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98
3 History andExamination ofEar
(i) Swelling/growth/mass
• Site—It may present at any site, but
the causes are different.
– Preauricular—preauricular LN,
parotid tumour, TM joint tumour,
preauricular abscess
– Postauricular—mastoid abscess,
mastoid osteoma, mastoid
haematoma
– Pinna—haematoma, subperichon-
drial cyst and abscess, perichondritis, keloid, tumour
– External auditory canal—exosto-
sis, osteoma, furunculosis, granulation, carcinoma, otitis externa,
furunculosis
– Tympanic membrane—myringitis
bullosa, acute otitis media,
myringitis.
• Duration—Duration is noted to classify swelling into acute or chronic.
– Short duration (less than
12 weeks)—abscess, perichondritis, haematoma, myringitis bullosa,
mastoid abscess.
– Long duration (more than
12 weeks)—osteoma, exostosis,
cauliower ear, perichondritis.
• Progression—It is a process of progression to attain the present status. It
can be
– Fast progressive—when a swelling
that increases in size at a greater
speed is caused by haematoma,
abscess, carcinoma.
– Slow progressive—dermoid cyst,
sebaceous cyst, osteoma, keloid,
benign tumours.
– Non-progressive—exostosis.
• Mode of onset
– Sudden—haematoma, abscess,
mastoiditis, subperiosteal abscess,
insect bite, foreign body reaction
(metal), otomycosis, swimmer’s
ear.
– Gradual—dermoid cyst, sebaceous
cyst, benign tumour (osteoma,
chondroma).
• Associated symptoms of swelling ear
– Pain—abscess, haematoma, mas-
toiditis, furunculosis, diffuse otitis
externa
– Discharge—preauricular sinus
with abscess, postaural abscess
with stula
– Bleeding—haemangioma
– Itching in ear—swimming ear,
otomycosis
– Rash—herpes zoster infection,
drug reaction
– Facial nerve palsy—carcinoma,
mastoiditis with cholesteatoma
– Fever—cholesteatoma with
meningitis
– Hearing loss—furunculosis, oto-
mycosis, myringitis bullosa
(j) Foreign body in ear—A foreign body in
ear can be lodged in preauricular, auricular and postauricular area, but EAC is the
commonest site. There are various types
of foreign body like live insect, inert FB,
active FB, vegetative FB, and inert FB
like rubber, metal, plastic. Some foreign
body, e.g. battery, live insect, needs
urgent removal; otherwise, they can
cause serious damage to ear.
• Presentation of foreign body in ear—
The presentation depends on types of
FB in ear and history of attempts of
removal.
– The common symptoms are pain,
bleeding, swelling, foul smelling
discharge, hearing loss.
– History of FB insertion, vertigo,
facial palsy.
– Feeling like something in ear.
– Additional history of removal
either by self or by other should be
noted.
• Site
– Preauricular—This is uncommon
site of ear, where FB can lodge is
due to trauma like rearm injury,
RTA .
– Auricular—External auditory
canal is commonest site, where
Meniere’s disease,
3.1 Symptoms/History/Chief Complaints ofEar Diseases
99
foreign body can lodge. These can
be classied into dangerous and
non-dangerous.
– Postauricular—This is uncommon
sites, where FB can lodge is due to
trauma like gunshot.
• Duration
– Short duration—Active FB like
insect or vegetative FB like peanut
and gram causes more symptoms
and so presents early.
– Long duration—A inert FB can
remain for longer duration with
causing much discomfort to patient.
• Type
– Vegetative (peas, gram) or non-
vegetative (rubber, plastic, metal)
– Live (insect, aunt, maggots) or
dead (insect)
– Active (peas, gram) or inactive
(rubber, plastic, metal)
– Dangerous (battery, live insect) or
non-dangerous (rubber, plastic)
• Side—noted
• Associated symptoms/h/o injury (gun-
shot, RTA, blast), facial palsy,
attempts of removal, bleeding.
(k) Vesicle/eruption/blebs—Skin lesions
can present on temporal region.
• Site
– Preauricular—contact drug reac-
tion, herpes zoster oticus.
– Postauricular—contact drug
reaction.
– Auricular
Pinna—frostbite, contact drug
reaction (ethyl alcohol), herpes
zoster oticus, Juvenile spring
eruption, burn.
External auditory canal—herpes zoster oticus.
Tympanic membrane—bullous
myringitis, granular myringitis
• Mode of onset
– Sudden—frost bite, burn, bullous
myringitis
– Gradual—herpes zoster oticus
• Duration—The vesicular eruptions
are usually for short duration.
