PHYSICAL EXAMINATION. Examination of the ear and related head and neck structures should be...
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PHYSICAL PHYSICAL EXAMINATIONEXAMINATION
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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OtoscopyOtoscopy
Examining an adultExamining an adult
Examining a child/infantExamining a child/infant
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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
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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
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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).
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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CERUMENCERUMEN
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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)
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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)
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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
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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
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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
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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
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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
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ANCILLARY PROCEDURESANCILLARY PROCEDURES
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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
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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
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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
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CLINICAL HEARING CLINICAL HEARING TESTSTESTS
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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
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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
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- 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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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)
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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)
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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VESTIBULAR TESTSVESTIBULAR TESTS
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HISTORY HISTORY
most important diagnostic tool most important diagnostic tool
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Quality Quality Temporal Course – speed of onset, durationTemporal Course – speed of onset, duration Associated symptoms Associated symptoms Exacerbating factorsExacerbating factors
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ChronologyChronology
General PatternGeneral Pattern
Auditory Symptoms – hearing loss, tinnitusAuditory Symptoms – hearing loss, tinnitus
ear diseaseear disease
Ocular problemsOcular problems
CNS - ataxia, dysequilibriumCNS - ataxia, dysequilibrium
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Vestibular ExaminationVestibular Examination
TWO PRINCIPAL COMPONENTSTWO PRINCIPAL COMPONENTS
Eye Movement ExaminationEye Movement Examination
Balance and Coordination examinationBalance and Coordination examination
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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
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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
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NYSTAGMUSNYSTAGMUS
CAN BE:CAN BE:– spontaneousspontaneous– ProvokedProvoked– inducedinduced
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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
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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
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THANK YOUTHANK YOU
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