EARS

OBJECTIVES

At the end of this lesson the students must:

Demonstrate knowledge of the anatomy and physiology of the ears as it relates to
hearing and balance.
Identify the common landmarks of the tympanic membrane.
Recognize important topics for health promotion and risk reduction related to the ear
and hearing.
Collect subjective and objective data related to the ears and hearing.
Identify normal and abnormal findings in the inspection and palpation of the ears.
 Demonstrate proper technique for otoscope use.
Document and communicate data using appropriate medical terminology.
Consider age, condition, gender, and culture of the patient to individualize the ear
assessment.
 DEFINITION OF TERMS

Tinnitus -perception of buzzing or ringing in one or both ears that does not correspond with an external sound.
Frequency - the number of cycles per second the sound waves make, is measured in units of hertz (Hz)
Decibels (dB) -Measurement unit of amplitude
Otorrhea -Drainage that comes out of your ear. Sometimes called “runny ears”
Otalgia - Earache

Vertigo - True spinning motion, feels like the room is spinning around them
Equilibrium
- Balance
SKIN

The ear is the sense organ of hearing and

equilibrium. It consists of three distinct
parts: the external ear, the middle ear,
and the inner ear. The tympanic
membrane separates the external ear
from the middle ear. Both the external
ear and the tympanic membrane can be
assessed by direct inspection and by
using an otoscope. The middle and inner
ear cannot be directly inspected. Instead,
testing hearing acuity and the conduction
of sound assesses these parts of the ear.
Before learning assessment techniques, it
is important to understand the anatomy
and physiology of the ear.
STRUCTURES OF THE EAR
EARS
Sound is perceived in two ways: Air Conduction (AC) and Bone Conduction (BC).
AC, the most efficient method, is the normal pathway for sounds to travel to the inner
ear. BC uses a different pathway, bypassing the external ear and delivering sound
waves/vibrations directly to the inner ear through the skull. A compromise in either
pathway causes hearing loss.
HEARING DIFFICULTIES

1. Conductive hearing loss occurs when sound wave transmission through the external
or middle ear is disrupted. It may result in either blockage of the external auditory canal
by cerumen or fluid in the middle ear. The health care provider can easily remedy
external auditory blockage by clearing the obstruction. Fluid in the middle ear requires
further investigation for pathology.
HEARING DIFFICULTIES

2. Sensorineural Hearing Loss (SNHL) results from a problem somewhere beyond the
middle ear, from inner ear to auditory cortex. Prenatal congenital SNHL can include
inner ear malformations related to genetics and viral infections such as rubella,
cytomegalovirus (CMV), congenital syphilis, and toxoplasmosis.
HEALTH ASSESSMENT

Beginning when the nurse first meets the client, assessment of hearing provides
important information about the client’s ability to interact with the environment.
Changes in hearing are often gradual and go unrecognized by clients until a severe
problem develops. Therefore, asking the client specific questions about hearing may
help in detecting disorders at an early stage.
HEALTH ASSESSMENT

HISTORY OF PRESENT HEALTH CONCERN

NEED TO KNOW RATIONALE

1. Changes in Hearing Describe any recent A sudden decrease in ability to hear in one
changes in your hearing. ear may be associated with otitis media.
Sudden sensorineural hearing loss (SSHL) or
sudden deafness (up to a 3-day period)
may be a medical emergency and thus
should be referred for immediate follow-up.
2. Are you ever concerned that you may be Presbycusis, a gradual hearing loss, is
losing your ability to hear well? common after the age of 50 years.
HEALTH ASSESSMENT

HISTORY OF PRESENT HEALTH CONCERN

NEED TO KNOW RATIONALE

3. Do you have any ear drainage? Describe Drainage (otorrhea) usually indicates
the amount and any odor. infection. Purulent, bloody drainage
suggests an infection of the external ear
(external otitis)
4. Do you have any ear pain? If the client Earache (otalgia) can occur with ear
answers yes, use COLDSPA infections, cerumen blockage, sinus
infections, or teeth and gum problems.
HEALTH ASSESSMENT