• Progression—Increasing in size or
numbers or not
• Associated symptoms like pain, hearing loss, vertigo, facial nerve
paralysis.
(l) Itching—EAC is the most common site
for itching.
• Site—external auditory canal (otitis
externa, otomycosis, dermatitis),
pinna—dermatitis.
• Duration
– Chronic—chronic otitis externa,
seborrhoeic dermatitis
– Acute—otomycosis, acute OE
• Associated symptoms—black colour
ear discharge (otomycosis), pain (otomycosis, acute otitis externa).
(m) Sensation of blockage/heaviness—It is
a feeling of pressure, blocking sensation,
may or may not be associated with pain,
discharge.
• Duration
– Acute—wax, otomycosis, hay
fever, allergy, acute otitis media,
acute otitis externa.
– Chronic—retracted drum,
Eustachian tube dysfunction
(ETD), serous otitis media,
Retracted TM, Meniere’s disease,
tympanosclerosis.
• Mode of onset
– Sudden—acute otitis media, wax,
keratosis obturans, barotrauma,
trauma, myringitis bullosa.
– Gradual—retracted TM, ETD,
tympanosclerosis
• Associated symptoms of hearing loss
(SOM, retracted TM), pain (otomycosis, trauma). Any h/o injury air travel,
noise exposure, URI, vertigo
(Meniere’s disease), ear discharge
(CSOM, ASOM).
100
3 History andExamination ofEar
(n) Discoloration
• Type of discoloration
– Bluish colour—Battle’s sign, hae-
mangioma, ochronosis.
– Reddish colour—inammation,
otitis externa, insect bites, contact
dermatitis.
• Site
– Postaural—Battle’s sign (bluish
colour) is sign of fracture temporal
bone fracture.
– Pinna—perichondritis, haemangi-
oma.
– External auditory canal—eczema-
tous otitis externa.
• Associated symptoms and history—
trauma, RTA, alkaptonuria.
(o) Deformity of ear—Ear is one of the
commonest sites for congenital or
acquired deformity. Almost 50% of the
malformations affect the ear.
Malformations of the outer and middle
ear are predominant as compared to inner
ear. Deformities of ear can be unilateral
or bilateral. Ear malformations may be
genetic (associated with syndromes or
not, with family history, spontaneous
mutations) or acquired in nature and not
infrequently in combination (Table3.46).
• Presentation of deformities
– Pinna—These deformities may be
presented as deformed pinna in
size, shape and site or it is absent.
The hearing loss may or may not
be present.
– External auditory canal—The EAC
may be narrow or absent and may
be associated with hearing loss or
deaf ear.
– Middle ear—The deformities of
middle ear are presented as hearing
loss.
– Inner ear—The inner ear deformi-
ties are presented as hearing loss,
vertigo, absent speech.
• Site of deformities
Table 3.46 Inner ear deformities and their presentation
Name of deformity Denition Clinical presentation
Michel’s deformity (complete
labyrinthine aplasia)
Cochlear dysplasia/aplasia Absence or dysplasia of cochlea Sensory hearing loss
Common cavity deformity No differentiation between cochlea
Incomplete partition type 1 (cystic
cochleovestibular anomaly)
Cochlear hypoplasia Small rudimentary cochlea Sensory hearing loss
Mondini deformity (incomplete
partition type 2)
Enlarged vestibular aqueduct Dilated vestibule enlarged
Cochlear nerve deciency Hypoplasia of eighth nerve CI—contraindicated
Complete absence of inner ear SNHL
CI—contraindicated
Brainstem implant is treatment
choice
CI is treatment of choice array
inserted through oval window
Sensory hearing loss
and vestibule
Figure of 8 appearance
Lack of entire module cochlea
appears cystic
Small cochlea (1.5 turn)
Middle and apical turns form cystic
apex
endolymphatic sac and cochlear
dysmorphism
CI with precurved array
Sensory hearing loss
CI with straight array
CI can be done but full electrode not
inserted
Sensory hearing loss
CI is treatment of choice
Fluctuating sensory HL, present in
Pendred syndrome
Brainstem implant is choice of
treatment
3.1 Symptoms/History/Chief Complaints ofEar Diseases
101
– External ear—The deformities of
external ear can involve pinna or
EAC or both.
Pinna—The deformities of
pinna may present either alone
or in combination with other
deformities. Pinna may have
deformity in shape, size and
position, and sometimes, it is
absent.
