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10.2 Purposes ofOtologic Examination
1. Hearing assessment: An otologic examination is used to identify potential problems that may be causing hearing loss or hearing problems. This is a critical step
in determining the cause of hearing loss and planning appropriate treatment.
2. Balance assessment: The inner ear contains important structures that control balance. An otologic examination can be used to identify balance problems, which
can help us understand the cause of symptoms such as vertigo.
10.2.1 Anamnesis
The most common basic complaints of patients with ear disease are hearing loss, ear
pain (otalgia), ear discharge (otorrhea), ear itching, dizziness, vertigo, and ringing
in the ears (tinnitus).
These complaints should be evaluated rst in patients presenting to the clinic.
10.2.2 Hearing Loss
This is one of the most common reasons for visiting an outpatient clinic. It can be
unilateral or bilateral, short-term, or long-term. Hearing loss is discussed in detail in
the relevant sections [1].
10.2.3 Ear Pain (Otalgia)
It is one of the most common reasons for admission to an otology clinic. These
pains can occur with ear pathologies or as a reection of extra-aural pathologies. If
the source of the pain is the ear, it is called otalgia, while if the ear pain is a reection of another pathology in the head and neck, it is called referred otalgia.
The most common causes of ear-related otalgia are infections of the external
auditory canal (EAC) and otitis media. The cause of referred otalgia may be any
traumatic, inammatory, or tumorous condition that may occur in the areas innervated by the trigeminal, facial, glossopharyngeal, vagal, and Cervical 2 or Cervical
3 nerves, or pain in the temporomandibular joint. Therefore, a detailed head and
neck examination should be performed in the differential diagnosis [2–4].
10.2.4 Ear Discharge (Otorrhea)
Ear discharge can come from the EAC or the middle ear. It can be acute or chronic.
A detailed history and otoscopic examination can help determine the pathology of
the ear discharge. If the discharge is bloody and purulent, it may be due to infection,
tumor, or trauma, while a clear discharge may be due to cerebrospinal uid leakage.
10 Otologic History Taking andBasic Examination Techniques
The color and odor of the discharge and the presence or absence of pain or trauma
in the patient are important in determining the etiology [5].
191
10.2.5 Itchy Ear
It is one of the other common reasons for admission. The most common cause is
occasional irritation by cerumen. Pathologies of the skin of the EAC such as dermatitis, etc. and frequent ear cleaning by the patient are other causes [6].
10.2.6 Dizziness andVertigo
There can be many reasons for this. It is one of the most common presenting complaints. The causes can be otological, neurological, psychological, and iatrogenic.
These are discussed in detail in the relevant sections [7].
10.2.7 Ringing inEars (Tinnitus)
There may be more than one cause in terms of etiology. Basically, it is when you
experience ringing, tingling, roaring, etc. sounds that are not caused by an external
stimulus. There are two types of tinnitus: objective and subjective. The most common cause of subjective tinnitus is sensorineural or conductive hearing loss [8].
10.2.8 Physical Examination
The physical examination for otologic disorders begins with an inspection of the
auricles and continues with an examination of the EAC and tympanic membrane.
This is followed by a hearing assessment. A few basic instruments are needed to
perform a physical examination of the ear. These are an ear speculum, a head or clar
mirror, an otoscope, and a tuning fork (preferably 512Hz). The most important
thing to remember is to perform a bilateral examination, even if the patient only
complains about one ear [9].
10.2.8.1 Inspection
First, the auricle is examined. The shape, size, and position of the pinna are assessed.
The presence of discharge in the EAC and, if present, its color and odor are noted.
Congenital, infectious, or tumorous lesions may be noted. Developmental abnormalities in the auricle may be a sign of an abnormality in the EAC or middle ear.
Infectious lesions such as impetigo and erysipelas may be diagnosed in the auricle,
as well as the vesicular rash of Ramsay Hunt syndrome or gout. Malignancy, which
is denitively diagnosed by biopsy, is also suspected on inspection [9, 10].
