PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Examination of the ear and related head and Examination of the ear and related head and neck structures should be performed in a neck structures should be performed in a systematic and consistent manner so that systematic and consistent manner so that no part of the exam is neglectedno part of the exam is neglected

EXTERNAL AUDITORY CANAL EXTERNAL AUDITORY CANAL (EAC)(EAC)

composed of cartilage covered by skincomposed of cartilage covered by skin outer 1/3 cartilaginous (mobile) outer 1/3 cartilaginous (mobile)

- inner 2/3 bony - inner 2/3 bony with narrowing at the bone-cartilage junction with narrowing at the bone-cartilage junction

(narrowest area)(narrowest area) skin lining cartilaginous portion is thickerskin lining cartilaginous portion is thicker

Bony portion of the EAC is the only structure Bony portion of the EAC is the only structure in the body where there is skin directly in the body where there is skin directly overlying bone with no subcutaneous tissueoverlying bone with no subcutaneous tissue

area is very sensitive and swelling is very area is very sensitive and swelling is very painful as there is no room for expansionpainful as there is no room for expansion

AURICLE OR PINNAAURICLE OR PINNA

- A complex cartilaginous structure that is - A complex cartilaginous structure that is covered with skincovered with skin

- Has a variety of folds which are generally Has a variety of folds which are generally consistent but vary slightly from individual to consistent but vary slightly from individual to individualindividual

- Important to know the embryology of the Important to know the embryology of the auricle in understanding the different auricle in understanding the different pathological conditionspathological conditions

Development of the auricle embryologically Development of the auricle embryologically is complicated, sometimes resulting in is complicated, sometimes resulting in developmental anomalies including pre developmental anomalies including pre auricular skin tags, and small accessory auricular skin tags, and small accessory auriclesauricles

Cosmetically pleasing auricle is generally Cosmetically pleasing auricle is generally positioned with the concha at a 90 degree positioned with the concha at a 90 degree angle lateral to the headangle lateral to the head

helix and antihelix must be well formedhelix and antihelix must be well formed

Noticeable differences , even if minor, Noticeable differences , even if minor, between an individuals right and left auricles between an individuals right and left auricles are abnormal and should suggest a are abnormal and should suggest a pathological processpathological process

INSTRUMENTS USED IN DOING INSTRUMENTS USED IN DOING OTOSCOPYOTOSCOPY

PenlightPenlight Aural speculum Aural speculum OtoscopeOtoscope Appropriate source of illumination – Appropriate source of illumination –

floor lamp, head mirror, head lightfloor lamp, head mirror, head light

Ear Examination InstrumentsEar Examination Instruments -penlight - may be used to examine -penlight - may be used to examine

external ear and ear canalexternal ear and ear canal - ear speculum - utilized to widen the - ear speculum - utilized to widen the

opening of the ear canal opening of the ear canal - floor lamp - necessary for viewing the - floor lamp - necessary for viewing the

external and middle ear using a head mirrorexternal and middle ear using a head mirror

Head Mirror - used together with a floor Head Mirror - used together with a floor lamp and ear speculum to view external and lamp and ear speculum to view external and middle earmiddle ear

Otoscope - used in place of a head mirror Otoscope - used in place of a head mirror - does not require use of a floor lamp - does not require use of a floor lamp because of its built - in light sourcebecause of its built - in light source

Select correct size of speculumSelect correct size of speculum examine ear canal for inflammation, redness examine ear canal for inflammation, redness

of skin, secretions, impacted cerumen or ear of skin, secretions, impacted cerumen or ear waxwax

always disinfect speculum to avoid cross-always disinfect speculum to avoid cross-contaminationcontamination

OTOSCOPYOTOSCOPY

Adequate examination of the external Adequate examination of the external auditory canal requires proper positioning of auditory canal requires proper positioning of the patientthe patient

Patient’s head must be tilted towards the Patient’s head must be tilted towards the opposite shoulderopposite shoulder

Since tilting the head is a position the Since tilting the head is a position the patients do not normally assume, you patients do not normally assume, you should explain to them why you are doing should explain to them why you are doing thisthis

