When the ear is being examined with an otoscope the patients head should be?

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Approach the examination in a systematic way, starting from the outer parts of the ear before moving to the inner parts of the ear; be prepared to be instructed to move on quickly to certain sections by any examiner.

Pinna and Post Auricular Area

Inspect the pinna and the mastoid:

• Obvious deformities or abnormal cartilaginous fragments
• Scars or skin changes
  • Including for skin malignancies
• Signs of inflammation
  • An inflamed mastoid may push the pinna forward

Palpate the lymph nodes and pinna, specifically:

• Pre- and post-auricular lymph nodes
• Tragus
  • Tragal tenderness is a sign of otitis externa

By TeachMeSeries Ltd (2022)

Figure 1 – A basal cell carcinoma located on the posterior aspect of the outer ear

External Ear Canal

Inspect the outer aspect of the external ear canal using the otoscope as a light source

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

Look for signs of:

• Wax or a foreign body
• Skin changes or erythema
• Discharge

Tympanic Membrane

Hold the otoscope like a pen between thumb and index finger, left hand for left ear and right hand for right ear, resting your little finger on the patient’s cheek – this acts as a pivot.

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

For a normal tympanic membrane, you should be able to observe*:

• Lateral process of malleus
• Cone of light
• Pars tensa and pars flaccida

*The cone of light can be used to orientate; it is located in the 5 o’clock position when viewing a normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic membrane.

Adapted from work by Michael Hawke MD [CC BY 4.0], via Wikimedia Commons

Figure 2 – A normal right tympanic membrane

For an abnormal tympanic membrane, common signs may include:

• Perforations
• Tympanosclerosis
• Red and bulging membrane
• Retraction of the membrane

Ensure to check the function of the facial nerve

By Michael Hawke MD / CC BY (https://creativecommons.org/licenses/by/4.0)

Figure 3 – A traumatic perforation of the left tympanic membrane

Assessment of Hearing

Rinne Test

Strike the tuning fork (512Hz) against your elbow and place against the mastoid process (bone conduction), then once patient stops hearing it, hold it near the external ear canal (air conduction)

• For normal hearing or sensorineural hearing loss, air conduction is heard better than bone conduction (Rinne positive)
• For conductive hearing loss, bone conduction is heard better than air conduction (Rinne negative)

Weber Test

Strike the tuning fork (512Hz) against your elbow and place on the patient’s forehead in the midline. Ask the patient whether the sound is heard in the midline or has lateralised

• For normal hearing, the sound is heard in the midline
• For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing deficit
• For sensorineural hearing loss, the sound is loudest on the contralateral side to the hearing deficit

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

Cerumen impaction refers to a buildup of cerumen that causes symptoms such as hearing loss, ear fullness, itching, otalgia, tinnitus, cough, or rarely imbalance. In the presence of any of these symptoms, removal is indicated. The diagnosis of cerumen impaction can be made by direct visualization through an otoscope. Cerumen removal should occur if the examiner cannot visualize the entire TM. There are three options for intervention: irrigation, cerumenolytic agents, manual removal. If multiple attempts of removal are unsuccessful, referral to an otolaryngologist is warranted.[14][3][15]

Acute Otitis Media (AOM)

AOM is defined as an infection of fluid accumulated in the middle ear. It is primarily a pediatric diagnosis since most cases occur in patients 6 to 24 months of age, and decrease with advancing age so long as the patient has normal palatal muscle function. The most reliable symptom seen in AOM patients is otalgia, and up to two-thirds of patients present with fever. However, patients, especially children, can present with non-specific symptoms such as tugging on the affected ear, irritability, headache, poor sleep, poor feeding, vomiting, and diarrhea. Otoscopic examination is indicated with all children presenting with upper respiratory infection symptoms.[16][17]

In the context of the above symptoms, otoscopic findings help diagnose AOM. If necessary, cerumen should be removed to visualize the TM fully. The examiner evaluates the position, translucency, color, and mobility of the TM. AOM is associated with a bulging, opaque, erythematous, and immobile TM. The bulging and erythematous TM is the essential otoscopic finding used to distinguish AOM from otitis media with effusion (OME).

The preferred treatment for AOM is high dose amoxicillin, though amoxicillin/clavulanate is an option if the patient has taken amoxicillin within the last 30 days or has shown no improvement after 2 to 3 days of amoxicillin treatment. Oral cephalosporins, such as cefuroxime or cefdinir, are given for patients with a penicillin allergy. If these patients show no improvement after 2 to 3 days, the patient can receive intramuscular or intravenous ceftriaxone or clindamycin. Azithromycin and trimethoprim/sulfamethoxazole are associated with high rates of resistance and, therefore, should be avoided. Accurate diagnosis and avoidance of unnecessary antibiotic treatment are critical to prevent resistance to current first-line treatments. Tympanostomy tube placement is the preferred treatment for recurrent AOM.[18][14][19][20][21]

