Examination of ear

DR MANPREET SINGH NANDA
PROFESSOR ENT

1. Examination of Ear

2. General Physical Examination Mental state Consciousness Built and nutrition Attitude and Gait Facies Pallor – palmar creases, mm lips cheeks, conjuctiva , nail beds Cyanosis – tongue (central), nail bed , tip of nose, palmar skin Jaundice – sclera, nail bed , ear lobule, tip of nose Skin eruptions – macules ( change in skin colour ), papules , vesicles, pustules (solid projections) Neck nodes

3. Vitals Pulse – pulse rate, rhythm (regular, irregular) Respiratory rate – fast, slow Temperature – continous ( fluctuates less than 1 deg), remittent ( fluctuates more than 2 deg), intermittent Blood Pressure

4. Local Examination Examine the affected region Inspection Palpation Movements Measurements’ LYMPH NODES General Examination- Cranial Nerves, Respiratory CVS for surgery purpose

5. EAR EXAMINATION External Ear - Auricle/ Pinna - Pre auricular region - Post auricular/Mastoid region EAC TM Middle ear mucosa Eustachian tube Facial nerve and other CN Neck Nose and Throat

6. EXTERNAL EAR PINNA/AURICLE INSPECTION Size – anotia (absence), microtia (small) Shape – cauliflower ear, bat ear (auricle protrudes anteriorly ) Colour - red ( perichondritis ) Position - displacement of auricle forwards, laterally or inferiorly – mastoid abscess Swelling Scar Ulcer

7. PALPATION Superficial palpation Using fingers (digital palpation) of cartilage and soft tissue Soft tissue – mobility of skin (lost in malignancy), thickening, swelling Raised temperature, tenderness Cartilage – defect or loss Deep palpation Tragal tenderness- inflammation Painful movement of pinna – acute otitis externa

8. PRE AURICULAR REGION Sinus – pre auricular sinus Fistula Scar Swelling – cystic, lymphadenitis

9. POST AURICULAR/MASTOID REGION INSPECTION Scar, dermatitis, swelling, fistula Change in mastoid contour Normally – uneven bone, skin over it mobile PALPATION Superficial palpation Skin – mobile Raised temperature Swelling – margins, cystic (sebaceous cyst) Iron out mastoid – smooth surface – coalescent mastoiditis

10. Deep palpation Tenderness – mastoiditis 1. Cymba concha – bony landmark for mastoid antrum 2. Midpoint of posterior border of mastoid 3. Tip of mastoid NECK EXAMINATION Bezold’s abscess – pus track along SCM inferiorly Citelli’s abscess – pus track along digastric into submandibular triangle Luc’s abscess – pus around zygoma IJV as hard cord on palpation along SCM – IJV thrombosis

11. EXAMINATION OF EXTERNAL AUDITORY CANAL (EAC) Direct examination Without speculum Size of meatus – atresia /wide/narrow Wide – post op, syphilis, otosclerosis Narrow – congenital atresia , scar due to trauma, burns tumour - osteoma Content of meatus – wax, discharge, FB, Polyp Digital examination – Adults – pinna pulled upwards, backwards and laterally, tragus pulled forwards Children – pinna pulled downwards and laterally

12. Look for furuncle, swelling Fungal infection ( otomycosis ) – black – aspergillus niger , yellow – candida albicans Polyp – probe test – if probe all around – arise from middle ear Impacted wax – whole EAC occluded Tumours With speculum examination – deep meatus to straighten the canal Largest speculum which can enter Black coated Introduce in slow rotatory fashion upto cartilage only

13. Cough – vagal irritation Sagging of posterior superior EAC – cholesteatoma , mastoid abscess, mastoiditis Absence of sensation in post sup EAC – Hitselberger’s sign – mass lesion in CP angle

