examination of ear - dr girish s

EXAMINATION OF EAR

DR.GIRISH.S

HISTORY TAKING CHIEF COMPLAINT : his/her own words

FURTHER DESCRIPTION– site pertaining to the complaint, character of the problem, intensity. CHRONOLOGY – The time of onset of the problem.

ACUITY OF THE PROBLEM: when exactly the symptoms turned worse.

ASSOCIATED SYMPTOMS: Any associated symptoms should be sought

History taking includes

Previous ear surgery Previous head injury systemic diseases like diabetes / hypertension Use of ototoxic drugs Exposure to noise during work Family h/o deafness H/O atopy / allergy

Symptomatology

1. DEAFNESS 2. DISCHARGE 3. TINNITUS 4. PAIN 5. VERTIGO

DEAFNESS AGE OF THE PATIENT: Older pts- natural degeneration of hair cells High frequency hearing loss is seen in pts >60yrs. Presbyacusis -inability to comprehend spoken words.

UNILATERAL / BILATERAL: Bilateral deafness - Noise induced hearing loss, Otosclerosis.

Deafness ONSET – GRADUAL / SUDDEN

Sudden deafness – usually its due to trauma Transient deafness in Head injury – haematoma of middle ear

cavity

Fluctuating Hearing Loss

Wax – Conductive Deafness Meneire’s disease – SNHL

Usually starts off as low frequency loss and progresses to involve upper frequencies.

Drug History / Occupation Eliciting drug history is a must in evaluation of deafness SM, Gentamycin and Aspirin cause damage to outer hair cells of

cochlea – SNHL Noise exposure can cause damage to outer hair cells of cochlea

Noise induced hearing loss SNHL initially covering higher frequencies are seen

To start with , it causes Temporary threshold shift (reversible)

Later it become Permanent threshold shift (irreversible)

NOISE INDUCED HEARING LOSS TEMPORARY THRESHOLD SHIFT: HL is transient. If the patient is removed from noisy environment hearing will improve. due to Auditory fatigue.

SHORT TERM FATIGUE - Recovery occurs within minutes. LONG TERM FATIGUE - Recovery requires several minutes to days. depends on the duration of noise exposure.

PERMANENT THRESHOLD SHIFT: HL is permanent. This tends to occur in patients with temporary threshold shift who continue to be exposed to the offending noisy environment.

OTOSCLEROSIS another cause of bilateral deafness. Commonly deafness is conductive in nature in this condition These patients reveal that they are able to hear better in noisy

environment (Paracusis Willisi) PTA - bilateral conductive hearing loss.

Progressive / sudden: SUDDEN DEAFNESS

1. Sudden vascular insults 2. Head injuries 3. Traumatic injuries to ear drum and middle ear structures

PROGRESSIVE DEAFNESS 1. Accumulation of cerumen 2. Otitis media 3. Presbyacusis 4. Noise induced hearing loss

VERTIGO sensation of unsteadiness / rotation. commonest peripheral causes – dses of the inner ear. associated with tinnitus/ blocking

PERIPHERAL VERTIGO ==== CENTRAL VERTIGO

[[[Central nystagmus due to cerebellar pathology manifests with rotatory / vertical nystagmus ]]]

TINNITUS hearing abnormal sounds in the ear.

OBJECTIVE TINNITUS is the one which is heard by both the examiner and the patient e.g. palatal myoclonus.

SUBJECTIVE TINNITUS is heard only by the patient. e.g. impacted wax can cause subjective tinnitus by the process of amplification of endogenous sound -in the absence of impacted cerumen indicates early SNHL.

-caused by damage to hair cells of the cochlea. (medicines like those belonging to the group of antibiotics, diuretics or cytotoxic drugs.)

BIGGER'S SIGN

Tinnitus with dizziness and vertigo Improves at high altitude such as in an airplane Ménière's disease

Tinnitus associated with crepitus in the jaw, headache, and ear pain

TEMPOROMANDIBULAR JOINT SYNDROME

DISCHARGE common problem

1. Duration of the discharge 2. Quantity of discharge 3. Quality of discharge 4. Aggravating & relieving factors

ACUTE CONDITIONS A.S.O.M. - Serosanguinous in nature (blood tinged), preceded by an episode of severe ear pain, pain subsides as soon as discharge starts, preceding episodes of upper respiratory infection.

OTOMYCOSIS - candida and aspergillus fumigatus. Candida gives a curdy appearance Aspergillus fumigatus appears as a black color ,not profuse in nature,

associated with intense itching.

C.S.F. OTORRHOEA - The discharge is watery in nature

C.S.F. OTORRHOEA Handkercheif test – CSF does not cause stiffening Halo sign / Ring sign / Double-ring sign. Presence of glucose – Benedicts test Confirmatory test – Beta 2 transferrin

Ear discharge associated with pain is a feature of: OTITIS EXTERNA ACUTE OTITIS MEDIA

In acute otitis media pain subsides after discharge begins.

