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128
3 History andExamination ofEar
Fig. 3.50 (a, b)
Perforation with
cholesteatoma in pars
accida
a b
AP
A
P
tympanic membrane above the malleolar fold. This may present in
anterior, posterior and central part
of TM.This type of perforation is
always associated with cholesteatoma (Fig.3.50a, b).
Others
Healed perforation/monomere—
A monomere is an area of thin,
transparent tympanic membrane
due to the absence of the dense
brous layer. It usually occurs after
a perforation. Monomeres are usually not a problem unless the patient
experiences severe and sudden
pressure changes. They can perforate more easily than normal TM
(Fig.3.51).
Fig. 3.51 Healed perforation in TM which is thinner and
transparent
3.2 Examination ofEar
(f) Examination of middle ear—The middle
ear can be examined through the perforation
in tympanic membrane.
• Middle ear mucosa—The middle ear cavity is lined with a thin mucosal mem-
brane that covers all structures, such as
the ossicles, and is continuous with the
mucosal membrane in the mastoid antrum,
Eustachian tube and nasopharynx.
– Status of middle ear mucosa
Normal—It is indicative of no
active infection of middle ear
(Fig.3.52a)
Abnormal
129
Red (congested)—A congested mucosa is a
sign of active infection (Fig.3.52b).
White—This may be due to tympanoscle-
rosis extending to middle ear.
Oedematous mucosa—It is a sign of active
infection or tuberculosis (Fig.3.52c).
– Status of middle ear ossicles—ossicu-
lar status/continuity, specially incudostapedial joint, long process of malleus;
stapes suprastructure can be examined
through large perforation.
Fig. 3.52 Status of
middle ear mucosa. (a)
Normal middle ear
mucosa; (b) congested
mucosa; and (c)
oedematous mucosa
a
b
c
130
bc
3 History andExamination ofEar
Normal middle ear ossicle
(Fig.3.53)—There are three ossicle forms and two joints, which
connect the TM to inner ear for
transmission of sound. These ossicles are malleus, incus and stapes,
and joints are incudomalleolar
and incudostapedial joints
(Fig.3.54).
Erosion of ossicles—Modication
of Austin’s classication of
ossicular chain defect. Incus is the
most common ossicle to be eroded.
Shortening of handle of malleus—
This may be due to medialization of
handle of malleus, but this not true;
true shortening is due to erosion of
handle of malleus.
(a) Malleus head, incus is absent.
(b) Malleus and incus are absent.
(c) Head of malleus, incus and stapes suprastructure are absent.
(d) Malleus, incus and stapes suprastructure are absent.
(e) Malleus handle absent.
(f) Stapes suprastructure is absent.
a
def
b
ab
3.2 Examination ofEar
131
c
a
d
g
k
h
i
Fig. 3.53 Middle ear structures. (A) Handle of malleus;
(B) long process of incus; (C) head of stapes; (D) stapedial tendon; (E) ponticulus; (F) funuculus; (G) oval window area; (H) round window niche; (I) hypotympanic air
cells; (J) promontory; and (K) Eustachian tube opening
j
c
f
e
d
effect and presents with disproportionate hearing loss.
Round window bafe effect—
Pressure sensitive transducer tympanic membrane performs
conduction of sound waves across
the middle ear, and acts as a shield
to the round window preventing the
direct exposure of sound waves
called as ‘round window bafe’. In
large perforation or posterior perforation, in which round window is
exposed, the sound wave strikes
both oval and round window at
same time thus cancelling each
other effect with no movement of
perilymph, and thus, hearing loss is
dipropionate to perforation.
Round window shielding effect—
Patient hears better in the presence
of discharge rather than dry ear.
This effect is produced by discharge
by maintaining phase differential,
while in dry ear, sound wave strikes
both oval and round window at
same time, thus cancelling each
other effect with no movement of
perilymph and thus less hearing
(Fig.3.55).
– Presence of granulation—Formation
of granulation tissue in the middle ear
Fig. 3.54 Intact ossicular chain. (A) Handle of malleus;
(B) long process of incus; (C) head of stapes; (D) stapedial tendon; (E) posterior crura of stapes; and (F) anterior
crura of stapes
– Exposure of round window—This is a
common nding in large-sized perforation specially when perforation
involves the posterior part of tympanic
membrane. An exposed round window
causes loss of round window bafe’s
Fig. 3.55 Exposed round window niche can be seen
through perforation
132
3 History andExamination ofEar
space begins with a break in the basement membrane of surface epithelial
cells (Fig.3.56). Inammatory cells in
the underlying lamina propria traverse
through the broken basement membrane and enter the lumen of the middle ear space. On inspection, the
granulation tissue may be light red in
colour, moist and bumpy on appearance, and on palpation, it is soft, pulseless and painless but bleeds on touch.
The granulation is caused by CSOM
with cholesteatoma, tubercular COM,
tympanostomy tube in situ, COM.
– Presence of glue—On examination,
TM appears yellowish in colour or
bubbles in middle ear (Fig.3.57). This
is caused by serous otitis media or secretary otitis media.