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S. Celik et al.
10.2.8.2 Palpation
The auricle should be palpated for tenderness or swelling. If there is pain with
movement of the auricle or after pressure on the tragus, an infection in the EAC
should be considered. Assess for swelling, pain, and redness in the postauricular
area. If there is tenderness to pressure in the mastoid area, the presence of infection
in the mastoid area should be investigated [11].
10.2.8.3 Otoscopy
An otoscopic examination is the use of light to examine the EAC and eardrum. An
otoscope is an instrument with a light source and magnifying system used to examine the ear. While only a speculum and forehead mirror can be used to examine the
EAC, advanced technology microscopes and endoscopes can also be used. In cases
where sufcient magnication cannot be achieved with an otoscope, a microscope
may be preferred for examination. However, the most commonly used and preferred
examination tool is the otoscope (Fig.10.1).
Otoscopes are examination instruments that are easy to use and relatively cheap
than other instruments; they allow us to obtain clear images with their lens. They
can be used as portable or wall mounted. Although the head mirror speculum examination is a more primitive and old-fashioned examination method because it can be
performed with two eyes, it is more advantageous in this respect than the examination with an otoscope. Otoscopy is a one-eye examination, and it is more difcult
and risky to intervene in EAC with an otoscope. It is easier to examine pediatric
patients with an otoscope, especially those who are crying and maladjusted. The
otoscope that is added to the normal otoscopy instrument and evaluates middle ear
pathology by blowing air into the EAC is called a pneumatic otoscope [12–15].
Endoscopy, another examination option, provides much more light and magnication than an otoscopic examination. Although the tympanic membrane is most
clearly seen with the endoscope, the image is one-dimensional and the ability to
intervene with the EAC is more limited. One of the main advantages of using an
endoscope is the ability to record and document well. Considering that otoscopic
examination can provide sufcient information to the physician, these systems do
not have serious advantages over the otoscope in the examination of the ear. Today,
endoscopic systems are mostly used for interventional purposes rather than for
examination [16, 17].
Fig. 10.1 Portable
otoscope
10 Otologic History Taking andBasic Examination Techniques
193
Microscopic examination is generally required for complicated cases and procedures to be performed for treatment purposes. Microscopic examination is important in diseases of the EAC due to foreign body, exostosis, tumor, necrotizing
external otitis, osteoma, etc., which prevent examination of the EAC and tympanic
membrane; in cases where the posterior and anterior parts of the tympanic membrane cannot be clearly observed due to cerumen, granulation tissue, etc.; in severe
middle ear and tympanic membrane pathologies such as marginal perforation,
retraction pockets, polyps or granulation tissue, etc.; and in planning surgical treatment. By cleaning cerumen, epithelial debris and discharge from the EAC and tympanic membrane under the microscope, it is possible to fully visualize the tympanic
membrane and assess the severity of the pathology (e.g., depth of the retraction
pouch, whether the squamous epithelial cells have invaded the middle ear).
Therefore, it will be sufcient to use microscopes in these cases and in centers
where these pathologies can be treated [18].
10.2.9 Examination Technique withanOtoscope
The rst step in an otoscopic examination is to position the patient appropriately
and then stabilize the head. The otoscopic examination is usually performed with
the patient in a sitting position. The patient’s head is tilted toward the shoulder
opposite the ear to be examined and rotated to the left for the right ear and to the
right for the left ear until the prole disappears. The patient’s head should rest on the
headrest of the chair [12, 13]. This is to prevent the patient’s head from moving suddenly during the examination, which could lead to accidents. For children, the
child’s head should rest on the parent’s chest, if possible. The clinician should stand
on the right side of the patient during the otoscopic examination (Fig.10.2).
