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 Ear chief complaints (history taking):

External ear Pain (primary or secondsry), Pruritus,

Discharge, Hearing loss, Tinnitus, Vertigo.

Inspection

Pinnae
Inspect the pinnae for:

• Asymmetry: by comparing the pinnae you may identify subtle unilateral

pathology.
• Deformity of the pinnae: this may be acquired (e.g. cauliflower ear) or
congenital (e.g. anotia, microtia, low-set ears).
• Ear piercings: can be a potential source of infection, an allergen and a cause of
trauma.
• Erythema and oedema: typically associated with otitis externa.
• Scars: indicative of previous surgery.
• Skin lesions: look for evidence of pre-malignant (actinic keratoses) and
malignant (e.g. basal cell carcinoma, squamous cell carcinoma) skin changes.

Mastoid
Inspect the mastoid region:

• Erythema and swelling: typically associated with mastoiditis.

• Scars: indicative of previous surgery (e.g. mastoidectomy).

Pre-auricular region
Inspect the pre-auricular region (in front of the ear):

• Pre-auricular sinus/pit: a common congenital deformity that appears as a

dimple in the pre-auricular region. These sinuses can sometimes become
infected and require surgical drainage.
• Lymphadenopathy: typically associated with an ear infection (e.g. otitis media,
otitis externa).
Palpation
Palpate the tragus for tenderness which is typically associated with otitis externa.

Palpate the regional lymph nodes:

• Pre-auricular lymph nodes

• Post-auricular lymph nodes

•
Anatomy of the ear

•
Inspect the external ear
•
Otitis externa

•
Mastoiditis
•
Basal cell carcinoma 3

•
Low-set ears
•
Microtia

•
 Anotia

Cauliflower ear

Cauliflower ear is an irreversible condition that develops as a result of repeated blunt ear
trauma. Blunt trauma causes bleeding under the perichondrium of the pinna, stripping
away the ear’s cartilage. This cartilage normally relies on the perichondrium for
its nutrient supply and as a result, once separated it becomes fibrotic,
causing distortion of the ear’s architecture.

Congenital deformity of the ears

There are several types of congenital ear deformity including:

• Anotia: a complete absence of the pinna.

• Microtia: underdevelopment of the pinna.
• Low-set ears: the ears are positioned lower on the head than usual. Low-set ears
are a feature of several genetic syndromes including Down’s syndrome and
Turner’s syndrome.

Otoscopy
To help decide which ear to examine first:

• Check if the patient has any ear discomfort and if so examine the non-painful
side first.
• Ask the patient which is their “better” ear and examine this one first (this can be
useful for comparison).

Inserting the otoscope

• Ensure the light is working on the otoscope and apply a sterile speculum
(the largest that will comfortably fit in the external auditory meatus).
 •
Prepare the otoscope

2. Gently pull the pinna upwards, backwards and outwards

3. Position the otoscope at the external auditory meatus:

• The otoscope should be held in your right hand for the patient’s right ear and vice
versa for the left ear.
• Hold the otoscope like a pencil and rest your hand against the patient’s cheek for
stability. This will prevent damage to the ear if there is sudden movement.
4. Advance the otoscope under direct vision. Slowly insert around 1-1.5cm just past the
hair of the lateral canal.

Be careful! This may cause the patient discomfort if they have inflammation in

their EAM

External auditory canal assessment

5. Inspect the external auditory canal for:

• Excessive ear wax: the most common cause of conductive hearing loss.
 • Erythema and oedema: typically associated with otitis externa.
• Discharge: may suggest otitis externa or otitis media with associated tympanic
membrane perforation.
• Foreign bodies: these may include cotton buds, insects and other small objects.

Tympanic membrane assessment

Systematically inspect the four quadrants of the tympanic membrane (TM) to avoid
missing pathology.

Colour
A healthy TM should appear pearly grey and translucent.

Erythema suggests inflammation of the TM which can occur in conditions such as

acute otitis media.

•
Acute otitis media

Shape
A healthy TM should appear relatively flat.

Bulging of the TM suggests increased middle ear pressure, which is commonly

caused by acute otitis media with effusion (there is often an associated visible fluid
level).
Retraction of the TM suggests reduced middle ear pressure, which is commonly
caused by pharyngotympanic tube dysfunction secondary to upper respiratory tract
infections and allergies.

•
Normal tympanic membrane

Light reflex
The light reflex (also known as the “cone of light”) is visible when a light is shone onto
the TM.

If a TM is healthy, the cone-shaped reflection of light should appear in the anterior

inferior quadrant.

In the left ear, the light reflex should be positioned at approximately 7 o’clock to 8
o’clock.

In the right ear, the light reflex should be positioned at approximately 4 o’clock to 5
o’clock.

Absence or distortion of the light reflex is associated with otitis media (due to bulging
of the TM).

Perforation
Note the size and the position of any perforations of the TM.
 •
Traumatic perforation of tympanic

Causes of TM perforation include infection (e.g. otitis media with effusion), trauma (e.g.
diving-related), cholesteatoma and insertion of tympanostomy tubes (also known as
grommets).

