Overview of Ear Examination
Examining the ear is a crucial task for many healthcare professionals, including those specializing in ear, nose, and throat care, family doctors, emergency room doctors, paramedics, and pediatricians. A variety of health conditions can lead to unusual findings during an ear exam. These conditions can range from common and harmless ones, such as an inner ear infection caused by a virus, to rare and potentially very serious ones, like an infection in the bony air cells in the skull behind the ear.
Anatomy and Physiology of Ear Examination
Understanding the structure of the ear is important for doctors to interpret symptoms which might be vague or misleading. It’s also crucial to understand how the ear connects to the brain, skull, and certain nerves in the head, because some issues may involve these areas. Generally, problems with the outer and middle ear lead to a loss of hearing due to difficulties in sound waves reaching the eardrum (conductive hearing loss). Problems with the inner ear tend to result in hearing loss due to nerve damage (sensorineural hearing loss).
Outer Ear
The outer ear includes the ear flap (auricle or pinna), the ear opening and canal, and the outermost layer of the eardrum. The main job of the outer ear is to guide sound waves towards the eardrum and into the middle ear. Very early during development in the womb, the ear flap is formed by the coming together of six swellings of tissue. If these don’t come together properly, it can lead to the formation of pits, cysts, or small pockets near the ear. During an ear examination, the doctor can view the entire outer ear directly.
Middle Ear
The middle ear is a complex, air-filled space located within a bone in the side of the skull. It contains three tiny bones, the inner part of the eardrum, and the opening of the Eustachian tube. It is covered in a type of lining that is continuous with the lining of the Eustachian tube and the upper parts of the digestive and respiratory tract. The main job of the middle ear is to transmit sound waves from the eardrum of the outer ear to a part of the inner ear called the oval window via the tiny bones. During an examination, parts of the middle ear can be seen through the eardrum. The flexibility of the middle ear can be measured with a test called tympanometry. This test measures how well sound waves can pass through the middle ear. Several conditions can result in abnormal results, such as fluid in the middle ear or disruption of the tiny bones. If tympanometry isn’t available, a tool called a pneumatic otoscope can be used to assess the flexibility and movement of the eardrum.
Inner Ear
The inner ear includes the vestibular system and the cochlea, both of which have a bony and a membranous part. Its job is to convert sound vibrations into nerve impulses for hearing and to detect and send signals about head movement for balance. None of the inner ear can be directly seen during an ear examination. However, signs of inner ear disease, such as nerve damage related hearing loss or problems with balance, can be identified during the examination.
Why do People Need Ear Examination
If you’re experiencing symptoms like ear pain, fluid coming from the ear, dizziness, ringing in the ears, a feeling of fullness in the ear, hearing loss, or weakness in the face, you might need to have an ear exam. It’s really important to explain the qualities of your dizziness. This will let the doctor know if it’s true vertigo, which feels like the room is spinning and shows that there might be issues with your body’s balance-machine inside the ear, or if it’s associated with feeling faint (which generally happens right before fainting), feeling light-headed (which can mean a lot of different things), or an imbalance linked to problems with coordination or walking. A lot of people describe all of these different sensations with the umbrella term “dizziness”, so it’s important to provide more specific details.
Much less common reasons to have an ear exam include if you or your doctor suspect a down-the-back-of-your-throat disease such as nasopharyngeal carcinoma, a type of cancer that affects the part of the throat that connects your nose to your mouth, and it’s presenting problems such as blockage of the tube that connects your ear to the back of your throat. Additionally, if you’ve had an accident involving your head and neck and experienced a decrease in your level of consciousness, an ear exam may be necessary if there are any concerns of an injury to the base of your skull on the side (lateral basal skull injury). This could be indicated by the presence of cerebrospinal fluid (the fluid in your brain and spine) coming from the ear, or by a CT scan showing a fracture in the bone around your ear.
Finally, if there are any signs of hearing impairment detected during regular hearing tests, like the ones that are part of the Newborn Hearing Screening Program in the UK’s National Health Service (NHS), this should immediately be followed by a full ear examination.
When a Person Should Avoid Ear Examination
An ear exam can’t happen without the permission of a patient who is capable of making such a decision. In patients experiencing ear pain, extra care should be taken because the exam can cause discomfort.
Equipment used for Ear Examination
An otoscope is a tool doctors use to look at the outer part of your ear (the pinna), the passage that leads to your eardrum (external auditory canal), and the eardrum itself (tympanic membrane). This device also has a light that helps doctors check the areas in front of and behind your ear closely. We use different sizes of detachable parts (known as specula) to fit the otoscope for each patient.
Sometimes, a doctor needs to see how well your eardrum moves. For this, they perform what’s called a pneumatic otoscopy. This involves an otoscope with a special bulb that can puff a little air at your eardrum, along with special speculae that can make a tight seal within the ear passage so the air won’t escape.
Your doctor might also need a tool called a tuning fork to help figure out if any hearing loss is because of problems with the parts that carry sound in the ear (conductive hearing loss) or issues with the nerves that send sound signals to your brain (sensorineural hearing loss). The best tuning forks are ones that make a sound that lasts a long time but doesn’t cause a lot of vibration (because that could make you feel the vibration and mistake it for sound). Ear, nose, and throat doctors (known as otolaryngologists) usually use a 512-Hz tuning fork because it offers the best balance between these sound and vibration features.
