What is the complete diagnostic workup for a patient presenting with fullness in the ears?

Diagnostic Workup for Patients Presenting with Ear Fullness

A comprehensive diagnostic workup for ear fullness should include otoscopy, pneumatic otoscopy, audiometric testing, and tympanometry to differentiate between conductive and sensorineural causes, with particular focus on identifying eustachian tube dysfunction, which is the most common cause (28.9%) of ear fullness. 1

Initial Evaluation

History

• Assess for associated symptoms:
  • Tinnitus, hearing disturbance, and autophony (strongly correlated with ear fullness) 1
  • Nasal obstruction and sore throat (moderately correlated) 1
  • Vertigo, balance problems, or pain 2
  • Unilateral vs bilateral presentation 3
  • Duration of symptoms (recent onset vs persistent) 3
  • Pulsatile vs non-pulsatile character 3

Physical Examination

1. Otoscopic examination:

   • Visualize ear canals and tympanic membranes 2
   • Look for cerumen impaction, which can cause fullness and requires removal before further assessment 2
   • Assess for middle ear fluid, tympanic membrane perforation, or other abnormalities 2

2. Pneumatic otoscopy:

   • Create an air-tight seal in the ear canal
   • Assess tympanic membrane mobility 2
   • Normal membrane moves briskly with pressure; minimal/sluggish movement suggests fluid 2

Diagnostic Testing

Audiologic Assessment

1. Pure tone audiometry (gold standard):

   • Measures hearing sensitivity through air and bone conduction 2
   • Establishes pattern and degree of hearing loss 2
   • Differentiates between conductive and sensorineural hearing loss 2

2. Speech audiometry:

   • Evaluates word recognition ability 2
   • Poor word recognition may indicate need for referral 2

3. Tympanometry:

   • Objective measure of middle ear function 2
   • Requires air-tight seal in ear canal 2
   • Flat tracing indicates fluid in middle ear 2
   • Shifted peak indicates pressure abnormality 2

4. Acoustic reflex testing:

   • Evaluates stapedial muscle reflex 2, 3
   • Helps differentiate conductive from sensorineural pathology

5. Tuning fork tests (Weber and Rinne):

   • Help differentiate between conductive and sensorineural hearing loss 2
   • Weber test: Place vibrating tuning fork at midline of forehead
   • Rinne test: Compare bone to air conduction 2

Additional Testing (When Indicated)

1. Eustachian tube function tests:

   • Tubotympanoaero-dynamic graphy (TTAG) 4
   • Particularly valuable as most patients with eustachian tube dysfunction show normal middle ear pressure on tympanometry 4

2. Imaging studies (only when specific indications present):

   • CT angiography: For pulsatile tinnitus 3
   • MRI with contrast: For unilateral fullness with asymmetric hearing loss or focal neurological findings 3

3. Temporomandibular joint (TMJ) examination:

   • Assess mandibular range of motion
   • Check for TMJ crepitation and pain on palpation 5
   • Consider when ear fullness persists despite normal otologic findings 6

Diagnostic Algorithm

1. First-line assessment:

   • Otoscopy → Remove cerumen if present → Repeat otoscopy
   • Pneumatic otoscopy
   • Tuning fork tests
   • Tympanometry
   • Pure tone audiometry

2. If normal otoscopic findings but persistent fullness:

   • Evaluate for eustachian tube dysfunction (most common cause) 1, 4
   • Assess for TMJ dysfunction (common in patients with unexplained ear fullness) 6, 5
   • Consider migraine disorder or anxiety as potential causes 6

3. If abnormal findings on initial assessment:

   • Conductive hearing loss → Evaluate for otitis media with effusion (13.4% of ear fullness cases) 1
   • Sensorineural hearing loss → Consider sudden sensorineural hearing loss, especially if unilateral 7
   • Mixed hearing loss → Refer to otolaryngologist 2

Common Pitfalls and Caveats

1. Failure to remove cerumen:

   • Impacted cerumen must be removed before establishing a diagnosis 2
   • Cerumen can prevent accurate assessment and diagnosis of middle ear disease 2

2. Overlooking non-otologic causes:

   • TMJ dysfunction can present primarily as ear fullness without obvious jaw symptoms 5
   • 94.7% of patients with unexplained ear fullness may have TMJ dysfunction, intermittent eustachian tube dysfunction, migraine disorder, or anxiety 6

3. Inadequate testing:

   • Standard tympanometry alone may miss eustachian tube dysfunction 4
   • Comprehensive eustachian tube ventilatory testing is essential when ear fullness persists despite normal tympanometry 4

4. Bilateral assessment:

   • Functional imbalance between eustachian tubes can cause fullness sensation 4
   • Always evaluate both ears, even when symptoms are unilateral

By following this systematic diagnostic approach, clinicians can effectively identify the underlying cause of ear fullness and direct appropriate treatment, improving patient outcomes and quality of life.