•
Cholesteatoma with large tympanic membrane perforation
Cholesteatoma typically causes perforation in the superior part of the TM and there
may be visible granulation tissue and discharge in this region.

Scarring
Scarring of the TM is known as tympanosclerosis and can result in
significant conductive hearing loss if it is extensive.

Tympanosclerosis often develops secondary to otitis media or after the insertion of

a tympanostomy tube.

•
Tympanic membrane retraction
 •
Tympanosclerosis

Final steps

7. Withdraw the otoscope carefully.

8. Repeat your assessment on the other ear, comparing your findings. If the patient has
an infection in one ear, you should change the speculum on the otoscope before
examining the other ear.

9. Discard the otoscope speculum into a clinical waste bin.

 •
Repeat otoscopy on the other ear

Gross hearing assessment

Assessment

1. Position yourself approximately 60cm from the patient’s ear and then whisper a
number or word.

2. Mask the ear not being tested by rubbing the tragus. Do not place your arm across
the face of the patient when rubbing the tragus, it is far nicer to occlude the ear from
behind the head. If possible, shield the patient’s eyes to prevent any visual stimulus.
3. Ask the patient to repeat the number or word back to you. If they get two-thirds or
more correct then their hearing level is 12db or better. If there is no response use a
conversational voice (48db or worse) or loud voice (76db or worse).

4. If there is no response you can move closer and repeat the test at 15cm. Here the
thresholds are 34db for a whisper and 56db for a conversational voice.

5. Assess the other ear in the same way.

•
Whisper a number 60cm from the ear
 •
Mask the ear not being tested by rubbing the tragus

Weber’s test
Explain to the patient that you are going to test their hearing using a tuning fork.

1. Tap a 512Hz tuning fork and place in the midline of the forehead. The tuning fork
should be set in motion by striking it on your knee (not the patient’s knee or a table).

2. Ask the patient “Where do you hear the sound?”

These results should be assessed in context with the results of Rinne’s test before any
diagnostic assumptions are made:

• Normal: sound is heard equally in both ears.

• Sensorineural deafness: sound is heard louder on the side of the intact ear
(non- affected ear).
• Conductive deafness: sound is heard louder on the side of the affected ear.
A 512Hz tuning fork is used as it gives the best balance between time of decay and
tactile vibration. Ideally, you want a tuning fork that has a long period of decay and
cannot be detected by vibration sensation.

•
Tap a 512Hz tuning fork and place in the midline of the forehead

Rinne’s test
1. Place a vibrating 512 Hz tuning fork firmly on the mastoid process (apply pressure to
the opposite side of the head to make sure the contact is firm). This tests bone
conduction.

2. Confirm the patient can hear the sound of the tuning fork and then ask them to tell
you when they can no longer hear it.

3. When the patient can no longer hear the sound, move the tuning fork in front of the
external auditory meatus to test air conduction.

4. Ask the patient if they can now hear the sound again. If they can hear the sound, it
suggests air conduction is better than bone conduction, which is what would be
expected in a healthy individual (this is often confusingly referred to as a “Rinne’s
positive” result).
Summary of Rinne’s test results
These results should be assessed in context with the results of Weber’s test before any
diagnostic assumptions are made:

• Normal result: air conduction > bone conduction (Rinne’s positive)

• Sensorineural deafness (partial hearing loss): air conduction > bone
conduction (Rinne’s positive) – due to both air and bone conduction being
reduced equally
• Conductive deafness: bone conduction > air conduction (Rinne’s negative)
• Negative Rinne’s if the examined ear is dead (complete loss of hearing) and
the sound heard in the contra lateral ear
 Place a 512 Hz tuning fork on the mastoid process
Ask the patient to tell you when they can no longer hear it
•
When the patient can no longer hear the sound, moving the tuning fork in front of the external au

ABSOLUTE BONE CONDUCTION

used to identify sensorineural hearing loss.

Method : In this test the hearing level of the patient is compared to that
of the examiner. The examiner's hearing is assumed to be normal. In
this test the vibrating fork is placed over the mastoid process of the
patient after occluding the external auditory canal. As soon as the
patient indicates that he is unable to hear the sound anymore, the fork is
transferred to the mastoid process of the examiner after occluding the
external canal.

Result
In cases of normal hearing the examiner must not be able to hear the
fork.
In cases of sensorineural hearing loss the examiner will be able to
hear the sound.
Conductive vs sensorineural hearing loss

Conductive hearing loss occurs when sound is unable to effectively transfer at any
point between the outer ear, external auditory canal, tympanic membrane and middle ear
(ossicles). Causes of conductive hearing loss include excessive ear wax, otitis externa,
otitis media, perforated tympanic membrane and otosclerosis.

Sensorineural hearing loss occurs due to dysfunction of

the cochlea and/or vestibulocochlear nerve. Causes of sensorineural hearing loss include
increasing age (presbycusis), excessive noise exposure, genetic mutations, viral infections
(e.g. cytomegalovirus) and ototoxic agents (e.g. gentamicin).
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