Who is needed to perform Ear Examination?
To properly check your ears, only a doctor and you, the patient, are needed. If a child’s ears are being examined, it can be helpful to have a parent there along with a nurse or play specialist who has prior experience. These individuals can help ensure the child stays still and follows the doctor’s instructions during the examination.
Preparing for Ear Examination
When a doctor needs to examine a patient’s ears, the patient is seated comfortably in the middle of the room. This arrangement allows the doctor to move around and check the ears from behind. Before starting the examination, the doctor always asks if the patient is experiencing any discomfort or pain.
The doctor will also want to know if the patient has any issues related to their ears, such as fluid coming out, pain, or problems with hearing. The patient is asked to identify which of their ears they believe has better hearing because the standard procedure is to check this ear first.
To avoid any confusion or discomfort during the exam, the doctor clearly explains what will happen during each step of the examination. This is especially important for certain tests that need the patient’s help, like when a tuning fork is used to test hearing.
As is standard in all medical exams, the doctor reviews the patient’s medical history and prior test results before starting. This includes notes from previous visits and referral letters, as well as any imaging scans or hearing tests that have been done.
Lastly, to stop the spread of germs, doctors follow the World Health Organization’s guidelines for cleaning their hands. There are five specific points during the exam when they must wash their hands to keep both the patient and doctor safe.
How is Ear Examination performed
Examining your ears requires a particular system to ensure nothing is overlooked. Usually, doctors would do a general check first before looking at your ears more closely and using a special tool called an otoscope. This is followed by a series of tests, which includes checking your hearing, and examining your facial nerve and other areas in your head and neck. If you’ve come in for an ear problem, you’d usually be seen at an outpatient clinic. However, if the doctor has any worries about your overall health, they might evaluate your condition using a special health check system.
Firstly, the doctors will take a good look at your ears with you sitting in front of them. They’d be looking for any differences in the shape or position of your ears or any differences in your facial features. Using the otoscope as a torch, they would also look at the area around your ear (preauricular area) for any surgical scars, lumps, skin changes, or any signs pointing to an abnormal connection between your skin and the tissues underneath it.
The outer part of your ear (pinna) will be looked at closely for birth defects, scars, redness, swelling, lumps, or any discharge from the outer ear canal. If you have any ear piercings, they would look for any signs of infection. Lastly, the back of your ear (postauricular area) should be looked at for scars and redness.
The opposite ear then gets the same treatment. After that, the doctor would apply some pressure to the mastoid bone (behind your ears) and the tragus (the small pointed part of your ear) to check for tenderness, which can point to an infection of the mastoid bone or outer ear canal.
Using an otoscope, the doctor would gently insert the instrument into your outer ear canal. This procedure is usually painless but if you do feel any discomfort, do let the doctor know. They would then check for swelling, discharge, wax, foreign objects, and whether there’s a hole in the wall of your ear canal from previous surgery.
The eardrum can be seen in this test and the doctor would be looking for any holes, thickening, or inward bulging. They might also press gently on the eardrum to see how well it moves. If you have an infection in the middle part of your ear (acute otitis media), the eardrum would bulge outward and doesn’t move with the gentle pressure as it usually would.
Next, they’ll conduct a basic hearing test. It won’t be as comprehensive as the official hearing test but can give a quick indication of whether you have significant hearing loss and how severe it might be.
Afterwards, they might do a fistula test. A fistula in the ear is an abnormal opening between the inner and middle parts of your ear that allows fluid from the inner ear (perilymph) to leak out into the middle part of your ear. The doctor would apply some pressure to your tragus, and observe your eyes. If they observe your eyes moving in the direction of the ear being tested, this could mean you have this condition.
The next tests are tuning fork tests that are designed to identify the type of hearing loss you might have.
Weber’s test is conducted by striking the tuning fork and placing it in the middle of your forehead. You will then be asked if the sound seems louder in your left ear, right ear, or equal in both ears.
Rinne’s test is then performed by hitting the tuning fork and holding it about an inch away from your outer ear (air conduction). Immediately after, the base of the tuning fork is pressed onto the bone behind your ear (bone conduction). You will be asked which sound was louder to you.
What Else Should I Know About Ear Examination?
Through an ear examination, doctors can detect many health problems. If there’s something foreign stuck in your ear canal, the doctors can remove it there and then in the clinic. They can give you antibiotics and steroid creams to treat outer ear infections (otitis externa). They may also prescribe oral antibiotics to treat middle ear infections (otitis media).
Sometimes, if the results of the examination are concerning, additional tests may be needed. Computed tomography (or a CT scan), which is a type of X-ray that gives a detailed view of your ear, might be required if there are signs of severe middle ear infection, a cholesteatoma (a type of skin cyst that can be found in the middle ear), or if there’s been some trauma that affected the ear. If the doctor finds symptoms of facial nerve issues or one-sided hearing loss, they might recommend a magnetic resonance imaging (MRI) test, which uses a large magnet and radio waves to look at organs and structures inside your body.
If there’s any indication of hearing loss, at this point the doctor may suggest more specialized hearing tests, like pure-tone audiometry and tympanometry, which can help gauge the extent and type of hearing loss more accurately.
Lastly, conditions like cholesteatoma or a large hole in the eardrum (tympanic membrane), or abnormalities of the outer ear (pinna) could start discussions about possible surgical options.
