Key Takeaways for In-Ear Physical Examination
1. Master the Essential Visualization Technique: Remove Obstructions and Achieve Complete Tympanic Membrane Visualization
The most critical step in ear examination is achieving complete visualization of the tympanic membrane by first removing any obstructing cerumen, as impacted cerumen must be completely removed prior to establishing any diagnosis. 1
- Use a handheld speculum, otoscope, or binocular microscope to systematically examine the external auditory canal for cerumen impaction, foreign bodies, canal edema, or signs of otitis externa 2
- The binocular microscope provides superior magnification and depth perception, particularly useful for detecting subtle tympanic membrane abnormalities such as atrophy, sclerosis, and retraction pockets 2
- Cerumen impaction is more common in older adults and should be completely removed to allow adequate sound conduction through the external auditory canal 1
- Select the correct speculum size for the patient's ear canal—this is a skill that improves with training and directly impacts diagnostic accuracy 3
- Examine for structural abnormalities including stenosis, atresia, large exostoses, canal cholesteatoma, granulation tissue, or otorrhea 1
2. Distinguish Conductive from Sensorineural Hearing Loss Using Otoscopy and Tuning Fork Tests
Patients cannot accurately distinguish conductive from sensorineural hearing loss based on symptoms alone—physical examination with otoscopy and tuning fork testing is essential for this differentiation. 1, 2
- Perform the Weber test by placing a vibrating 256 or 512 Hz tuning fork at the midline of the forehead or on maxillary teeth; sound lateralizing to one ear indicates either conductive hearing loss in that ear OR sensorineural hearing loss in the opposite ear 1, 2
- Perform the Rinne test by placing the vibrating tuning fork over the mastoid bone, then moving it to the entrance of the ear canal; if sound is heard better by bone conduction, there is conductive hearing loss in that ear 1, 2
- Patients with sensorineural hearing loss almost always have a normal otoscopic examination, whereas those with conductive hearing loss typically show abnormalities 1, 2
- Look for signs of conductive hearing loss including middle ear fluid, otitis media, perforated tympanic membrane, tympanosclerosis, retraction, opacity, or bulging of the tympanic membrane 1, 2
- Add pneumatic otoscopy by creating an air-tight seal and applying positive/negative pressure—a normal tympanic membrane moves briskly, movement is minimal with middle ear fluid, and no motion occurs with perforation 2
3. Recognize Red Flags Requiring Urgent Further Evaluation Beyond Routine Examination
Certain examination findings mandate immediate comprehensive evaluation rather than routine management, including bilateral sudden hearing loss, focal neurologic findings, or signs suggesting systemic disease. 1, 2
- Assess for bilateral sudden hearing loss, which is rare and should raise concern for specific causes including autoimmune disorders, metabolic disorders, or neurological conditions 1
- Look for focal neurologic findings including downbeating or gaze-evoked nystagmus, concurrent weakness, dysarthria, hemiataxia, encephalopathy, severe headaches, or diplopia 1, 2
- Evaluate for syndromic features in patients with hearing loss, including visual anomalies (heterochromia irides, retinitis pigmentosa), facial/cervical dysmorphology (preauricular pits, branchial cysts), cardiac symptoms (syncope, arrhythmia), renal abnormalities (hematuria), or integumentary changes (premature graying, white forelock) 1
- Document any history of severe head trauma coincident with hearing loss, recent acoustic trauma, or concurrent eye symptoms (pain, redness, photophobia) 1, 2
- In children, assess for risk factors including NICU admission for 2+ days, family history of childhood sensorineural hearing loss, congenital infections, craniofacial abnormalities, and syndromes known to include hearing loss 4