The second step in an otoscopic examination is to select the appropriate ear speculum and insert it into the EAC.Ear speculums are available in different sizes, and
as the diameter of the part of the speculum that enters the EAC decreases, the length
of the speculum increases. The purpose of the ear speculum is to ensure that the
otoscope is inserted into the EAC and directed toward the tympanic membrane. For
this reason, the selected ear speculum does not need to be small enough in diameter
and long enough to penetrate deep into the EAC.On the contrary, the possibility of
damaging the bony part of the EAC is higher with long and small diameter speculums. A narrow speculum also reduces the clinician’s eld of view. Therefore, an
otoscopic examination should begin with the largest speculum that will t into the
patient’s EAC, and when inserting the speculum into the EAC, ensure that the EAC
is positioned so that the tympanic membrane is visible. This procedure should not
be haphazard; the speculum should be carefully inserted by looking through the
otoscope rather than inserting rst and looking later. Because of the convexity of the
EAC, the auricle should be pulled upward to eliminate the convexity at the base of
the EAC and backward to eliminate the anterior convexity. However, because the
development of the EAC and adjacent bony structures is not complete, especially in
children, it is not possible to accurately predict the axis between the cartilaginous
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Fig. 10.2 Examination
with otoscope
S. Celik et al.
and bony portions of the EAC.When inserting the speculum in children, it should
be viewed through the otoscope and after pulling the blade slightly outward (laterally) and backward, it should be moved up or down to nd the position where the
tympanic membrane is fully visible. During these procedures, the dominant hand
(usually the right) should use the otoscope, and the other hand (usually the left)
should pull the pinna. After completing the examination of the right ear, the clinician standing to the right of the patient should turn the patient’s head to the right to
examine the left ear as described above, then move the left hand over the patient’s
head and pull the pinna. The otoscope should again be in the right (dominant). The
most common mistake made by inexperienced physicians is to hold the otoscope in
the left hand when examining the left ear and try to pull the pinna with the right
hand. In this case, it is difcult for the physician to control the otoscope with the left
hand. When performing an otoscopic examination, it is also important that there is
no light source next to or behind the patient that would interfere with the clinician’s
eyes [12–16].
The use of a pneumatic otoscope is similar. The patient is positioned. The instrument contains a light and air source. Air is blown or sucked. The examiner blows or
sucks air into the ear canal using the air source of the pneumatic otoscope.
Meanwhile, the movement of the eardrum is observed. The response and movement
10 Otologic History Taking andBasic Examination Techniques
195
of the tympanic membrane are assessed. Normally, the eardrum exes inward when
air is blown in and outward when air is sucked in [19].
10.2.10 Examination withanOtomicroscope
In this method, after the patient is placed in the supine position on the examination
table, a speculum suitable for the auditory canal is inserted into the EAC.The
patient is asked to turn his/her head slightly to the other side. While holding the
speculum in the EAC with the left hand, maneuvers are performed with the right
hand to adjust the distance of the microscope to the speculum and the tympanic
membrane. This is done in an attempt to obtain a clear image. If cerumen, secretions, epithelial debris, or foreign bodies are present in the external ear canal, they
should be cleaned with a holder or aspirator to better visualize the tympanic membrane. After cleaning, the external ear canal and tympanic membrane are easily
visible. If the tympanic membrane is perforated or extremely thin, many structures
in the middle ear will be visible. After adjusting the magnication and reduction
according to the characteristics of the microscope, an otoscopic examination is performed. This adjustment varies according to the procedure to be performed. The
magnication rates vary depending on the technical characteristics of the microscope. When performing otomicroscopy, only part of the membrane and the EAC
can be seen from the same position; therefore, the position of the speculum in the
EAC and the angle of the microscope should be changed depending on the area to
be examined. One of the disadvantages of otomicroscopy is that the membrane and
the EAC cannot be seen as a whole at the same time. Therefore, in order not to miss
the pathologies of the pars accida, this area must be observed at the appropriate
angle and position. Surgical procedures can also be performed with an otomicroscope, and it plays an important role in the postoperative follow-up of patients [18]
(Fig.10.3).