OtoscopyOtoscopy

Examining an adultExamining an adult

Examining a child/infantExamining a child/infant

In adults, the tragus should be gently pulled In adults, the tragus should be gently pulled anteriorly and the pinna lifted in the postero anteriorly and the pinna lifted in the postero superior direction to straighten the ear canalsuperior direction to straighten the ear canal

In infants and young children, the pinna In infants and young children, the pinna should be pulled inferiorly because of the should be pulled inferiorly because of the downward curvature of the normal infantile downward curvature of the normal infantile EACEAC

In many individuals, the EAC is sufficiently In many individuals, the EAC is sufficiently large that drawing the tragus anteriorly and large that drawing the tragus anteriorly and lifting the auricle upwards and posteriorly lifting the auricle upwards and posteriorly opens the meatus sufficiently wide to give opens the meatus sufficiently wide to give us a good view of the EAC and tympanic us a good view of the EAC and tympanic membrane (TM). membrane (TM).

If not, a nonreflective aural speculum can be If not, a nonreflective aural speculum can be used to control the soft tissues of the lateral used to control the soft tissues of the lateral EAC and thus facilitate visualization o the EAC and thus facilitate visualization o the medial EAC and TM.medial EAC and TM.

The largest speculum that will fit comfortably The largest speculum that will fit comfortably gives the best exposuregives the best exposure

Use your non dominant hand to hold Use your non dominant hand to hold speculum so the dominant hand can be left speculum so the dominant hand can be left free for instrumentationfree for instrumentation

INSERTING THE SPECULUMINSERTING THE SPECULUM

The hand holding the speculum should The hand holding the speculum should gently rest against the patient’s head so that gently rest against the patient’s head so that inadvertent movement by the patient will inadvertent movement by the patient will move the head and speculum together and move the head and speculum together and prevent accidental injury to the EAC or TM.prevent accidental injury to the EAC or TM.

Speculum should not be inserted past the Speculum should not be inserted past the cartilaginous portion as this is the only part cartilaginous portion as this is the only part which is mobile or stretchablewhich is mobile or stretchable

Contact with the inner bony 1/3 of the canal Contact with the inner bony 1/3 of the canal is painful and does nothing to enhance is painful and does nothing to enhance visualizationvisualization

OtoscopeOtoscope

Advantages:Advantages: - handheld, portable- handheld, portable- quick and easy to use - quick and easy to use - with good magnification - with good magnification - easily available and cheaper - easily available and cheaper

Limitation:Limitation: - absence of binocular vision - absence of binocular vision

MicroscopeMicroscope

Advantages:Advantages:

-allows binocular vision, maximum -allows binocular vision, maximum illumination and magnification, illumination and magnification,

-leaves the dominant hand free for effective -leaves the dominant hand free for effective and relatively easy instrumentationand relatively easy instrumentation

Limitation: Limitation:

-availability and cost-availability and cost

CERUMENCERUMEN

Typical pH of cerumen is 6.1Typical pH of cerumen is 6.1

Conveyed along the EAC by the normal Conveyed along the EAC by the normal movements of the lower jaw while eating, movements of the lower jaw while eating, yawning, and talkingyawning, and talking

CERUMENCERUMEN

Consists of a combination of desquamated Consists of a combination of desquamated epithelium, thick sebaceous gland epithelium, thick sebaceous gland secretions, and thinner apocrine gland secretions, and thinner apocrine gland secretionssecretions

Water resistant, traps debrisWater resistant, traps debris

With both bacteriostatic and bactericidal With both bacteriostatic and bactericidal activity due to the presence of saturated activity due to the presence of saturated fatty acids, lysozymes and low pHfatty acids, lysozymes and low pH

CERUMENCERUMEN

METHODS IN CLEANING THE EARMETHODS IN CLEANING THE EAR

Should always be done under direct Should always be done under direct visualization using a cerumen spoonvisualization using a cerumen spoon

Using a handheld otoscope with magnifying Using a handheld otoscope with magnifying lens (operating otoscope)lens (operating otoscope)

Aural Irrigation with warm water (not to be Aural Irrigation with warm water (not to be performed among patients with perforated performed among patients with perforated TM’s, had otologic surgery, otitis externa, TM’s, had otologic surgery, otitis externa, and with acute episodes of vertigo)and with acute episodes of vertigo)