Fig. 3.56 Granulation in middle ear
– Presence of cholesteatoma—Choles-
teatoma is clinically dened as an
abnormal extension of skin into the
middle ear and mastoid air cell spaces.
The point of entrance of skin into the
middle ear is reliably identiable on
otoscopic examination as a perforation
or retraction pocket of the tympanic
membrane. Cholesteatoma is considered a benign, expanding and destructive epithelial lesion of the temporal
bone that is the result of a multifactorial
process presents as primarily white,
compressible, ovoid lesions which,
when intact, are surrounded by a thin
wall. Cholesteatomas are subdivided
into three categories: the congenital
form which is specic to children, the
acquired type which affects both adults
and children, and the unclassiable type
which is a cholesteatoma whose origin
cannot be accurately determined.
Types of cholesteatoma
Congenital cholesteatoma—It is
typically an expanding cystic mass
of keratinizing squamous epithelium located medial to the intact
tympanic membrane. It is assumed
to be present at birth but is usually
diagnosed during infancy or in early
childhood in patients with no prior
history of otorrhoea, perforation of
the tympanic membrane or previous
ear surgery.
Fig. 3.57 Glue in
middle ear
3.2 Examination ofEar
Fig. 3.58 Various types
of clinical pictures of
cholesteatoma
133
Acquired cholesteatoma—The
acquired type cholesteatoma is presumed to arise due to Eustachian
(g) Other clinical tests
tube dysfunction following prior
bouts of middle ear disease.
Acquired cholesteatoma is further
subclassied as a retraction pocket
variant (primary cholesteatoma) of
cholesteatoma and a non-retraction
pocket variant (secondary
cholesteatoma).
Theories of acquired cholesteatoma formation—The pathogene-
sis is proposed by four main
theories: invagination, basal cell
hyperplasia, epithelial invasion and
squamous metaplasia.
Appearance on clinical examination—Cholesteatoma is the name
given to a collection of skin cells
deep in the ear that form a pearly
white greasy-looking lump/debris
in the middle ear and mastoid. It
presents on pars accida area and/
or posterosuperior quadrant of tympanic membrane (Fig.3.58).
• Clinical tests for mobility of tympanic
membrane
– Siegel’s test/Siegelization—It is per-
formed to check the mobility of the
tympanic membrane with help of
Siegel’s speculum. The mobility is
tested by varying the pressure levels in
external auditory canal and observing
the movements of the eardrum in
response to these pressure changes.
Normal TM moves in response to pressure changes; i.e. it moves inwards
when positive pressure is applied and
moves outwards when negative pressure is applied.
– Procedure of Siegel’s test—The specu-
lum should be snuggly tting for this
test to be performed. The speculum
should be introduced in such a manner
that the eye piece is oriented towards
the anteroinferior slant of the eardrum.
134
3 History andExamination ofEar
Pressure at the external canal is applied
by pressing the bulb. The eardrum
could be seen moving inwards. On
releasing the pressure in the bulb, negative pressure is created pulling the
eardrum towards the speculum.
Normally, this to and fro movement of
the eardrum can be observed during
this procedure.
Parts of Siegel’s Speculum (Fig.3.59)
Bulb—Made from rubber with a one-way
valve which will enable it to pump out
air. It is connected by a rubber tube to a
speculum adapter.
Speculum adapter is provided with a
slanting lens which is convex in nature.
This lens provides 2 1/2-time magnication of the image.
Aural specula—Their sizes are 4, 5 and
6 mm. These aural specula t snugly
into the speculum adapter.
– Pneumatic otoscopy—It is an oto-
scopic examination that determines the
mobility of tympanic membrane (TM)
in response to pressure changes. The
normal tympanic membrane moves in
response to pressure (Fig. 3.60).
Immobility may be due to uid in the
middle ear, a perforation or tympanosclerosis, among other reasons. The
causes of immobile (adhered or xed)
TM are adhesive otitis media, Grade 4
retraction of pars tensa and of less
mobile TM are Grade 3 retraction,
SOM, tympanosclerosis, thickened
TM, oedematous TM. The hypermobile tympanic membrane is found in
healed TM, thin TM.
• Clinical tests for lateral sinus
thrombophlebitis
– Queckenstedt or Tobey-Ayer test—
Compression of IJV on normal side
leads to rapid rise on CSF pressure
(50–100 mm water) and rapid fall on
release of compression, while compression of IJV on thrombosed side
has no effect on CSF pressure.
– Lillie-Crowe-Beck test—Pressure on
IJV on normal side causes engorgement of retinal veins plus papilloedema seen on fundoscopy in case of
lateral sinus thrombophlebitis of the
opposite side but no changes on compression on thrombosed side.
– Tenderness along internal jugular vein
due to involvement of jugular bulb and
IJV.
– Griesinger’s sign is positive.
• Clinical tests for facial nerve functions
– Tests for motor functions of facial
nerve—This has been discussed in
Chap. 2.
– Tests for taste—This has been dis-
cussed in Chap. 2.
