Ear examination

• Check infants and children's ears whenever they come to the clinic
• Always look at 'good' ear first
• If you find anything abnormal or worrying — medical/specialist consult

Position person

Infants/toddlers

• Put infant/toddler on carer’s lap. Have ear you want to check first facing outward
• Ask carer to stop any movement by
• Tucking the child’s arm under their armpit and holding the child’s head firmly against their chest
• With their other hand firmly hold child’s body and other arm — Figure 8.27
• If child kicking — carer puts child’s legs between their thighs and holds tight

Bigger children/adults

• Ask child to stand OR adult to sit comfortably and tilt their head slightly away from you — Figure 8.28

Check outside of ear

• Look at mastoid (bone behind ear) and area under ear crease for signs of infection and surgical scars
• Gently run hand over area —  feel for heat, sponginess, swelling 

Check ear canal

Attention

• Use new clean earpiece for each ear
• Dry mop any discharge (pus) before examining inside ear

If ear drum chronically stretched, retracted (sucked in), thinned — can look like a perforation (large hole) or defect

What you need

• Otoscope with right sized earpiece. Use largest size (adult or child) that fits comfortably in ear canal

What you do

• To straighten ear canal
• Infants and toddlers — hold pinna (edge of ear) and pull gently down — Figure 8.29
• Young children — pull pinna straight back — Figure 8.30
• Older children and adults — hold top of ear and gently pull back and up — Figure 8.31

• Look at entrance to ear canal for pus (discharge), swelling, redness
• Hold otoscope like a pen — hold in left hand to examine left ear, right hand to examine right ear
• Otoscope handle can be pointing up or down
• Must brace otoscope to stop injury if person moves suddenly
• Brace by putting your fist against cheek or head — Figure 8.32, Figure 8.33
• Gently put earpiece into ear canal — never force
• Look through earpiece as you go so you can see where you are putting it, and see behind any discharge (pus) or objects/foreign bodies

Look

• At walls of ear canal — check for swelling, sores, scratches, injuries
• For debris, wax or pus, objects/foreign bodies (eg flies, beads, old tissue, cotton wool)
• At condition of drum
• Colour — grey, yellow, white
• Dull or shiny
• Bulging outward or inward
• Bubbles/fluid behind drum
• See Ear examination chart

Photos provided by Dr Michael Hawke, Hawke Library.

Test ear drum for movement

Attention

• Do not test drum for movement if ear too painful
• Only test eardrum you can see clearly
• If drum doesn’t move — usually effusion (fluid in middle ear)
• Can be difficult to get a good seal with otoscope earpiece in young children
• Tympanometry can be used to test drum mobility and middle ear — if available and practitioner has training. Do not use on children under 6 months

What you need

• Otoscope with right sized earpiece
• Use largest size (adult or child) that fits comfortably in ear canal
• Puffer (insufflation) bulb that connects to otoscope

What you do

Using puffer bulb

• Attach puffer bulb to otoscope
• Explain that they will feel pressure in ear but it shouldn't hurt
• Slightly compress the puffer bulb
• Gently push earpiece into outer canal as far as it will comfortably go, to make airtight fit

• Release the puff bulb — Figure 8.35
• Watch for fast movement of eardrum
• If none — do it again with a little bit more pressure on bulb until there is movement or you are certain it will not move. Stop if it causes pain
• Gently take out earpiece and throw it away

Popping ears — Valsalva manoeuvre

• Get person to hold fleshy end of nose to block it, at the same time try to blow out through their nose with their mouth closed — Figure 8.36
• Autoinflation devices may be useful for children
• If eardrum intact and normal — it will move. Ask person if one or both ears 'popped'

Tympanometry

Tympanometry is a test that measures the function and movement of the eardrum and middle ear by creating variations of air pressure in the ear canal. The results of tympanometry are represented on a graph called a tympanogram. The test is usually quick and painless, unless the eardrum or middle ear are inflamed

Attention

• Only to be performed by appropriately trained staff 
• Otoscopy must be performed before tympanometry
• Do not perform tympanometry if any 
  
• Ear pain
• Ear drum is inflamed, bulging or perforated
• Discharge or foreign objects in the ear canal
• Within 6 weeks of ear surgery, or in accordance with medical advice
• Child cannot be speaking, sucking or swallowing during test
• If child not willing OR staff/parent have concerns — medical consult

What you need

• Suitable room with minimal external noise
• Tympanometer with spare batteries 
  
• 1000 Hz probe tone for infants under 6 months
• 226 Hz probe tone for children 6 months and over
• Disposable ear tips of various sizes
• Tympanometry printer (fully charged) and spare paper rolls (as applicable)

What you do

• Select an ear tip slightly larger than external auditory canal
• For infants — hold pinna (edge of ear) and pull gently down — Figure 8.29
• For young children — pull pinna straight back — Figure 8.30
• Use other hand to put in probe into external auditory canal
• Create air-tight seal by gently rotating wrist towards the child’s eye, so screen is on top and can be viewed
• Watch screen to confirm that seal has been achieved, then hold tympanometer still
• When test complete, remove ear probe by gently rotating wrist to break seal
• Record measurements (as displayed on the screen) for pressure, compliance and ear canal volume

• Repeat procedure on other ear

Interpreting results

Results are to be considered together with history and otoscopy (and audiology if applicable) to make clinical judgements about the need for referral and follow-up

Testing hearing

Attention

•  Tuning fork tests not as accurate as audiometers but provide useful information, can be used by all health practitioners
• Tuning fork tests easier to interpret if hearing problem only on one side
• Do not use tuning fork tests to assess children's hearing
• Children with ear disease or hearing impairments must be referred for audiology

Weber test

Tests for one-sided conductive loss (loss of sound travelling through outer or middle ear) or sensorineural loss (nerve or hair cell damage in inner ear)

• Do Weber test before Rinne test

What you need

• A middle C (512Hz) tuning fork, best with wide base

What you do

• Strike tuning fork lightly against your hand or knee
• Keeping single bar of tuning fork up straight, put it against middle of person’s forehead — Figure 8.38

• Ask person if tone sounds the same in both ears
• If it does — record ‘normal’ in file notes
• If it doesn't this is 'not normal' — record which ear heard loudest sound
• If one ear known to have hearing loss
• If sound louder in problem ear — conductive loss in problem ear
• If sound louder in good ear — sensorineural loss in problem ear

Rinne test

Compares air-conduction and bone-conduction hearing

• Do Rinne test after Weber test

What you need

• A middle C (512Hz) tuning fork, best with wide base

What to do

• Strike tuning fork against your hand or knee
• On left ear, put single bar on base of bone behind ear (mastoid process) — Figure 8.39
  
• Count in seconds and ask person to tell you when sound stops. Remember how many seconds it took (bone conduction)

• Move tuning fork next to ear opening but do not touch ear — Figure 8.40
  
• Count in seconds and ask person to tell you when sound stops again (air-conduction)
• Record both times
• Number of seconds against bone
• Number of seconds next to ear opening
• Do again for right ear
• Normal hearing if
• Sound louder next to ear
• Sound next to ear lasts twice as long as sound against bone
• Conductive hearing loss if
• Sound louder against bone
• Sound against bone lasts the same time or longer than sound next to ear

Supporting resources

• PLUM and HATS hearing checklists