CERUMENCERUMEN

Ceruminolytics –Ceruminolytics –

also called “cerumen softeners”also called “cerumen softeners”– Hydrogen peroxideHydrogen peroxide– Mineral oil, baby oilMineral oil, baby oil– Commercially prepared otic drops (Otosol, Commercially prepared otic drops (Otosol,

Auralgan)Auralgan)– WaterWater

CERUMENCERUMEN

After complete cerumen removal, evaluate the After complete cerumen removal, evaluate the size and shape of the EACsize and shape of the EAC

If the diameter of the EAC is less than 4 mm., it is If the diameter of the EAC is less than 4 mm., it is considered stenoticconsidered stenotic

TYMPANIC MEMBRANETYMPANIC MEMBRANE

Eardrum-divides external from middle earEardrum-divides external from middle ear conical structure with the point of the cone, conical structure with the point of the cone,

umbo, directed mediallyumbo, directed medially outer -epidermal layer; middle- fibrous layer; outer -epidermal layer; middle- fibrous layer;

and an inner mucosal layerand an inner mucosal layer fibrous layer is absent above the lateral fibrous layer is absent above the lateral

process of malleus making it flaccid -process of malleus making it flaccid -Sharpnell’s membraneSharpnell’s membrane

Take note of the color of the tympanic Take note of the color of the tympanic membranemembrane

Normally it is grayish with variable Normally it is grayish with variable transparencytransparency

Covered by smooth squamous epithelium Covered by smooth squamous epithelium ““cone of light” is seen at the anterior inferior cone of light” is seen at the anterior inferior

quadrantquadrant

The tympanic membrane is mobile and to The tympanic membrane is mobile and to perform its function, it should be able to perform its function, it should be able to vibratevibrate

Restrictions in movement may be due to Restrictions in movement may be due to effusion in the middle eareffusion in the middle ear

Ask patient to do Valsalva Maneuver to test Ask patient to do Valsalva Maneuver to test mobility or use a pneumatic otoscopemobility or use a pneumatic otoscope

ANCILLARY PROCEDURESANCILLARY PROCEDURES

IMAGING STUDIESIMAGING STUDIES

Radiographic X-rays –Radiographic X-rays – done to visualize the done to visualize the middle ear structures, should always middle ear structures, should always compare both sides, gives limited compare both sides, gives limited informationinformation

– Schullers View – demonstrates mastoid air cellsSchullers View – demonstrates mastoid air cells– Stenvers View –demonstrates petrous ridge and Stenvers View –demonstrates petrous ridge and

apexapex

COMPUTERIZED TOMOGRAPHYCOMPUTERIZED TOMOGRAPHY

For temporal bone imagingFor temporal bone imaging With the ability to define specific bone With the ability to define specific bone

structuresstructures Axial and coronal cutsAxial and coronal cuts

MAGNETIC RESONANCE MAGNETIC RESONANCE IMAGINGIMAGING

Best for detecting tumors, suspected Best for detecting tumors, suspected vascular lesionsvascular lesions

Less superior than CT in defining bony Less superior than CT in defining bony structuresstructures

CLINICAL HEARING CLINICAL HEARING TESTSTESTS

TUNING FORK TESTSTUNING FORK TESTS

Goal: to differentiate between conductive Goal: to differentiate between conductive and sensorineural hearing lossand sensorineural hearing loss

CONDUCTIVE Hearing Loss (CHL)- caused CONDUCTIVE Hearing Loss (CHL)- caused by diseases of the external auditory canal or by diseases of the external auditory canal or middle earmiddle ear

SENSORINEURAL Hearing Loss(SNHL) – SENSORINEURAL Hearing Loss(SNHL) – caused by problems in the cochlea and caused by problems in the cochlea and inner earinner ear

512 Hz TF - most commonly used512 Hz TF - most commonly used Can use a TF that vibrates between 250 and Can use a TF that vibrates between 250 and

800 Hz 800 Hz Lower frequencies are avoided due to Lower frequencies are avoided due to

interference from perception of low interference from perception of low frequency vibrationsfrequency vibrations