HISTORY OF PRESENT HEALTH CONCERN

NEED TO KNOW RATIONALE

5. Do you experience any ringing, roaring Ringing in the ears (tinnitus) may be
or crackling in your ears? associated with excessive earwax buildup,
high blood pressure, or certain ototoxic
medications.
6. Do you ever feel like you are spinning or Vertigo (true spinning motion) may be
that the room is spinning? Do you ever feel associated with an inner-ear problem. It is
dizzy or unbalanced? termed subjective vertigo when clients feel
that they are spinning around and objective
vertigo when clients feel that the room is
spinning around them.
HEALTH ASSESSMENT

PERSONAL HEALTH HISTORY

NEED TO KNOW RATIONALE

1. Have you ever had any problems with A history of repeated infections can affect
your ears such as infections, trauma, or the tympanic membrane and hearing.
earaches?
HEALTH ASSESSMENT

FAMILY HISTORY, LIFESTYLE AND HEALTH PRACTICES

NEED TO KNOW RATIONALE

1. Is there a history of hearing loss in your Age-related hearing loss tends to run in
family? families

2. Do you work or live in an area with Continuous loud noises (e.g., machinery,
frequent or continuous loud noise? How do music, explosives) can cause a hearing loss
you protect your ears from the noise? unless the ears are protected with ear
guards.
3. Do you spend a lot of time swimming or Otitis externa, often referred to as
in water? How do you protect your ears swimmer’s ear, can occur when water stays
when you swim? in the ear canal for long periods of time,
providing the perfect environment for
germs to grow and infect the skin. Germs
found in pools and at other recreational
water venues are one of the most common
causes of swimmer’s ear
PHYSICAL EXAMINATION

Equipment
• Watch with a second hand for Romberg’s test
• Tuning fork
• Otoscope
OTOSCOPE

The otoscope is a flashlight-type viewer used to visualize the eardrum and external ear
canal.
Some guidelines for using it effectively follow.
1. Ask the client to sit comfortably with the back straight and the head tilted slightly
away from you toward his or her opposite shoulder.
2. Choose the largest speculum that fits comfortably into the client’s ear canal (usually
5 mm in the adult) and attach it to the otoscope. Holding the instrument in your
dominant hand, turn the light on the otoscope to “on.”
3. Use the thumb and fingers of your opposite hand to grasp the client’s auricle firmly
but gently. Pull out, up, and back to straighten the external auditory canal. Do
not alter this positioning at any time during the otoscope examination.
4. Grasp the handle of the otoscope between your thumb and fingers and hold the
instrument up or down.
OTOSCOPE

5. Position the hand holding the otoscope against the client’s head or face. This
position prevents forceful insertion of the instrument and helps to steady your hand
throughout the examination, which is especially helpful if the client makes any
unexpected movements.
6. Insert the speculum gently down and forward into the ear canal (approximately 0.5
inch). As you insert the otoscope, be careful not to touch either side of the inner
portion of the canal wall. This area is bony and covered by a thin, sensitive layer of
epithelium. Any pressure will cause the client pain.
7. Move your head in close to the otoscope and position your eye to look through the
lens.
INSPECTION AND PALPATION OF THE EAR

Assessment procedure Normal Findings Abnormal Findings

1. Inspect the auricle, tragus, Ears are equal in size Ears are smaller than 4 cm or
and lobule. Note size, shape, bilaterally (normally 4–10 larger than 10 cm.
and position cm). The auricle aligns with Misaligned or low-set ears
the corner of each eye and may be seen with
within a 10- degree angle of chromosomal defects.
the vertical position.
Earlobes may be free,
attached, or soldered
2. Continue inspecting the The skin is smooth, with no
auricle, tragus, and lobule. lesions, lumps, or nodules.
Observe for lesions, Color is consistent with
discolorations, and facial color. Darwin’s
discharge. tubercle, which is a clinically
insignificant projection, may
be seen on the auricle. No
discharge should be present.
INSPECTION AND PALPATION OF THE EAR
INSPECTION AND PALPATION OF THE EAR

