Ear Station Approach

– History –

  • CC: most likely will present as hearing loss:
    • Site: uni\bi-lateral? Alternates?
    • Onset: first time? When? What were you doing (after loud noise)? Gradual\sudden? Continuous\intermittent? Getting better\worse?
    • Duration: how long does each episode last? How frequent?
    • Relieving\aggravating factors:
    • Characteristics: background noises? Quiet settings? Speech discrimination?
    • Severity: Interfering w\ ADL?
  • Associated sx:
    • Constitutional: fever, fatigue, wt loss, loss of appetite, night sweats, chills?
    • Ear: ear pain, discharge, tinnitus, ringing, popping sensation?
    • Inner ear: vertigo, dizziness, balance problems, N\V?
    • Eye: eye pain, blurred\double vision, lacrimation?
    • Nose: obstruction\breathing difficulty, stuffed nose, snoring, epistaxis, discharge, loss of smell?
    • Sinusitis: headache, facial pain\numbness, pressure, recent flu\ear infection?
    • Throat: difficulty swallowing, speech problems, loss of taste?
    • If peds: any delay in development (speech, motor), infections during pregnancy, neonatal (sepsis, seizures, jaundice), head trauma?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • Neurological (meningitis, MS)
      • Autoimmune ds
    • Medications: abx, aspirin, diuretics, chemo
    • Surgery (Ear procedures\interventions; wax removal), hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation (pilot, work in “loud noises” -> motorbikes, airports, factories)marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx
    • Diet, exercise
    • “Ear-specific activities”; Diving? Swimming? Excessive use of Q-tips\headphones?


– Ear Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Proper position and exposure of both ears
  • General inspection of the pt and surroundings
  • Mention that you should do a full head and neck exam, but for now, you’ll focus on the ears

1. External Inspection

  • Pinna (auricle): shape, anomalies, deformities
  • Pre-auricular: pits, sinuses, fistula, bony outgrowths
  • Post-auricular: scars, redness
  • Symmetry, swellings
  • Discharge, wax

2. Palpation:

  • Swellings
  • Tenderness
  • Temperature

3. Rinne and Weber test: using 512 Hz tuning fork 

  • Check the pic at the end for interpretation of the results

4. Otoscope: start with the good ear”:

  • Tell the pt that they might feel some discomfort, but they should let you know if the feel any pain!
  • Test the light, use the largest speculum that will comfortably fit, hold it like a pen
  • Pull the pinna upwards and outwards to straighten the auditory canal
  • As you’re going into the canal, comment on:
    • Wax
    • Discharge
    • Swellings
    • Redness
    • Polyps
    • Foreign bodies
  • Tympanic membrane; inspect all four quadrants and comment on:
    • Translucency
    • Color
    • Bulging\retracted
    • Drainage
    • Perforation
    • Scarring
    • Light reflex
    • Cholesteatoma
    • Mobility: by using a pneumatic otoscope (mention only)
    • “Normal translucent pale tympanic membrane, in neutral position; not bulging nor retracted, no signs of (drainage, perforation, scarring, cholesteatoma), with intact light reflex”

5. To complete:

  • Full exam of: head and neck, ENT, eyes (nystagmus), CN (esp facial nerve), and LN


– Differential Diagnosis –

  • Conductive:
    • External ear: impacted cerumen, foreign body, otitis externa, osteoma, exostosis
    • Middle ear: AOM, OME, TM perforation, ossicular fixation\discontinuity, otosclerosis, cholesteatomas
  • SNHL:
    • Congenital: hereditary (non-\syndrome associated), intrauterine infections, teratogens
    • Acquired: presbycusis (aging), noise-induced, sudden SNHL, ototoxicity, Meniere’s, vestibular schwannoma\acoustic neuroma, infections (meningitis, labyrinthitis), temporal bone trauma
      • Sudden SNHL is defined as: happens in < 3 days, in 3 consecutives frequencies, drop in > 30 dp


– Investigations –

  • Audiogram
  • Tympanogram
  • Imaging: head CT, MRI


– Management –

  • Conservative -> medical -> surgical
  • Sudden SNHL: steroids




Download the PDF version: here

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