14. EXAMINATION OF TYMPANIC MEMBRANE (TM) Normal – pearly white colour , obliquely set, anterior and posterior malleolar fold (longer) Handle of malleus – whitish bony landmark Umbo Cone of light/light relex – triangular in shape anterio inferiorly – unreliable landmark Short or lateral process of malleus – small yellowish prominence – at 12 o clock position - always present – last landmark to be destroyed in disease Quadrants – 4 – imaginary line through tip of umbo , 2 nd vertically along handle of malleus – ant sup/ inf , post sup/ inf

15. COLOUR Colour of TM – normal pearly white/ greyish white, red in ASOM, acute myringitis Congestion with yellowish tint – ASOM Diffuse congestion/ localised at handle of malleus – ASOM Dark grey colour /dull appearance – tubal occlusion Dull white/thickened cotton like drum – senile sclerosis, scarring Chalky white appearance – tympanosclerosis after otitis media Dull lusterless/bulging – secretory otitis media Blue drum – transudative otitis media Dark blue drum - haemotympanum

16. POSITION TM normally inclined downwards and medially Protrude outwards – bulging drum – acute otitis media (pus), Haemotympanum (blood),OME with good ET function (air) – increase length of handle of malleus , less prominent short process and malleolar folds, absence of cone of light Pulled inwards – retracted TM- OME with poor ET function, ET obstruction, atelectasis – shortening of handle of malleus , more prominent short process, anterior and post malleolar folds, distorted cone of light Retraction – attic region (retraction pocket) if deepens – cholesteatoma sac

17. MOBILITY Siegle’s pneumatic speculum/ Valsalva maneuvre Normal – change in shape of triangular light reflex/ handle of malleus movement Decreased/absent – ET dysfunction, adhesive otitis media (fixed), ankylosis of ossicular chain, SOM Hypermobility – Patulous ET, atrophy of TM

18. SURFACE Perforation – ovoid/ kidney shaped/ round, small, medium, large, sub total, total, central/marginal, pars tensa /attic, dry/wet, single/multiple (TB, measles, wegner’s granulomatosis ), margins – regular/irregular, edge of perforation – thick (CSOM)/ thin (ASOM) Scars Bulla – grey/red/bluish pearls like structures attached to surface of TM Chalky white patch - tympanosclerosis

19. MIDDLE EAR EXAMINATION Only through perforation/ if TM thinned out/ semitransparent Middle ear mucosa – oedema / polyp Granulation tissue Ossicles , ET, round window, oval window FB Fistula

20. EUSTACHIAN TUBE EXAMINATION Posterior rhinoscopy / Nasopharyngoscopy / DNE/ Through perforation Valsalva Maneuvre ET catheterisation – check patency of ET Few drops in ear if perforation and bitter taste in mouth TUNING FORK TESTS Rinne’s Weber ABC

21. FISTULA TEST Apply intermittent pressure on tragus/ siegle’s pneumatic speculum – ask patient to look straight – check for vertigo/ nystagmus towards opposite side FACIAL NERVE EXAMINATION Paralysis in ASOM, CSOM, Malignant otitis externa , herpes zoster, tumours and trauma Wrinking of forehead/ closure of eyes/ loss of naso labial folds/ deviation of angle of mouth/ cant whistle or blow

22. NOSE AND THROAT EXAMINATION Rhinitis/sinusitis Pharyngitis /tonsillitis/adenoids EYE EXAMINATION Nystagmus Corneal relex – absent in acoustic neuroma Blue sclera – osteogenesis imperfecta Papilloedema – CP angle tumours / otitic hydrocephalus/ temporal abscess Interstitial keratitis – congenital syphilis

23. RS/CVS/CNS CN paralysis VI – petrous apex lesions IX, X, XI, XII – advanced malignant otitis externa / advanced glomus jugulare tumours AUSCULTATION Stethoscope over ear canal/ mastoid – bruits heard in vascular lesions Stethoscope into EAM – transmitted sounds heard in patulous ET