Assessment procedure Normal Findings Abnormal Findings

3. Palpate the auricle and Normally the auricle, tragus, A painful auricle or tragus is
mastoid process. and mastoid process are not associated with otitis externa
tender. or a post auricular cyst.
Tenderness over the mastoid
process suggests mastoiditis.
Tenderness behind the ear
may occur with otitis media.
INTERNAL EAR OTOSCOPIC EXAMINATION

Assessment procedure Normal Findings Abnormal

Findings
1. Note any discharge along A small amount of odorless
with the color and cerumen (earwax) is the only
consistency of cerumen discharge normally present.
(earwax). Cerumen color may be yellow,
orange, red, brown, gray, or black.
Consistency may be soft, moist,
dry, flaky, or even hard.
2. Observe the color and The canal walls should be pink
consistency of the ear canal and smooth, without nodules.
walls and inspect the
character of any nodules.
3. Inspect the tympanic The tympanic membrane should
membrane (eardrum). Note be pearly, gray, shiny, and
color, shape, consistency, translucent, with no bulging or
and landmarks. retraction. It is slightly concave,
smooth, and intact..
ABNORMAL DISCHARGES

Abnormal Findings

• Bloody, purulent discharge—otitis media with ruptured tympanic membrane

• Blood or watery drainage (cerebrospinal fluid)—skull
• Impacted cerumen blocking the view of the external ear canal—conductive hearing loss
• Refer any client with presence of foreign bodies such as bugs, plants, or food to the
health care practitioner for prompt removal due to possible swelling and infection.
• Foul-smelling, sticky, yellow discharge— otitis externa or impacted foreign body
Abnormal findings in the ear canal may include:
• Reddened, swollen canals—otitis externa
• Exostoses (nonmalignant nodular swellings)
• Polyps may block the view of the eardrum.
ABNORMAL FINDING IN THE URICLE, TARGUS AND LOBULE

Abnormal Findings

Abnormal findings in the auricle, tragus and lobule

• Enlarged preauricular and postauricular lymph nodes—infection
• Tophi (nontender, hard, cream-colored nodules on the helix or antihelix, containing uric
acid crystals)—gout
• Postauricular cysts - Blocked sebaceous glands
• Ulcerated, crusted nodules that bleed— skin cancer
• Otitis Externa—Redness, swelling scaling
• Frostbite—Pale blue ear color
ABNORMAL FINDING IN THE URICLE, TARGUS AND LOBULE

Abnormal Findings

TOPHI POSTAURICULAR CYSTS

FROSTBITE
ABNORMAL FINDINGS IN THE EXTERNAL EAR

Abnormal Findings

MICROTIA MACROTIA EDEMATOUS

EAR
ABNORMAL FINDINGS IN THE EXTERNAL EAR

Abnormal Findings

PSEUDOMONAS IFXN AURICULR CANCER

CYST
ABNORMAL FINDING IN THE TYMPANIC MEMBRANE

Abnormal Findings

Abnormal findings in the tympanic membrane

• Red, bulging eardrum and distorted, diminished, or absent light reflex—acute otitis
media
• Yellowish, bulging membrane with bubbles behind—serous otitis media
• Bluish or dark red color—blood behind the eardrum from skull trauma
• White spots—scarring from infection
• Perforations—trauma from infection
• Prominent landmarks—eardrum retraction from negative ear pressure resulting from an
obstructed eustachian tube
• Obscured or absent landmarks—eardrum thickening from chronic otitis media
INTERNAL EAR OTOSCOPING EXAMINATION