- The TF should have a broad base- The TF should have a broad base

-- The base of the TF should be pressed firmly The base of the TF should be pressed firmly against the cranial bone inorder to transmit against the cranial bone inorder to transmit the vibrations to the bone and overcome the vibrations to the bone and overcome dampening by the skindampening by the skin

WEBER TESTWEBER TEST

The TF is placed in the midline of the skull, The TF is placed in the midline of the skull, (vertex or forehead), vibration is transmitted (vertex or forehead), vibration is transmitted by bone conduction to cochleaby bone conduction to cochlea

When hearing is normal, vibrations are When hearing is normal, vibrations are perceived equally loud on both sides perceived equally loud on both sides (midway between the ears)(midway between the ears)

Comparing the right and left earComparing the right and left ear

Weber Test (con’t)Weber Test (con’t)

When hearing is abnormal, sound will When hearing is abnormal, sound will lateralize to one sidelateralize to one side

SNHL – lateralizes to the better hearing earSNHL – lateralizes to the better hearing ear CHL- sound lateralizes to the poorer hearing CHL- sound lateralizes to the poorer hearing

ear because the vibrational energy is more ear because the vibrational energy is more poorly transmitted from the cochlea through poorly transmitted from the cochlea through the middle ear and would be harder for the the middle ear and would be harder for the sounds to reach the cochleasounds to reach the cochlea

RINNE TESTRINNE TEST

In Rinne, we compare the levels of air and In Rinne, we compare the levels of air and bone conduction in the same earbone conduction in the same ear

Air conduction (AC) – tested by holding the Air conduction (AC) – tested by holding the TF just outside the ear canal without TF just outside the ear canal without touching ittouching it

Bone conduction (BC) – tested by pressing Bone conduction (BC) – tested by pressing the TF base firmly against the mastoid bonethe TF base firmly against the mastoid bone

Rinne Test (con’t)Rinne Test (con’t)

Patient is asked to compare loudness in the Patient is asked to compare loudness in the 11stst position( AC) with the 2 position( AC) with the 2ndnd position (BC) position (BC)

Rinne Test Positive – AC > BC and lasts at Rinne Test Positive – AC > BC and lasts at least 15 seconds longerleast 15 seconds longer

Rinne Test Negative – AC< BCRinne Test Negative – AC< BC

BASIC AUDIOMETRYBASIC AUDIOMETRY

Audiometry – measurement of auditory Audiometry – measurement of auditory functionsfunctions

Goals: - detection Goals: - detection

-lateralization -lateralization

-quantification of a hearing disorder-quantification of a hearing disorder

Human ear can perceive sound between 20 - Human ear can perceive sound between 20 -

20, 000 Hz20, 000 Hz Velocity of sound ranges from 340m/s in air to Velocity of sound ranges from 340m/s in air to

approximately 5000 m/s in solid media such as approximately 5000 m/s in solid media such as bonebone

Noise- most common acoustic stimulusNoise- most common acoustic stimulus Voice- most important sound source in humansVoice- most important sound source in humans

( approx. 100Hz- males, 200Hz- females)( approx. 100Hz- males, 200Hz- females)

Classification of Hearing Loss by Classification of Hearing Loss by Severity (Quantification)Severity (Quantification)

Normal hearing - < 20 dbNormal hearing - < 20 db Mild hearing loss – 20-40 dbMild hearing loss – 20-40 db Moderate hearing loss – 40-60 dbModerate hearing loss – 40-60 db Severe hearing loss - 60-90 dbSevere hearing loss - 60-90 db Profound hearing loss – 90-and aboveProfound hearing loss – 90-and above

Congenital deafness - refers to the absence Congenital deafness - refers to the absence of hearing; failure of speech developmentof hearing; failure of speech development

Acquired deafness – loss of sense of Acquired deafness – loss of sense of hearing; loss of speech comprehension; hearing; loss of speech comprehension; have developed speech and language have developed speech and language development depending on age when this development depending on age when this occurredoccurred

BEHAVIORAL AUDIOMETRYBEHAVIORAL AUDIOMETRY

Based on an active and usually voluntary Based on an active and usually voluntary response from the test objectresponse from the test object