Size—small size (microtia),
absent pinna (anotia).
Shape—cup ear, bat ear, constricted ear, loop ear, Stall’s ear
Site of pinna—low-set ear
Sinus—preauricular sinus
EAC—aural atresia, aural stenosis and absent EAC.
Both pinna and EAC—The
deformities of pinna and EAC
may coexist.
– Middle ear—Middle ear malfor-
mations can affect the conguration and size of the middle ear
spaces and the number, size and
conguration of the ossicles. There
may be anomalies of the oval window and, rarely, of the round
window.
– Inner ear—Inner ear malforma-
tions can arise from arrested or
aberrant embryological development. Aplasia, hypoplasia and malformations of the labyrinth and
sensory patches are in its entirety.
Additionally, the vestibular aqueducts may be narrow or enlarged.
The cochlear aqueducts, in contrast, very rarely show malformations. The vestibuloacoustic
ganglion cells are often reduced in
number in inner ear malformations. The internal auditory canal
can also be affected by malformations, and arteries and nerves
(especially the facial nerve) can be
displaced. These are total complete
labyrinthine aplasia, cochlear aplasia, common cavity malformation,
cochlear nerve deciency, incomplete partition type 1 and 2 and
enlarged vestibular aqueduct.
• Time of onset
– Congenital deformities (if present
at birth)—anotia, microtia, cup ear,
constricted ear labyrinthine aplavsia, cochlear aplasia, common cavity malformation, cochlear nerve
deciency, incomplete partition
type 1 and 2 and enlarged vestibular aqueduct.
– Acquired deformities (develop
after birth)—split ear, partial loss
of pinna, stenosis of EAC.
• Type
– Partial—microtia, stenosis of EAC,
Mondini’s dysplasia, etc.
– Complete—Michel’s deformity,
anotia, EAC atresia, etc.
• Side
– Unilateral—traumatic, congenital
microtia
– Bilateral—congenital anotia,
microtia, split ear
• Associated symptoms—associated
other deformity, hearing loss, deafmute, vertigo, h/o injury, disease, drug
or alcohol use in pregnancy, diet low
in carbohydrate and folic acid, use of
isotretinoin in pregnancy (microtia).
• Age of onset
– Congenital—if deformity present
since birth.
– Acquired—if deformities develop
later.
• Associated symptoms—trauma (RTA,
assault), Iatrogenic (surgery), chemical agent (thalidomide, quinine, aminoglycosides) exposure, malnutrition,
irradiation, hypoxia, bleeding during
rst trimester, RH incompatibility,
diabetes mellitus, TORCH infection
during pregnancy, family h/o
malformation.
102
3 History andExamination ofEar
3.2 Examination ofEar
Examination of ear—The examination of ear should be started with inspection on preauricular, postauricular and pinna. The pinna has to be pulled laterally, posteriorly and superiorly to visualize the external auditory canal and TM.
Examination of preauricular area
Examination of postauricular area
Examination of auricular area
Examination of external ear
Examination of tympanic membrane
and middle ear
Examination of inner ear
Special test
Audiological clinical tests
Vestibular function test
Facial nerve examination
(a) Examination of preauricular area
• Inspection
– Sinus/opening—If present, the exact
location should be noted. D/D preauricular sinus, parotid stula, etc.
– Tag—present/absent—ear tag (it is
located anterior to tragus and may be
single or multiple).
– Swelling—lymphadenitis, parotid
swelling, preauricular abscess.
– Scar—If present, the site, size and
shape are noted; this scar may be due
to surgery for preauricular sinus, TM
joint surgery, preauricular approach
ear surgery.
• Palpation
– Tenderness
Tragal tenderness—It is elicited by
pressing tragus medially towards
EAC.The differential diagnosis of tragal tenderness is acute otitis externa,
furunculosis and otomycosis.
Tenderness over TM joint—It is
elicited by pressing over TM joint
while at rest and during movement
of jaw. The D/D are subcondylar
fracture, TM joint dysfunction, TM
joint arthritis.
Tenderness over swelling—parotid
abscess, preauricular abscess, acute
lymphadenitis.
– Swelling
Consistency: soft—preauricular
abscess; rm—preauricular lymphadenitis, parotid swelling; and
hard—TM joint swelling.
Palpation while clinching the
teeth—swelling is less prominent
(swelling located medially to masseter), swelling is more prominent
(swelling located in masseter muscle), no effect (swelling lateral to
masseter).
– Deformities—aural tag, absence of
tragus.