– Tests for lacrimation
Fig. 3.59 Parts of
Siegel’s speculum
3.2 Examination ofEar
135
Fig. 3.60 (a) Otoscope
with pneumatic bulb and
(b) pneumatic otoscopy
Fig. 3.61 Schirmer’s
test
a
b
Schirmer’s test—This test is performed by placing a small strip of
lter paper inside the lower eyelid
(inferior fornix) than the eyes are
closed for 5 min. The patient is
asked to open both eyes and look
upwards so the test strips may be
removed and amount of moisture is
measured (Fig.3.61). The Schirmer
test score is determined by the
length of the moistened area of the
strips (using the scale packaged
with the strips).
How to Read Results of Schirmer’s Test
Normal which is ≥10 mm wetting of the
paper after 5min.
Abnormal—tear deciency which is
<5mm wetting of the paper after 5min.
Modied Schirmer’s test or cotton thread test—Fine cotton thread
is used instead of the lter paper of
the Schirmer’s test. One end stained
with uorescein is inserted into the
lateral upper conjunctival sac for
5–30 s. The length of the soaked
portion is measured in millimetres,
and the two eyes are compared with
each other. One test consists of several consecutive measurements.
Advantages of Modied Schirmer’s Test or
Cotton Thread Test
1. It takes less time (5–30 s, compared to
Schirmer’s method which takes 5min).
2. It is less injurious to the eye than the
stiff and rather large absorbing paper.
(continued)
136
3 History andExamination ofEar
3. A diagnosis of lacrimal deciency must
be based on several consecutive measurements and the comparison between
two eyes in each measurement (the lacrimation normally is very irregular in
the same person). It is difcult to measure consecutively with lter paper.
4. The ne thread itself acts as a potent
mechanical trigeminal stimulator and as
absorbing agent.
5. The thread maintains a stable position in
the eye, while the lter paper which
hangs on the lower lid sometimes shifts
out of place.
6. The uorescein dye disappearance and
dilution tests can be performed
simultaneously.
7. This method can be applied to children.
Measurement of an iron-binding
molecule called lactoferrin. The
amount of this molecule appears to
be closely related to tear production. Patients with low tear production and dry eyes have low levels of
this molecule.
Measurement of lysozyme—This
enzyme is found in tear.
Measurement of time of tear
drained to nose—In this test, eye
drops, which contain a uorescein
dye, are placed in the eye. The dye
should drain with the tears through
the lacrimal duct into the nose
within 2min. If patients do not have
enough tears to ush the dye into
the nose, this time will be longer.
Causes of Dry Eye
• Ageing
• Arthritis
• Corneal ulcers and infections
• Diabetes
• Eye infections (e.g. conjunctivitis)
• Secondary tearing deciency associated
with disorders such as lymphoma, leu-
kaemia, GVHD (graft vs. host disease,
after a transplant)
• Sjögren’s syndrome
• Triple A syndrome
• Vitamin A deciency
• Dry eye syndrome
• Clinical tests for assessment of hearing
– Whisper test/Speech test—Exclude
one ear from testing, and then examiner should whisper softly from distance 2ft. from the patient. The person
with normal hearing acuity can correctly repeat what was whispered. If a
patient is unable to repeat one triplet
set of numbers or 50% of four sets of
triplet number, it suggests a hearing
loss of more than 30dB.
– Finger friction test—The nger fric-
tion test or rubbed nger test is rough
but quick method to test highfrequency hearing. In this test, examiner rubs his ngers together 6in. away
from EAC, and asks the patient either
he hears or not. No response to two or
more of six rubs suggests more than
25 dB loss. This method fails when
patients pretend to hear.
– Watch test—A clicking watch is
brought near to ear till patient starts
hearing or at 6in. if there is no response
to two or more of six presentations of
watch ticks; it suggests more than
25dB loss.
• Tuning fork tests for assessment of
hearing—There are various types of tuning fork test performed routinely to assess
the type and degree of hearing loss clinically. The tuning fork test is used to differentiate between conductive and
sensorineural hearing loss. The test is per-
3.2 Examination ofEar
137
formed with different types of frequency
like 128, 256, 512, 1024 and 2048 Hz.
Routine practices are done at 256, 512
and 1024Hz (Fig.3.62).
– Rinne’s test—This test is proposed by
Heinrich Adolf Rinne in which air
conduction is compared with bone
conduction to assess the type of hearing loss (Fig.3.63).
128
Fig. 3.62 Various tuning forks
256
512
1024
2048
– Procedure—This test can be per-
formed in two ways as described
below.
– To check the intensity of sound—A
vibrating tuning fork rst should be
kept 5cm away from EAC, then over
the mastoid bone. The examiner asks
patient which sound is louder.
– To check the duration of sound—A
vibrating tuning fork rst should be
placed over mastoid bone, and when
he stops hearing the sound, then the
tuning fork should be placed 5 cm
away from EAC. The examiner asks
patient whether he hears or not.
– Interpretation result—There are
two types of interpretation
– Rinne’s positive—Air conduction is
more than bone conduction (AC>BC).
This type of ndings presents in normal individual and in SNHL
individual.
Fig. 3.63 Rinne’s test.
(a) Air conduction and
(b) bone conduction
a
b