Causes of Profuse Ear Discharge Chronic Mastoiditis – Mastoid tenderness + may lead

onto subperiostael abscess Mastoid reservoir – Mastoid tenderness + Extra Dural Abscess – even on suction the EAC is

flooded with discharge

Quality of Ear Discharge Mucoid - ASOM Mucopurulent – CSOM and Mastoiditis Serous – common in ASOM Serosanguinous – ASOM n Otitis externa Watery – CSF otorrhoea

OTALGIA can arise from 2 sources, pain due to problems confined to the ear, referred otalgia i.e. pain that is referred to the ear

from a problem arising from other area

Pain due to inflammation external ear middle ear TRAGAL SIGN is negative in middle ear causes.

Pain due to mastoiditis otitis externa THREE POINT TENDERNESS middle finger to apply pressure over the well of the concha, index finger is applied over the mastoid process, thumb is used over the mastoid tip.

antral area, the presence of mastoiditis, inflammation and thrombosis of mastoid emissary vein.

External ear causes of otalgia: 1. Acute diffuse otitis externa (commonly caused by bacteria) 2. Acute localised otitis externa (commonly furuncle) 3. Chronic otitis externa 4. Eczematous otitis externa 5. Fungal otitis externa 6. Malignant otitis externa 7. Chronic Myringitis 8. Bullous myringitis / Bullous otitis externa

Middle ear causes of otalgia:

Acute otitis media Eustachian tube dysfunction Otitis barotrauma Herpes zoster oticus (Ramsay Hunt syndrome) Relapsing polychondritis

OTHER CAUSES Primary neoplasms arising from skull base / pinna / external

canal Trauma Hematoma Seroma Frost bite Burns / thermal injuries

Secondary / Referred otalgia shared anatomic innervation of the ear… by cr n

5,7,9,10.. the three logical sites for initial attention in a case of

referred otalgia are temporomandibular joint entire neck teeth.

TRIGEMINAL NERVE V3

FACIAL NERVE

GLOSSOPHARYNGEAL NERVE IX

INFECTIONS CAUSING OTALGIA 1. Tonsillar infections (i.e. Quinsy, tonsillitis) via the

glossopharyngeal nerve 2. Mumps parotitis – due to stretching of the sensitive

parotid fascia via trigeminal nerve 3. Rarely sinus infections also can cause otalgia 4. Dental infections like tooth decay may cause

referred otalgia

EAGLE SYNDROME otalgia, facial pain, and throat pain elongated styloid process / ossified stylohyoid

ligament.

OTHER CAUSES NEURALGIAS NEOPLASMS CERVICAL ARTHRITIS

EXAMINATION OF EARPHYSICAL EXAMINATIONFUNCTIONAL EXAMINATION

PHYSICAL EXAMINATION PINNA

1. size & shape of the pinna 2. Presence of tags / preauricular sinuses / pits 3. Evidence of trauma to pinna 4. Skin condition of pinna & external auditory canal 5. Evidence of previous surgery/ presence of scars in the post aural/end aural region 6. Discharge from the external canal 7. Neoplastic lesions of pinna

RED, LAX, OR FLOPPY EARS

Suggest RELAPSING POLYCHONDRITIS.

occurs with a sudden onset of unilateral or bilateral ear pain, swelling, and redness, sparing the lobules.

MILIAN’S EAR SIGN

Erysipelas can spread to pinna(cuticular affection), where as cellulitis cannot.

erysipelas involves the upper dermis and superficial lymphatics cellulitis involves the deeper dermis and subcutaneous fat

Pinna doesn’t contain deeper dermis tissue , so cellulitis can’t..

HAMILTON'S SIGN

Long ear hairs suggest normal androgenic function. 

PAUL DUDLEY WHITE'S WINKING EAR LOBE SIGN

Movement of the ear lobe coincident with the pulse TRICUSPID INSUFFICIENCY

PALPATION OF THE EAR Stiffness of the earlobe

suggests Addison's disease Stiffness of the pinna and auricular cartilage

hyperthyroidism, acromegaly, diabetes mellitus hypopituitarism.

Straightening Ear Canal

Using aural speculam

In adults pinna is pulled posterosuperior & laterally.

In infants it is pulled posteriorly and downwards.

EAC EXAMINATION WITHOUT A SPECULUM.

size of meatus (narrow or wide), contents of lumen (wax, debris, discharge or polyp) or swelling of its wall (furuncle, neoplasm).