– Movement of TM joint
No movement (TM joint
ankylosis).
Restricted movement (TM joint
dysfunction).
Painful movement of TM joint—
acute infection.
(b) Examination of mastoid (postaural/post-
auricular area)
• Inspection—The mastoid or postauricular
or postaural area is inspected for:
– Scar—The site, size and shape of scar
should be noted. It may be due to previous surgery or trauma (Fig.3.1a).
a b
Fig. 3.1 (a) Postauricular scar and (b) postaural stula
3.2 Examination ofEar
103
– Sinus/stula—postaural stula due to
cholesteatoma with erosion of outer
table of mastoid (Fig.3.1b).
– Redness/cellulitis—The cellulitis or
redness is caused by postaural cellulitis, periostitis, insect bite, contact
dermatitis, postaural abscess and
trauma (Fig.3.2).
– Swelling/mass/growth—The inspec-
tion of postaural swelling should be
done to note site, side, size, overlying
surface. The differential diagnosis is
subperiosteal abscess, mastoid osteoma, haematoma, lipoma, dermoid
cyst (Fig.3.3).
– Bluish discoloration (Battle’s sign)—
A bluish discoloration of mastoid is
indicative of fracture of middle cranial
fossa, basilar skull fracture (Fig.3.4).
– Oedema (Griesinger’s sign)—Oedema
and tenderness over posterior part of
mastoid bone are due to thrombosis of
mastoid emissary vein. It is a sign of
lateral sinus thrombophlebitis.
• Palpation—The palpation of postaural/
mastoid area is done to conrm mastoid
tenderness and palpation swelling.
– Mastoid tenderness—It is a cardinal
sign of inammation and elicited by
applying gentle pressure over various
sites of postaural area. The causes of
mastoid tenderness are acute mastoiditis, postaural abscess, fracture temporal bone, lateral sinus thrombophlebitis
and postaural lymphadenitis.
Cymba concha—This is area on
pinna corresponding to the
MacEwen’s triangle of mastoid
Fig. 3.2 Cellulitis in postauricular area Fig. 3.4 Battle’s sign
Fig. 3.3 Various
swelling in postaural
area
104
3 History andExamination ofEar
bone and thus antrum. Tenderness
is elicited by pressing over the
cymba concha area on pinna
towards medially.
Mastoid tip—It is elicited by pressing over the mastoid tip. Mastoid tip
tenderness is suggestive of infection/inammation/pus collection in
mastoid tip air cells.
Mastoid cortex—It is elicited by
pressing over the centre mastoid
bone. This is suggestive of acute
mastoiditis, subperiosteal abscess,
fracture mastoid.
– Palpation of swelling over mastoid
area—Palpation is done to conrm the
ndings of inspection and other additional ndings.
Size—Small—postaural lymph
node; medium—postaural lipoma,
dermoid, mastoid abscess.
Consistency—Hard (osteoma), rm
(postaural lymphadenitis) and soft
(postaural abscess, dermoid cyst).
Tender (postaural abscess, lymphadenitis) or non-tender (osteoma,
dermoid cyst, lipoma).
Surface—Smooth (postaural
abscess, dermoid), irregular
(osteoma).
Overlying skin—Mobile (lymphadenitis, osteoma, dermoid), xed
(postaural abscess).
Mobility (side by side, or superior
to inferior direction)—Mobile
(lymphadenitis, dermoid cyst),
xed (osteoma, pectoral abscess).
Cough impulse—Ask the patient to
cough while palpating, if cough
pulsation is transferred to swelling;
it suggests intracranial connection
of swelling.
(c) Examination of auricular area
• Examination external ear—It consists of
examination of pinna and examination of
EAC.
• Examination of pinna—The auricle/
auricula/pinna is the visible part of the
external ear that lies outside the head.
– Inspection of pinna
Site
Normal—It is located to the side of
head.
Abnormal—If one or both pinnas
are present lower site—low-set ear
Size
Normal—The pinna is approximately 2cm high and 1.5cm wide.
Its caudal surface is covered with
dense tufts of white-tipped hair.
Abnormal
Microtia—It is dened as small size
of pinna.
Macrotia—This is dened as bigger
size of pinna.
Anotia—Absence of pinna.
Shape
Normal—Pinna is special
helical-shaped.
Abnormal
Cauliower ear—It is collection of
blood between cartilage and skin of
ear, also known as haematoma
auris.
Bat ear—It is abnormally protruding ear with poorly developed antihelix and scapha.
Constricted (lop/cup) ear—The
outer rim of ear is rolled or folded.