-Pure – tone audiometry-Pure – tone audiometry

-Speech audiometry-Speech audiometry

-Response audiometry-Response audiometry

OBJECTIVE AUDIOMETRYOBJECTIVE AUDIOMETRY

Based on objectively measured parameters Based on objectively measured parameters that represent an involuntary physiologic that represent an involuntary physiologic responseresponse

- tympanometry- tympanometry

-otoacoustic emissions-otoacoustic emissions

-auditory evoked brain-stem potentials -auditory evoked brain-stem potentials (ABR, BAER)(ABR, BAER)

PURE TONE AUDIOMETRYPURE TONE AUDIOMETRY

Calibrated AC and BC stimuli are presented Calibrated AC and BC stimuli are presented thru standard acoustic transducers (TDH-thru standard acoustic transducers (TDH-39) or thru insert phones (ER-3A)39) or thru insert phones (ER-3A)

Signals are steady or pulsed and has a Signals are steady or pulsed and has a frequency range of 125 Hz to 8000Hz for AC frequency range of 125 Hz to 8000Hz for AC and 250 Hz – 4000 Hz for BCand 250 Hz – 4000 Hz for BC

Signal levels are expressed in decibels (db)Signal levels are expressed in decibels (db)

Makes use of an audiometer which is an Makes use of an audiometer which is an electronic instrument to test hearingelectronic instrument to test hearing

Done in a sound treated roomDone in a sound treated room Audiogram –graphic representation of the Audiogram –graphic representation of the

individual’s sensitivity for pure tonesindividual’s sensitivity for pure tones Red circle- refers to the right earRed circle- refers to the right ear Blue or black X refers to the left earBlue or black X refers to the left ear

Always test better ear firstAlways test better ear first Assessing the threshold – (weakest level at Assessing the threshold – (weakest level at

which a person will respond 50% of the time which a person will respond 50% of the time ) for each frequency) for each frequency

Start with 1KHz, 2KHz,4KHz,8KHz, re-Start with 1KHz, 2KHz,4KHz,8KHz, re-check 1KHz,500Hz, 250Hz, 125 Hzcheck 1KHz,500Hz, 250Hz, 125 Hz

Tones are presented to one ear at a timeTones are presented to one ear at a time

Test for AC first using headphones or insert Test for AC first using headphones or insert phonesphones

Prevent cross-hearing by maskingPrevent cross-hearing by masking

Test BC thresholds by using a vibrator pressed Test BC thresholds by using a vibrator pressed against the mastoid bone ( set the skull into against the mastoid bone ( set the skull into vibration to transmit sound into the inner ear)vibration to transmit sound into the inner ear)

AUDIOGRAMAUDIOGRAM

Sensorineural hearing loss – no significant Sensorineural hearing loss – no significant threshold differences between AC and BC threshold differences between AC and BC thresholdsthresholds

Conductive hearing loss –if AC is higher Conductive hearing loss –if AC is higher than BC by more than 10 dbthan BC by more than 10 db

Mixed type of hearing loss – greater air Mixed type of hearing loss – greater air conduction compared with bone conduction conduction compared with bone conduction but both abnormalbut both abnormal

SPEECH AUDIOMETRYSPEECH AUDIOMETRY

Measures the recognition and Measures the recognition and understanding of speech rather than the understanding of speech rather than the thresholdthreshold

Speech material is available in standardized Speech material is available in standardized form on compact discs and is presented at form on compact discs and is presented at designated levels using an audiometerdesignated levels using an audiometer

Speech audiogram indicates the percentage Speech audiogram indicates the percentage of syllables, words or sentences that the of syllables, words or sentences that the subject has heard correctlysubject has heard correctly

TYMPANOMETRY (Impedance TYMPANOMETRY (Impedance Audiometry)Audiometry)

Sound vibrations are reflected in the Sound vibrations are reflected in the eardrum and sensitive electrical equipment eardrum and sensitive electrical equipment records objectively the mobility of the drumrecords objectively the mobility of the drum

This test may show eustachian tube This test may show eustachian tube problems, middle ear disease, or a problems, middle ear disease, or a perforated drumperforated drum

Tympanogram – graphic results of an Tympanogram – graphic results of an immitance testimmitance test