EXAMINATION WITH A SPECULUM. Look for wax, debris, discharge, polyp, granulations, exostosis,

benign or malignant neoplasm, sagging of posterosuperior area (coalescent mastoiditis)

HITSELBERGER’S SIGN loss of sensation in the postero-superior part of external

auditory meatus supplied by Arnold’s nerve ( branch of Vagus nerve )  ACOUSTIC NEUROMA

TYMPANIC MEMBRANE

Color of Ear Drum Pearly White – Normal

Red drum – AOM, Glomus jugulare

Blue Drum – SOM, Haemotympanum

Pink Drum –Otospongiosis Chalky Drum - Tympanosclerosis

RISING SUN SIGN red vascular hue seen behind

the intact tympanic membrane

GLOMUS TUMOUR HIGH JUGULAR BULB ABERRANT CAROTID ARTERY

IN THE FLOOR OF MIDDLE EAR.

BROWNE'S SIGN Blanching noted when applying positive pressure {with Siegel's speculum} to the tympanic membrane. GLOMUS TUMOR.

SCHWARTZ SIGN FLAMINGO FLUSH SIGN it is seen because of increased vascularity in submucous layer

of promontory In active phase of Otosclerosis(otospongiosis).

LAUGIER'S SIGN

Blood behind the eardrum Suggests Basilar skull fracture

POSITION General retraction - tubal occlusion, retraction pockets - attic or postero superior region Adhesive otitis media very thin, deeply retracted and

is fixed to promontory Bulging tympanic membrane - Acute otitis media Haemotympanum Neoplasm of middle ear

RETRACTED TM

Dull and lustreless Cone of light absent or interrupted Handle of malleus appears foreshortened Lateral process of malleus becomes prominent Anterior and posterior malleal folds becomes sickle shaped

SURFACE OF TYMPANIC MEMBRANE vesicles or bullae (herpes zoster or myringitis bullosa),

perforation (acute or chronic otitis media) • central (in pars tensa)

• Small • Medium • Subtotal• Total

• attic (in pars flaccida)• marginal (at the periphery involving the annulus).

MOBILITY - Siegle's speculum normal tympanic membrane is mobile.

LIGHT HOUSE SIGN small pin hole perforation with a pulsatile ear

discharge is seen in Acute Suppurative Otitis Media.

MIDDLE EAR TM >semi-transparent, some structures can be seen through it.

In the presence of a perforation, it is possible to know the condition of middle ear mucosa and any in-growth of squamous epithelium from the edges of the perforation.

MASTOID swelling (abscess or enlarged nodes), obliteration of retroauricular groove (furuncle), fistula (burst abscess), scar (previous operation).

Normally, mastoid surface feels irregular on palpation "IRONED OUT" SMOOTH SURFACE in periosteal inflammation as

in subperiosteal abscess.

BATTLE’S SIGN  Mastoid ecchymosis Bruising over the 

mastoid process Is an indication of fracture of

middle cranial fossa of the skull

Extravasation of blood along the path of the posterior auricular artery

GRIESINGER'S SIGN Erythema & oedema of the postauricular soft

tissues overlying the mastoid process  thrombosis of the mastoid emissary vein. complication of LATERAL SINUS THROMBOSIS

EUSTACHIAN TUBE Tympanic orifice - anterior part of middle ear if there is

perforation Pharyngeal opening - posterior rhinoscopy

Function - Valsalva manoeuvre. Perforation>>air can be felt to escape from the ear when

patient tries to blow with mouth and nose closed.

LEUDET'S SIGN

Inflammation of the Eustachian tube.

Bright clicking sound heard by the examiner through the

otoscope while the patient experiences it as tinnitus.

Caused by reflex spasm of the TENSOR PALATI muscle.

FACIAL NERVE Paralysis of facial nerve may co-exist with disease of the ear,

e.g. ASOM/CSOM , herpes zoster oticus, malignant otitis externa, tumours of external or middle ear and trauma >> TOPODIAGNOSTIC TESTS

TOPODIAGNOSTIC TESTS FOR LESIONS IN INTRATEMPORAL PART

1. SCHIRMER'S TEST 2. STAPEDIAL REFLEX 3. TASTE TEST 4. SUBMANDIBULAR SALIVARY FLOW TEST

FUNCTIONAL EXAMINATION

AUDITORY FUNCTION (a) Voice test (b) Tuning fork tests (256,512,1024 Hz)

RINNE TEST WEBER TEST ABSOLUTE BONE CONDUCTION TEST.

VESTIBULAR FUNCTION (a) Spontaneous nystagmus (b) Fistula test (c) Romberg Test (d) Positional tests

RINNES TEST air conduction of the ear is compared with its bone conduction. A vibrating tuning fork is placed on the patient's mastoid and when he

stops hearing, it is brought beside the meatus. If he still hears, AC is more than BC.

POSITIVE RINNE AC > BC - normal persons /SNHL NEGATIVE RINNE (BC > AC) is seen in conductive deafness.

indicates a minimum air-bone gap of 15-20 dB.