Fig. 10.3 Otomicrosopic
examination
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S. Celik et al.
10.2.11 Examination withaVideo Endoscope
When otoscopic ndings are documented with a video camera, it is called video
otoscopy. Video recordings of the tympanic membrane can be made with a surgical
microscope or an endoscope. Images taken with an otomicroscope will include certain areas due to the restrictive size of the speculum. Because the speculum passes
through the narrowest part of the EAC and the distance between the microscope lens
and the speculum is long, it is often impossible to see the eardrum as a whole. This
is more of a problem in children because their ear canal is narrower, and it is more
difcult to cooperate. In addition, it is more difcult to determine the depth of the
areas with otomicroscopy. The main advantage of otoscopy performed with a video
endoscope is that the entire tympanic membrane can be seen, including the entire
annular ligament. Otoscopic examination with video endoscope is the most practical and effective method of documenting and learning the anatomy and pathology
of the EAC and tympanic membrane. Video-assisted otoscopy is a useful method in
otoscopic diagnosis [20, 21] (Fig.10.4).
There is a standard approach to examining the ear canal and tympanic membrane. First, the walls of the ear canal should be examined for debris or foreign
bodies, skin disease, tumors, and defects, especially the posterior wall of the attic
region. Then follow along the base of the meatus to the tympanic membrane.
Fig. 10.4 Endoscopic ear
examination
10 Otologic History Taking andBasic Examination Techniques
197
Posteriorly, the angle between the ear canal and the tympanic membrane is narrow,
and it is sometimes difcult to decide where the ear canal ends and the tympanic
membrane begins. The anatomy of the pars accida above is quite difcult; it usually has an irregular, jagged appearance, and it is often impossible to see the anterior
recess which is the junction of the ear canal and the anterior tympanic membrane.
After attempting to see these structures, the clinician should examine all parts of the
membrane and attempt to see the boundaries [12]. The annulus of the tympanic
membrane should be well evaluated. The normal characteristics of the tympanic
membrane and standard landmarks should be determined. First, focus on the central
region of the membrane and concentrate on identifying the head of the malleus. This
should be visible in any normal ear. Then try to identify the border between the pars
accida and pars tensa, where the anterior and posterior malleolar ligaments can be
seen. The long arm of the incus and the stapes tendon can also be seen in transparent
tympanic membranes [13]. Sometimes the shadow of the chorda tympani can be
seen. Attention should be paid to the integrity of the tympanic membrane and the
presence of perforations or integrity defects. Perforations in the pars tensa are called
marginal or central perforations, depending on whether the perforation extends to
the annulus around the tympanic membrane. Marginal perforations are classied as
small, medium, and large, as well as anterior marginal, inferior marginal, or posterior marginal, depending on the location. Central perforations are classied as
small, medium, and large, as well as anterior, posterior, or inferior depending on
their relationship to the handle of the malleus. While very large central perforations
are expressed as subtotal, very large marginal perforations are expressed as total.
Attic defects are characterized as small or large attic retraction pockets [16–19].
10.2.12 Hearing Examination
A hearing test is required to evaluate the function of the ear. Classication of hearing loss can be made by determining the degree of hearing loss with hearing tests.
There are three types of hearing loss. These are conductive hearing loss (CHL),
which results from pathology in the middle or external ear (EAC, eardrum, middle
ear, ossicles, and Eustachian tube) where the inner ear function is normal; sensorineural hearing loss (SNHL), which results from damage to the inner ear; and mixed
hearing loss, where both pathologies coexist.