Otitis Media with Effusion (OME)

OME is defined as accumulated fluid in the middle ear space without evidence of inflammation or infection. OME is a common pediatric presentation, with an incidence of 20% in children. The combination of clinical signs and findings on the otoscope exam gives the diagnosis. The most common presenting symptoms are ear fullness and conductive hearing loss. On the otoscope exam, the TM will look opacified with a loss of a light reflex. Retraction of TM and decreased mobility are also common findings. Unlike in AOM, bulging of the TM is not typical. Most cases of OME are self-limiting. Antibiotics, oral decongestants, or intranasal corticosteroids are not effective treatment options.[22][23][24][21]

Otitis Externa (OE) and Malignant Otitis Externa (MOE)

OE is defined as an infection or inflammation of the ear canal. It has a 10% lifetime prevalence, 90% of cases are unilateral, and the majority of cases are in adults. There is a strong association with high humidity, higher temperature, swimming, local trauma to the ear canal, hearing aid use, and history of diabetes mellitus. The hallmark symptom is otalgia, primarily associated with pinna manipulation. Pruritus is a common precursor symptom. Patients also complain of ear fullness and hearing loss secondary to canal edema and debris accumulation. Otoscope findings include ear canal edema and erythema with thick seropurulent otorrhea, which can be malodorous. Audiologic testing can help rule out middle ear involvement.

Most cases of otitis externa are bacterial in origin; however, approximately 10% of cases are due to fungal pathogens. In these cases, whitish studs (Candida spp.) or small black “fungal balls” (Aspergillus spp.) are present. Treatment of uncomplicated OE includes clearing the EAC, topical antimicrobials, and adequate pain control. Oral antibiotics should start in patients with poorly controlled diabetes mellitus or immunosuppression.[25][26][27]

MOE, severe sequelae of OE, is an invasive infection of the EAC and skull base. Early diagnosis is critical; therefore, MOE should be a consideration with any patient with refractory OE, fever above 39 C, diabetes mellitus, or immunosuppression. On the otoscope exam, granulation tissue is visible along the floor of the EAC at the bony-cartilaginous junction (i.e., isthmus). Cranial nerve exams are warranted when evaluating for MOE. Spread to the stylomastoid foramen can present with facial nerve palsy. Spread to the jugular foramen can present with glossopharyngeal, vagus, or accessory nerve palsies. MRI and CT (without contrast) scans are useful in diagnosis, with CT being more sensitive for bone erosion. The mainstay treatment for MOE is culture-sensitive long-term antibiotic therapy, and in some cases, surgical debridement.[27][28][29]

Cholesteatoma

Cholesteatomas are defined as an abnormal collection of keratinized squamous epithelium, usually involving the middle ear and mastoid. Cholesteatomas can either be acquired or congenital. They progress slowly, and the clinical presentation is usually insidious. The most common early signs are conductive hearing loss and painless otorrhea. Granulation tissue or polyps seen in the ear canal are concerning for a cholesteatoma until proven otherwise. Cholesteatomas get treated surgically, and early detection depends on an accurate otoscope exam and can lead to less invasive surgical repair and preservation of hearing. In addition to clinical symptoms and otoscope exam, high-resolution CT and diffusion-weighted MRI assist in the diagnosis. The fusion of these imaging modalities provides a precise location of cholesteatoma, which aids in surgical planning.

Acquired cholesteatomas present with recurrent painless, malodorous otorrhea. A retraction pocket in the posterosuperior quadrant of the TM is the hallmark finding. Congenital cholesteatomas more often present asymptomatically compared to acquired cholesteatomas. As they grow, they can decrease hearing by middle ear bone chain erosion or mass effect. Due to the transparency of a normal TM, congenital cholesteatomas are visible during an otoscope exam.[30][31][32][22][33][34]

Tympanic Membrane Perforation (TMP)

Direct trauma, infection, pressure changes, or a tumor causes a TMP. Patients typically present with otalgia, otorrhea (may be bloody), tinnitus, or hearing loss. Perforations should be easily visible using an otoscope. The suggestion is that fogging of the otoscope indicates the presence of a perforation. After identifying a perforation on an otoscope exam, it is critical to determine if an urgent Otolaryngology consult is warranted. This is the case with vertigo, sensorineural hearing loss, severe tinnitus, active and severe bleeding, or facial paralysis. A superoposterior perforation should prompt a cholesteatoma evaluation.

Most cases of TMPs resolve spontaneously. Physicians should make sure the pain is adequately controlled and advise the patient to keep the affected ear dry. Otic drops should be avoided unless there is a concomitant infection. Surgical intervention, via tympanoplasty, should be considered for severe cases when spontaneous healing is unlikely.[7][35][13]

When otoscopy is done the patient's head should be?

Which direction should the pinna be moved during the otoscope exam?

What part of the ear can be viewed with an otoscope?

When examining the ear with an otoscope How should the tympanic membrane look?