Cryptotia—The upper rim of the
ear is tucked underneath scalp skin.
Stahl’s ear—It is characterized by
an extra horizontal fold of cartilage.
The helix may be uncurl giving
pinna a pointed shape.
Position of pinna
Normal—Inclination (or tilt) of the
auricle, measured by the angle of its
long axis with respect to true vertical (a line drawn perpendicular to
the Frankfort horizontal plane), is
typically 15°–20° posteriorly. The
3.2 Examination ofEar
105
most superior point on the auricle
should align with the supratarsal
crease (Fig.3.5a).
Abnormal (Fig. 3.5b, c)
Pinna is positioned lower on the
head than usual—low-set ear.
Pinna is pushed laterally and anteriorly—mastoid abscess.
Overlying skin
Normal (Fig. 3.6a)—Skin is tightly
adhered to underlying cartilage on
lateral surface of pinna while
loosely adhered to cartilage on
medial surface.
Abnormal
Oedematous (Fig.3.6b)—perichon-
dritis, inamed (red) (Fig. 3.6c)—
perichondritis, abscess,
inammation.
Swelling over pinna
Size—measurements are done in
two directions.
Site—localized (haematoma, pseudocyst) or generalized
(perichondritis).
Side—side is noted.
Margins—well dened or ill
dened.
Consistency
Solid—keloid (Fig.3.7b), chondrodermatitis nodularis helicis
(Winker’s disease), broma,
chondroma.
Cystic—auricular haematoma
(Fig.3.7c), auricular abscess, sebaceous cyst, dermoid cyst, pseudocyst (Fig.3.7a).
Overlying skin of swelling—The
overlying skin can be either
inamed or normal.
Vesicles—Vesicle is dened as a
uid-lled sac in the outer layer of
skin. It can be caused by rubbing,
heat or diseases of the skin also
Fig. 3.5 (a) Normal
position of pinna; (b)
pushed anteriorly and
laterally; and (c) low-set
ears
Fig. 3.6 Skin overlying
pinna. (a) Normal skin;
(b) oedematous skin;
and (c) inamed skin
a b c
a b
c
106
3 History andExamination ofEar
a b
Fig. 3.7 Swelling over pinna. (a) Pseudocyst; (b) keloid; and (c) abscess
Fig. 3.8 Bat ear
called blister. Vesicle on pinna can
be caused by herpes zoster oticus,
burn, frost bite.
Sinus—preauricular sinus—It presents at the root of ascending crus of
helix.
Ulceration—Basal cell carcinoma.
Deformities—It may be congenital
or acquired.
Type 1—The body and superior crus of the
antihelix are compressed together so
that the upper portion is buried beneath
the skin.
Type 2—There is a gross contraction of the
body of the antihelix, and the inferior
crus of the antihelix is acutely bent over.
Congenital deformities of pinna
Bat ear or protruding ears or
prominent ears—Ears that, regard-
less of size, stick out more than
2cm from the side of the head. It is
also termed as bat ear (Fig.3.8).
Microtia (underdeveloped
pinna)—Microtia is a deformity of
the pinna.
This deformity can range from mild
structural problems to a completely
c
missing external ear (Table 3.47)
(Fig.3.9).
Constricted ears (lop ear or cup
ear): A variety of ear deformities
where the helical rim is folded over,
wrinkled or tight (Fig.3.10).
Cryptotia (buried ear or hidden
ear)—Ear cartilage framework that
is partially buried beneath the skin
on the side of the head. There are
two types of cryptotia as described
below (Fig.3.11).
Stahl’s ear: It has a pointy shape
and an extra cartilage fold (crus) in
the scapha portion of the ear
(Fig.3.12).
Ear tags: This is also known as an
accessory tragus or a branchial cleft
remnant; ear tags consist of skin and
cartilage. It is present in preauricular
area anterior to tragus (Fig.3.13).
3.2 Examination ofEar
107
Fig. 3.9 Showing
microtia. (a) Grade 1;
(b) Grade 2; and (c)
Grade 3
Table 3.47 Grades of microtia
Grade 1: The ear is slightly smaller than normal, though most normal features are present
Grade 2: A partial ear with a closed-off (‘stenotic’) external ear canal producing hearing loss
Grade 3: This is the most common form of microtia
Grade 4: Absent pinna—This is also called as anotia
Fig. 3.10 (a, b)
Constricted ear
a
b
a b
c
c
Fig. 3.11 Cryptotia
Fig. 3.12 Stahl’s ear