PHYSICAL EXAMINATION

1. PHYSICAL EXAMINATION

2. Examination of the ear and related head and neck structures should be performed in a systematic and consistent manner so that no part of the exam is neglected

3. EXTERNAL AUDITORY CANAL (EAC) • composed of cartilage covered by skin • outer 1/3 cartilaginous (mobile) - inner 2/3 bony • with narrowing at the bone-cartilage junction (narrowest area) • skin lining cartilaginous portion is thicker

4. Bony portion of the EAC is the only structure in the body where there is skin directly overlying bone with no subcutaneous tissue • area is very sensitive and swelling is very painful as there is no room for expansion

6. AURICLE OR PINNA - A complex cartilaginous structure that is covered with skin • Has a variety of folds which are generally consistent but vary slightly from individual to individual • Important to know the embryology of the auricle in understanding the different pathological conditions

7. Development of the auricle embryologically is complicated, sometimes resulting in developmental anomalies including pre auricular skin tags, and small accessory auricles

8. Cosmetically pleasing auricle is generally positioned with the concha at a 90 degree angle lateral to the head • helix and antihelix must be well formed

9. Noticeable differences , even if minor, between an individuals right and left auricles are abnormal and should suggest a pathological process

11. INSTRUMENTS USED IN DOING OTOSCOPY • Penlight • Aural speculum • Otoscope • Appropriate source of illumination – floor lamp, head mirror, head light

12. Ear Examination Instruments • -penlight - may be used to examine external ear and ear canal • - ear speculum - utilized to widen the opening of the ear canal • - floor lamp - necessary for viewing the external and middle ear using a head mirror

13. Head Mirror - used together with a floor lamp and ear speculum to view external and middle ear • Otoscope - used in place of a head mirror - does not require use of a floor lamp because of its built - in light source

14. Select correct size of speculum • examine ear canal for inflammation, redness of skin, secretions, impacted cerumen or ear wax • always disinfect speculum to avoid cross-contamination

15. OTOSCOPY • Adequate examination of the external auditory canal requires proper positioning of the patient • Patient’s head must be tilted towards the opposite shoulder

16. Since tilting the head is a position the patients do not normally assume, you should explain to them why you are doing this

17. Otoscopy • Examining an adult • Examining a child/infant

18. In adults, the tragus should be gently pulled anteriorly and the pinna lifted in the postero superior direction to straighten the ear canal

19. In infants and young children, the pinna should be pulled inferiorly because of the downward curvature of the normal infantile EAC

20. In many individuals, the EAC is sufficiently large that drawing the tragus anteriorly and lifting the auricle upwards and posteriorly opens the meatus sufficiently wide to give us a good view of the EAC and tympanic membrane (TM).

21. If not, a nonreflective aural speculum can be used to control the soft tissues of the lateral EAC and thus facilitate visualization o the medial EAC and TM. • The largest speculum that will fit comfortably gives the best exposure

22. Use your non dominant hand to hold speculum so the dominant hand can be left free for instrumentation

23. INSERTING THE SPECULUM • The hand holding the speculum should gently rest against the patient’s head so that inadvertent movement by the patient will move the head and speculum together and prevent accidental injury to the EAC or TM.

24. Speculum should not be inserted past the cartilaginous portion as this is the only part which is mobile or stretchable • Contact with the inner bony 1/3 of the canal is painful and does nothing to enhance visualization

25. Otoscope Advantages: - handheld, portable - quick and easy to use - with good magnification - easily available and cheaper Limitation: - absence of binocular vision

26. Microscope Advantages: -allows binocular vision, maximum illumination and magnification, -leaves the dominant hand free for effective and relatively easy instrumentation Limitation: -availability and cost

27. CERUMEN • Typical pH of cerumen is 6.1 • Conveyed along the EAC by the normal movements of the lower jaw while eating, yawning, and talking

28. CERUMEN • Consists of a combination of desquamated epithelium, thick sebaceous gland secretions, and thinner apocrine gland secretions • Water resistant, traps debris

29. With both bacteriostatic and bactericidal activity due to the presence of saturated fatty acids, lysozymes and low pH

30. CERUMEN

32. METHODS IN CLEANING THE EAR • Should always be done under direct visualization using a cerumen spoon • Using a handheld otoscope with magnifying lens (operating otoscope)

33. Aural Irrigation with warm water (not to be performed among patients with perforated TM’s, had otologic surgery, otitis externa, and with acute episodes of vertigo)

34. CERUMEN • Ceruminolytics – also called “cerumen softeners” • Hydrogen peroxide • Mineral oil, baby oil • Commercially prepared otic drops (Otosol, Auralgan) • Water

35. CERUMEN After complete cerumen removal, evaluate the size and shape of the EAC If the diameter of the EAC is less than 4 mm., it is considered stenotic

36. TYMPANIC MEMBRANE • Eardrum-divides external from middle ear • conical structure with the point of the cone, umbo, directed medially • outer -epidermal layer; middle- fibrous layer; and an inner mucosal layer • fibrous layer is absent above the lateral process of malleus making it flaccid -Sharpnell’s membrane

37. Take note of the color of the tympanic membrane • Normally it is grayish with variable transparency • Covered by smooth squamous epithelium • “cone of light” is seen at the anterior inferior quadrant

40. The tympanic membrane is mobile and to perform its function, it should be able to vibrate • Restrictions in movement may be due to effusion in the middle ear • Ask patient to do Valsalva Maneuver to test mobility or use a pneumatic otoscope

41. ANCILLARY PROCEDURES

42. IMAGING STUDIES • Radiographic X-rays – done to visualize the middle ear structures, should always compare both sides, gives limited information • Schullers View – demonstrates mastoid air cells • Stenvers View –demonstrates petrous ridge and apex

43. COMPUTERIZED TOMOGRAPHY • For temporal bone imaging • With the ability to define specific bone structures • Axial and coronal cuts

45. MAGNETIC RESONANCE IMAGING • Best for detecting tumors, suspected vascular lesions • Less superior than CT in defining bony structures

46. CLINICAL HEARING TESTS

47. TUNING FORK TESTS • Goal: to differentiate between conductive and sensorineural hearing loss • CONDUCTIVE Hearing Loss (CHL)- caused by diseases of the external auditory canal or middle ear • SENSORINEURAL Hearing Loss(SNHL) – caused by problems in the cochlea and inner ear

48. 512 Hz TF - most commonly used • Can use a TF that vibrates between 250 and 800 Hz • Lower frequencies are avoided due to interference from perception of low frequency vibrations

49. - The TF should have a broad base - The base of the TF should be pressed firmly against the cranial bone inorder to transmit the vibrations to the bone and overcome dampening by the skin

50. WEBER TEST • The TF is placed in the midline of the skull, (vertex or forehead), vibration is transmitted by bone conduction to cochlea • When hearing is normal, vibrations are perceived equally loud on both sides (midway between the ears) • Comparing the right and left ear