Assessment procedure Normal Findings Abnormal Findings

1 . To evaluate the mobility The healthy membrane With otitis media, the
of the tympanic membrane, flutters when the bulb is membrane does not move or
perform pneumatic otoscopy inflated and returns to the flutter when the bulb is
with a bulb insufflator resting position once the air inflated.
attached by using an released.
otoscope with bulb
insufflators. Observe the
position of the tympanic
membrane when the bulb is
inflated and again when the
air is released.
INTERNAL EAR OTOSCOPING EXAMINATION
INTERNAL EAR OTOSCOPING EXAMINATION
PHYSICAL ASSESSMENT

Assessment procedure Normal Findings Abnormal Findings

2. Perform the whisper test Able to correctly repeat the Unable to repeat a two
by asking the client to gently two-syllable word as syllable word
occlude the ear not being whispered.
tested and rub the tragus
with a finger in a circular More than 30% of people
motion. Start with testing the over age 65 have some type
better hearing ear and then of hearing loss; 14% of
the poorer one. With your people between 45 and 64
head 2 feet behind the client years of age have hearing
(so that the client cannot see loss.
your lips move), whisper a
two-syllable word such as
“popcorn” or “football.” Ask
the client to repeat it back to
you. If the response is
incorrect the first time,
whisper the word one more
time.
PHYSICAL ASSESSMENT

Assessment procedure Normal Findings Abnormal Findings

3. Perform Weber’s test if Poor ear receives most of the
the client reports diminished sound conducted by bone
or lost hearing in one ear. vibration.
The test helps to evaluate the
conduction of sound waves
through bone to help
distinguish between
conductive hearing
sensorineural hearing
PHYSICAL ASSESSMENT

Assessment procedure Normal Findings Abnormal Findings

4. Perform the Rinne test. Air conduction sound is Negative or abnormal Rinne
The Rinne test compares air normally heard longer than negative, air vibrations are
and bone conduction sounds. bone conduction sound (AC not being transmitted across
Strike a tuning fork and > BC) the external auditory canal,
place the base of the fork on the tympanic membrane, the
the client’s mastoid process ossicular chain,
Ask the client to tell you
when the sound is no longer
heard. Move the prongs of
the tuning fork to the front of
the external auditory canal.
Ask the client to tell you if
the sound is audible after the
fork is moved.
PHYSICAL ASSESSMENT

Conclussion
Rinne and Weber tests are exams that test for hearing loss. They help determine whether
you may have conductive or sensorineural hearing loss. This determination allows a doctor
to come up with a treatment plan for your hearing changes.
A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. Air
conduction hearing occurs through air near the ear, and it involves the ear canal and
eardrum. Bone conduction hearing occurs through vibrations picked up by the ear’s
specialized nervous system.
A Weber test is another way to evaluate conductive and sensorineural hearing losses.
Conductive hearing loss occurs when sound waves are unable to pass through the middle
ear to the inner ear. This can be caused by problems in the ear canal, eardrum, or middle
ear, such as:
•an infection
•a buildup of earwax
PHYSICAL ASSESSMENT

Assessment procedure Normal Findings Abnormal Findings

5. Perform the Romberg test. Client maintains position for Client moves feet apart to
Ask the client to stand with 20 seconds without swaying prevent falls or starts to fall
feet together, arms at sides, or with minimal swaying from loss of balance. This
and eyes open, then with the may indicate a vestibular
eyes closed. disorder.
 ASSESSMENT SEQUENCE

1. Inspect the external ear for color, shape, size, including position/ alignment of ear
lobes.
2. Palpate for the contour & texture of the cartilage Examine the internal auditory canal
& eardrums with the otoscope.
3. Test CN VII for hearing acuity through the:
a.) Voice test
b.) Weber Test
c.) Rinne Test
“You don’t build a house without its
foundation. You don’t build a
hospital without its Nurses.”
—NLab