Reduced Rinne Positive AC>BC but intensity of both sounds reduced

SNHL

Infinitely Positive Rinne BC not heard, AC heard Severe SNHL

False Negative Rinne BC>AC, but Weber test lat to other ear U/L SNHL

WEBER TEST vibrating tuning fork is placed in the middle of the forehead or

the vertex and the patient is asked in which ear the sound is heard. sound travels directly to the cochlea via bone.

Normally, it is heard equally in both ears

Lateralised to the worse ear in conductive deafness Lateralised to the better ear in sensorineural deafness.

Weber's test is a sensitive test, it can pin point even a 10 dB hearing difference between the ears.

ABSOLUTE BONE CONDUCTION (ABC) TEST

to identify SNHL. the hearing level of the patient is compared to that of the examiner. vibrating fork is placed over the mastoid after occluding the EAC. When patient indicates that he is unable to hear the sound anymore,

the fork is transferred to the mastoid process of the examiner.

In normal hearing the examiner must not be able to hear the fork.

In SNHL the examiner will be able to hear the sound, then the test is interpreted as ABC reduced.

SCHWABACH'S TEST – BC of pt compared wit examiners but meatus not occluded

BING’S TEST – BC test, tuning fork on mastoid , alternately closes n opens EAC

Nl/SNHL louder when canal occluded

GELLE'S TEST – BC test, using Siegel’s speculam n tuning fork on mastoid – decreased hearing when pressure is applied.

Negative in ossicular chain fixation

VESTIBULAR FUNCTION (A) SPONTANEOUS NYSTAGMUS

(B) FISTULA TEST

(C) ROMBERG TEST

(D) POSITIONAL TEST

Spontaneous Nystagmus involuntary, rhythmical, oscillatory movement of eyes. Horizontal, vertical or rotatory.

Vestibular nystagmus has a slow and a fast component

Direction of nystagmus is indicated by the direction of the fast component.

Intensity of nystagmus is indicated by its degree.

patient is seated in front of the examiner or lies supine on the bed.

the examiner keeps his finger about 30 cm from the patient's eye in the central position

moves it to the right or left, up or down, but not moving at any time, more than 30° from the central position to avoid gaze nystagmus.

presence of spontaneous nystagmus always indicates an organic lesion.

Degree of nystagmus1st degree It is weak nystagmus and is present when patient looks in the direction of

fast component.

2nd degree It is stronger than the 1st degree nystagmus and is present when patient looks straight ahead.

3rd degree It is stronger than 2nd degree nystagmus and is present even when patient looks in the direction of the slow component.

Positional nystagmus in peripheral and central lesions of vestibular system

CENTRAL PERIPHERALLatency No latency 2-20 secondsDuration More than 1 minute Less than 1 minuteDirection of nystagmus Direction changing Direction fixedFatiguability Non-fatiguable FatiguableAccompanying symptoms None or slight Severe vertigo

FISTULA TEST induce nystagmus by producing pressure changes in

the external canal which are then transmitted to the labyrinth. Stimulation of labyrinth results in nystagmus and vertigo.

Normally, the test is negative because the pressure changes in the external auditory canal cannot be transmitted to the labyrinth.

FISTULA TEST POSITIVE > erosion of horizontal semi circular canal

as in cholesteatoma surgically-created window in the horizontal canal

(fenestration), abnormal opening in the oval window (post-

stapedectomy fistula) or the round window (rupture of round window membrane)

FALSE NEGATIVE FISTULA TEST when cholesteatoma covers the site of fistula and does not allow pressure changes to be transmitted to the labyrinth.

HENNEBERT'S SIGN FALSE POSITIVE FISTULA TEST positive fistula test without the presence of a fistula is seen in congenital syphilis and cases of Meniere's disease

In 25% cases of Meneire’s ,fibrous bands form connecting utricular macule to stapes footplate.

In syphilis due to hypermobile stapes footplate.

ROMBERG TEST Patient is asked to stand with feet together and arms

by the side with eyes first open and then closed.

Peripheral vestibular lesions – patient sways to the side of lesion

HALLPIKE MANOEUVRE (POSITIONAL TEST)

When Patient Complains Of Vertigo In Certain Head Positions. It Also Helps To Differentiate A Peripheral From A Central Lesion

Patient Sits On A Couch. Examiner Holds The Patient's Head, Turns It 45° To The Right And Then Places The Patient In A Supine Position So That His Head Hangs 30° Below The Horizontal.

Patient's Eyes Are Observed For Nystagmus. The Test Is Repeated With Head Turned To Left And Then Again In Straight Head-hanging Position

Four parameters of nystagmus are observed: latency, duration, direction and fatiguability.

In BPPV , nystagmus appears after a latent period of 2-20 seconds, lasts for less than a minute and is always in one direction. On repetition of the test, nystagmus is fatiguable.

Patient also complains of vertigo when the head is in critical position.

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