Physical Examination of the Ear
The physical examination of the ear should be performed using otoscopy (with a handheld otoscope, speculum, or binocular microscope) to visualize the ear canal and tympanic membrane, supplemented by pneumatic otoscopy to assess tympanic membrane mobility, and tuning fork tests (Weber and Rinne) when hearing loss is suspected. 1
Essential Components of Ear Examination
Visual Inspection and Otoscopy
Examine the external ear canal using a handheld speculum, otoscope, or binocular microscope to identify cerumen impaction, foreign bodies, canal edema, or signs of otitis externa 1
Visualize the tympanic membrane to assess for perforation, middle ear fluid, opacity, bulging, retraction, or other abnormalities 1
Remove impacted cerumen prior to establishing a diagnosis if it prevents adequate visualization of the tympanic membrane or ear canal 1
The binocular microscope provides superior magnification and depth perception, particularly useful for assessing tympanic membrane abnormalities such as atrophy, sclerosis, and retraction pockets 1
Pneumatic Otoscopy
Create an air-tight (hermetic) seal in the ear canal and apply positive and negative pressure using the attached rubber bulb 1
Assess tympanic membrane mobility: A normal tympanic membrane moves briskly with applied pressure; movement is minimal or sluggish when middle ear fluid is present; no motion occurs if the tympanic membrane is perforated 1
This technique is essential for distinguishing conductive hearing loss from sensorineural hearing loss, as patients with sensorineural hearing loss typically have normal otoscopic findings while those with conductive hearing loss often show abnormalities 1
Tuning Fork Testing (When Hearing Loss is Suspected)
Weber Test 1:
- Place a vibrating 256 or 512 Hz tuning fork at the midline of the forehead or on maxillary teeth
- Normal finding: sound heard at midline or "everywhere"
- If sound lateralizes to one ear: indicates conductive hearing loss in that ear OR sensorineural hearing loss in the opposite ear
Rinne Test 1:
- Place vibrating 256 or 512 Hz tuning fork over the mastoid bone, then move to the entrance of the ear canal (without touching the ear)
- Normal finding: sound heard better via air conduction (at the entrance to the ear canal)
- If sound is heard better by bone conduction: indicates conductive hearing loss in that ear
- Repeat for the other ear
Key Diagnostic Findings
Signs of Conductive Hearing Loss 1:
- Cerumen impaction
- Middle ear fluid
- Otitis media
- Foreign bodies
- Perforated tympanic membrane
- Canal edema from otitis externa
- Abnormal otoscopic examination
Signs Requiring Further Evaluation 1:
- Bilateral sudden hearing loss
- Recurrent episodes of hearing loss
- Focal neurologic findings (weakness, dysarthria, hemiataxia, encephalopathy, severe headaches, diplopia)
- Downbeating or gaze-evoked nystagmus
- Severe head trauma coincident with hearing loss
- Concurrent eye symptoms (pain, redness, lacrimation, photophobia)
Common Pitfalls and Caveats
Patients cannot accurately distinguish subjective hearing loss as conductive versus sensorineural based on symptoms alone; physical examination is required 1
Cerumen impaction is diagnosed when cerumen causes symptoms OR prevents needed assessment, even if the canal is only partially occluded 1
Do not attempt irrigation or cerumen removal in patients with perforated tympanic membrane, patent tympanostomy tubes, prior ear surgery, coagulopathies, immunocompromised conditions, or history of head/neck radiation without specialized equipment and expertise 1
A normal otoscopic examination does not rule out sensorineural hearing loss; patients with sudden sensorineural hearing loss almost always have normal otoscopic findings 1
In children aged 2-60 months, cerumen was removed in 29% before diagnosing acute otitis media, demonstrating that cerumen can prevent accurate middle ear assessment 1