Type A tympanogram Type A tympanogram has a prominent, has a prominent, sharp peak between –100- 100 mmH20sharp peak between –100- 100 mmH20

Type B tympanogramType B tympanogram is flat or has a very is flat or has a very low, rounded peak. This indicates immobility low, rounded peak. This indicates immobility of the drum which may be due to fluid in the of the drum which may be due to fluid in the middle earmiddle ear

Type C tympanogramType C tympanogram has a peak in the has a peak in the negative pressure region below –100 negative pressure region below –100 mmH20 consistent with impaired middle ear mmH20 consistent with impaired middle ear ventilationventilation

AUDITORY EVOKED POTENTIALS AUDITORY EVOKED POTENTIALS (ABR,BAER)(ABR,BAER)

May be used in the diagnosis of neurologic May be used in the diagnosis of neurologic diseasesdiseases

Done to differentiate a cochlear froma Done to differentiate a cochlear froma retrocochlear lesionretrocochlear lesion

Important for threshold testing in pediatric Important for threshold testing in pediatric audiologyaudiology

OTOACOUSTIC EMISSIONSOTOACOUSTIC EMISSIONS

Clinically important in screening the function Clinically important in screening the function of the cochlea in infants, newborns and of the cochlea in infants, newborns and small childrensmall children

Provides a fast and simple way without Provides a fast and simple way without sedation or anesthesia thus facilitating early sedation or anesthesia thus facilitating early detection of hearing problemsdetection of hearing problems

Can also be used to investigate non-organic Can also be used to investigate non-organic hearing loss, assess cochlear functions in hearing loss, assess cochlear functions in high risk group and objectify audiometric high risk group and objectify audiometric findings in adultsfindings in adults

VESTIBULAR TESTSVESTIBULAR TESTS

HISTORY HISTORY

most important diagnostic tool most important diagnostic tool

Quality Quality Temporal Course – speed of onset, durationTemporal Course – speed of onset, duration Associated symptoms Associated symptoms Exacerbating factorsExacerbating factors

ChronologyChronology

General PatternGeneral Pattern

Auditory Symptoms – hearing loss, tinnitusAuditory Symptoms – hearing loss, tinnitus

ear diseaseear disease

Ocular problemsOcular problems

CNS - ataxia, dysequilibriumCNS - ataxia, dysequilibrium

Vestibular ExaminationVestibular Examination

TWO PRINCIPAL COMPONENTSTWO PRINCIPAL COMPONENTS

Eye Movement ExaminationEye Movement Examination

Balance and Coordination examinationBalance and Coordination examination

NYSTAGMUSNYSTAGMUS

repetitive to and fro movement of the eyes repetitive to and fro movement of the eyes with a fast and a slow component brought with a fast and a slow component brought about by the imbalance of the tonic activity about by the imbalance of the tonic activity of the vestibular systemof the vestibular system

This involves carefully observing the eye This involves carefully observing the eye movementsmovements

Has a slow component and a fast recovery Has a slow component and a fast recovery phasephase

NYSTAGMUSNYSTAGMUS

CAN BE:CAN BE:– spontaneousspontaneous– ProvokedProvoked– inducedinduced

CALORIC TESTCALORIC TEST

Each ear is irrigated for a fixed duration of 30-40 Each ear is irrigated for a fixed duration of 30-40 secondsseconds

Constant flow rate of water with a temperature of 7 Constant flow rate of water with a temperature of 7 degrees below body temperature (30 degrees) degrees below body temperature (30 degrees) and 7 degrees above (44 degrees)and 7 degrees above (44 degrees)

Supine position with the head tilted 30 degrees Supine position with the head tilted 30 degrees forwardforward

Eyes open behind frenzel glasses,total darknessEyes open behind frenzel glasses,total darkness

Romberg’s TestRomberg’s Test

Patient stands still with eyes closedPatient stands still with eyes closed Clasp hands together and pull apart inorder Clasp hands together and pull apart inorder

to divert attention (Jendrasik Maneuver)to divert attention (Jendrasik Maneuver) 20-30 seconds20-30 seconds Positive Romberg’s - fall on either sidePositive Romberg’s - fall on either side

THANK YOUTHANK YOU