Ear, Otoscopy and Hearing OSCE Examination

1. Introduction
2. General Inspection
3. Inspection of the Outer Ear
4. Otoscopy
5. Gross Hearing Assessment
6. Tuning Fork Tests – Weber’s Test
7. Tuning Fork Tests – Rinne’s Test
8. Completing the Examination
9. Quiz

Wash your hands and put on personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; Full name, Date of birth and NHS/Hospital number.

Obtain consent for the examination ensuring to explain what the examination will entail, including that you will need to look inside both ears and carry out some simple hearing tests.

Position the patient sitting upright on a chair, with you able to access both ears from the side.

Ask whether the patient has any ear pain or discharge before you begin, as the examination of a painful ear should be performed gently and last.

Gather your equipment before you start so that the examination flows smoothly: an otoscope with a working light, a selection of disposable specula in different sizes, a 512 Hz tuning fork for the Rinne and Weber tests, and alcohol gel for hand hygiene. Check the otoscope light works and is bright before you begin.

Begin by stepping back and observing the patient and their surroundings. Note whether the patient appears comfortable or in distress, and whether they are turning a particular ear towards you or watching your lips closely, which can be subtle clues to hearing impairment.

Look for any hearing aids, which immediately suggest a degree of established hearing loss, or a cochlear implant (a processor worn behind the ear with a magnetic disc on the scalp), which indicates severe sensorineural loss.

Inspect for an obvious facial nerve palsy, as the facial nerve (cranial nerve VII) runs through the temporal bone in close relationship to the middle ear and can be affected by middle ear disease, cholesteatoma, or surgery. Look at the bedside for any tissues, cotton buds, or evidence of discharge.

Image - A patient with left facial weakness attempting to show their teeth, with the mouth drawn towards the unaffected right side. The facial nerve’s course through the temporal bone means middle ear disease and ear surgery can cause facial weakness

Image source by Benjaminginterr [CC BY-SA 4.0]

Inspect each pinna in turn, comparing both sides. Look at the front and behind the ear, and remember to lift the pinna forwards to inspect the post-auricular sulcus and the area behind the ear.

Note the shape and size of each pinna. A deformity may be congenital, such as a small or absent pinna (microtia or anotia) or low-set ears seen in some genetic syndromes, or acquired, such as the lumpy cauliflower ear that follows repeated trauma and an untreated auricular haematoma.

Look for scars. A post-auricular scar may indicate previous mastoid surgery (mastoidectomy), while an endaural scar at the front of the ear canal suggests previous middle ear surgery. These point towards chronic ear disease such as cholesteatoma.

Inspect the skin for signs of inflammation, swelling or discharge. A red, swollen and tender pinna and canal with discharge suggests otitis externa (infection of the external ear canal). If the pinna itself is hot, red and exquisitely tender but the lobule (which contains no cartilage) is spared, consider perichondritis, an infection of the cartilage that can lead to permanent deformity if untreated.

Feel behind the ear for a tender, boggy swelling that pushes the pinna forwards and outwards with loss of the post-auricular sulcus. This is the classic appearance of mastoiditis, a serious complication of middle ear infection in which infection spreads into the air cells of the mastoid bone, and it requires urgent assessment.

Also note any obvious pre-auricular skin lesions (basal or squamous cell carcinomas are common on the sun-exposed pinna) and a pre-auricular sinus, a small congenital pit in front of the ear that can become infected.

Palpate the regional lymph nodes that drain the ear – the pre-auricular and post-auricular nodes and the upper cervical chain. Enlarged, tender nodes accompany local infection such as otitis externa, while a hard, fixed node should raise concern about malignancy of the pinna or canal.

Finally, gently move the pinna and press on the tragus. Pain on moving the pinna or pushing the tragus (a positive tragal sign) is typical of otitis externa, whereas pain on this manoeuvre is usually absent in otitis media, where the tenderness is felt deeper. This simple test helps distinguish outer ear from middle ear disease before you reach for the otoscope.

Otoscopy allows you to inspect the external auditory meatus and the tympanic membrane (eardrum). Examine the normal (asymptomatic) ear first so that you do not transfer infection and so that you have a comparison for the affected side.

Select the largest speculum that comfortably fits the canal, as this gives the best view and the most light. Turn the otoscope light on and hold it like a pen in your right hand for the patient’s right ear and your left hand for the left ear.

To straighten the naturally S-shaped ear canal in an adult, gently pull the pinna upwards and backwards. (In an infant or young child the canal is straightened by pulling the pinna downwards and backwards instead.) Brace the hand holding the otoscope against the patient’s cheek so that if they move suddenly the instrument moves with them, avoiding injury to the canal.

Advance the speculum under direct vision. Inspect the canal walls for wax, debris, discharge, swelling or foreign bodies. Wax (cerumen) is normal and protective but excessive wax may obscure the view and cause conductive hearing loss. Pus or debris in the canal suggests otitis externa.

Now examine the tympanic membrane. A normal eardrum is pearly grey, translucent and slightly concave. You should identify the handle of the malleus running downwards and backwards, the pars tensa below it, and a cone of light (light reflex) radiating anteroinferiorly from the tip of the malleus – classically at the 5 o’clock position in the right ear and the 7 o’clock position in the left ear. Above the malleus lies the smaller pars flaccida.

Image - A normal left tympanic membrane. It is pearly grey and translucent, with the handle of the malleus visible and a cone of light radiating anteroinferiorly

Creative commons source by Michael Hawke MD [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Look for the following abnormalities, each of which reflects a specific pathology:

• A red, bulging eardrum with loss of the normal landmarks and light reflex suggests acute otitis media, where pus under pressure pushes the drum outwards.
• A dull, retracted drum with a visible fluid level or bubbles behind it suggests otitis media with effusion (‘glue ear’), caused by Eustachian tube dysfunction and negative middle ear pressure. This is a common cause of conductive hearing loss in children.
• A perforation appears as a defect in the drum. It may follow infection or trauma, and a persistent perforation causes conductive hearing loss.
• A retraction pocket or whitish keratin debris, classically in the attic (pars flaccida), raises suspicion of a cholesteatoma – an expanding collection of keratinising squamous epithelium that erodes bone and can cause serious complications.
• Grommets (tympanostomy tubes) may be seen as small ventilation tubes inserted through the drum to treat recurrent effusions.

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