10.2.13 Hearing Assessment
10.2.13.1 Whisper Test
This is a simple and easy-to-perform hearing test. After the patient is asked to cover
one ear, simple syllable words are whispered and the patient is asked to repeat these
words. Ordinarily, a loud whisper is heard at 6–7m. The important point about this
test is that the patient cannot see the doctor’s lip movements. It is not a completely
reliable test. If the patient repeats the words completely, the hearing is considered to
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S. Celik et al.
be within 30dB.If the patient fails this test, further hearing evaluation should be
performed [22].
10.2.13.2 Tuning Fork Tests
Rinne Test
Each ear is evaluated separately. This test evaluates hearing loss by comparing air
conduction to bone conduction. Generally, a 512Hz vibrating tuning fork is used
and placed on the mastoid eminence (planum). This measures bone conduction. The
patient is asked to say when he or she can no longer hear the vibration. When the
patient says they can’t hear it, the tuning fork is moved 1cm in front of the auricle.
Meanwhile, the air conduction is measured. The time the patient continues to hear
the tuning fork sound is recorded [23, 24] (Fig.10.5). The results of the Rinne test
are interpreted as follows:
(a) Normal Hearing: Normal hearing has an air conduction time that is approxi-
mately twice as long as the bone conduction time. Accordingly, a normal person
should be able to hear the tuning fork sound in the EAC for about twice as long
as the sound heard on the mastoid. This is called Rinne positive [23].
Fig. 10.5 Weber test
10 Otologic History Taking andBasic Examination Techniques
199
(b) CHL: The hearing time is shortened when the tuning fork sound is in front of
the EAC.This is called Rinne negative [24].
(c) SNHL: Both air and bone conduction hearing are reduced. Therefore, the air/
bone conduction ratio is not impaired on the Rinne test. This condition is
referred to as pathological Rinne positive [24].
(d) Total Hearing Loss: If there is a severe or complete hearing loss in the tested
ear, the sound may be heard in the other ear due to the mastoid effect. In this
case, the patient cannot determine the direction of the sound and will report
hearing the sound but not the vibration of the tuning fork placed in front of the
EAC.As a result, the clinician performing the test may mistakenly believe that
the patient has a loss of air conduction. This situation is referred to as a falsenegative Rinne. Therefore, masking of the healthy ear is required when there is
a signicant hearing difference between two ears [24].
Weber Test
It is a method of testing bone conduction hearing in both ears simultaneously by
placing a tuning fork on the skull bones or teeth in the midline. After the tuning fork
is vibrated, it can be placed on the head in the midline (usually at the glabella or root
of the nose). The results are reported as “Weber in the middle, lateralized to the right
or left” in the direction in which the tuning fork vibration is heard [24–26]
(Fig.10.6). The results of the Weber test are interpreted as follows:
(a) Normal Hearing: A person with normal hearing will hear the vibration of the
tuning fork in the midline.
(b) SNHL: If SNHL is present in one ear, the patient will hear the tuning fork
vibration with the unaffected ear due to shortened bone conduction. This situation is called “Weber lateralized to the intact ear” [25].
(c) CHL: People with unilateral CHL would hear the tuning fork in the affected
ear. In this case, Weber is lateralized to the affected ear. Weber lateralizes with
minor conductive loss (< 5dB). The reason for this is as follows: The background noise level outdoors is usually around 30dB. This sound cannot be
heard in the affected ear because of the CHL, but it causes a masking effect in
the normal ear. In this way, the patient’s ear, which is not masked, hears the
vibration better. If the hearing loss is the same in both ears, Weber is in the
middle, but the duration of hearing the vibration is shortened. In cases of SNHL
in both ears, Weber is lateralized to the better ear [25].
Schwabach Test
Schwabach is a test based on examining the patient’s bone conduction hearing level
in comparison to that of a normal-hearing person. Typically, the clinician compares
it to his or her own ear. The purpose is to determine if the patient’s bone conduction
hearing is different from the examiner’s bone conduction hearing (i.e., normal). The
bone conduction time of the patient with SNHL is shortened, and the time of hearing the tuning fork vibration is shortened [24–26].