of the test ear
 Ask the patient “can you hear the fork?”
 Then place the base of the fork on the patient’s mastoid process and then position the prongs in
front again.
 Ask the patient “which is loudest – in front or behind?”
 Alternate several times in front and behind so that you are clear where they are hearing it the
loudest.
 You may need to strike the prongs again
Reporting and interpreting the findings of the Rinne’s test
If the sound is heard louder in front this is described as either:
 positive Rinne (air conduction > bone conduction)
It means that the hearing in that ear is either:
 normal – this is because the inner ear is more sensitive to sound transmitted through the air
than the sound transmitted via the bones of the base of the skull.
-OR there is a sensorineural hearing loss – this is because the sound perceived by air conduction
and the sound perceived by the conduction through the bones of the base of the skull are both
equally diminished by the sensorineural loss resulting in the sound being still perceived as
louder through the air.
If the sound is heard louder behind this is described as either:
 negative Rinne (bone conduction > air conduction)
It means that the hearing in that ear is either:
 conductive hearing loss >20dB - because of the difference in sensitivity between air and bone
conduction, the loss needs to be >20dB for it to have diminished to such a degree that it is
heard better through the bones of the base of the skull
-OR occasionally you will get a false negative Rinne’s test due to a sensorineural loss –this is
because the sound is transmitted to the better cochlea by bone conduction “bypassing” the bad
ear altogether.
Weber’s test
 Explain that you will be placing the base of the tuning fork on their forehead and that you need
to know whether they can hear it louder in one ear or the same in both ears.
 Strike the prongs of the fork and place the base in the middle of the forehead.
 Ask “Is the sound louder in one ear, or the same in both?”
 Repeat if necessary to be really sure
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Reporting and interpreting the findings of the Weber’s test
If the sound is heard the same in both ears this is described as
 sound is heard equally in both ears
It means that the hearing is either:
 normal in both ears
or
 there is a bilateral equivalent problem
If the sound is heard louder in one ear this is described as
 abnormal and lateralising to either the good or the bad ear
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If it lateralises to the “good” ear this means that there is a sensorineural problem in “bad”
ear because the sound transmitted through the bones of the skull to both inner ears cannot
be perceived as well in the bad ear because of its sensorineural problem.
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If it lateralises to the “bad” ear this means that there is a conductive problem in the bad
ear. This is because when the air conduction is impaired, this ear does not pick up
distracting background noise. This makes it comparatively more sensitive to transmission of
sound through bone than the normal ear, where the background noise is picked up. (You
can mimic a conductive problem by putting your finger in your ear and do the Weber test to
demonstrate this on yourself)
Closure
 Thank your patient
 Clean hands
 Report (if not already done so) or record your findings
SUMMARY OF WEBERS AND RINNES TESTS
Rinnes test
 Louder in front = normal or sensorineural deafness
 Louder behind = conductive deafness (occasional false negative sensorineural)
Webers test
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Heard equally well in both ears = normal or bilateral equivalent problem
Lateralises to “good” ear = sensorineural problem in “bad” ear
Lateralises to “bad” ear = conductive problem in “bad” ear
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Ear examination and hearing tests
Lead Lecturers: Phillipa Tostevin & Hamed Khan. Tutor Notes 2016-2017
Self directed learning
During attachments in General Practice and ENT you will be examining patient’s ears.
Please prepare for this in advance.
Clinical reasoning:
Use the otoscopy models and try to describe the changes seen in the following conditions
 Acute otitis media
 Serous effusion / secretory otitis media or “glue ear”
 Retracted tympanic membrane
 Perforation
 Healed perforation
 Tympanosclerosis
When examining the ear in children, you will need to pull slightly back and down on the
pinna to straighten the canal (as opposed to back and up for adults)
References & Further Reading
Journal articles
 Carney AS and Birchall JP. How to use an otoscope. sBMJ; 1995. Accessible online at
http://student.bmj.com/back_issues/0795/7-otos.htm
Textbooks
 Bickley L S, Hoekelman RA. Bates’ Guide to physical examination and history taking, 7th edition.
Philadelphia: Lippincott;1999.
 Douglas G, Nicol F, Robertson C. Macleod’s Clinical Examination 11th edition. Edinburgh:
Churchill Livingstone; 2005.
 Moore K L, Dalley A F Clinically Oriented Anatomy 5th Edition. London: Lippincott; 2006.
Acknowledgements
With thanks to Deborah Horton, Dr. Kerry Boardman and Philippa Tostevin for the use of their notes
and to Professor Prescott for the use of the diagrams above.
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