PHYSICAL ASSESSMENT: EARS

BY: RHODEVA JOY T. BRAGA, RN, USRN

Structure and Function
The ear is the sense organ of hearing and
equilibrium. It consists of three distinct parts:
– the external ear
– the middle ear
– inner ear.
The tympanic membrane separates the
external ear from the middle ear.
Both the external ear and the tympanic
membrane can be assessed by direct
inspection and by using an otoscope.
However, the middle and inner ear can- not be
directly inspected. Instead, these parts of the
ear are assessed by testing hearing acuity and
the conduction of sound. the anatomy and
physiology of the ear.
 External Ear

Auricle - pinna
Cerumen- a wax-like substance that keeps the
tym- panic membrane soft.
The tympanic membrane- or eardrum, has a
translucent, pearly gray appearance and
serves as a partition stretched across the inner
end of the auditory canal, separating it from
the middle ear
 Middle Ear

The middle ear- or tympanic cavity, is a small, air-

filled chamber in the temporal bone.
The middle ear contains three auditory ossicles:
the malleus
the incus
the stapes.
These tiny bones are responsible for transmitting
sound waves from the eardrum to the inner ear
through the oval window.
 Inner Ear
The inner ear, or labyrinth, is fluid filled and is
made up of the bony labyrinth and an inner
membranous labyrinth.
The bony labyrinth has three parts: the
cochlea, the vestibule, and the semicircular
canals.
The inner cochlear duct contains the spiral
organ of Corti, which is the sensory organ for
hearing.
 HEARING
The transmission of sound waves through the
external and middle ear is referred to as
“conductive hearing”.
Transmission of sound waves in the inner ear
is referred to as “perceptive” or “sensorineural
hearing.”
 TERMS and DEFINITION:
Earache- otalgia
Tinnitus- Ringing in the ears
Vertigo- true spinning motion
Subjective vertigo- when the client feels that
he is spinning around.
Objective vertigo- when the client feels that
the room is spinning around him
PREPARING THE CLIENT
Make sure the client is seated comfortably
during the ear examination.
In addition, the test should be explained
thoroughly to guarantee accurate results.
To ease any client anxiety, explain in detail
what you will be doing.
Also answer any questions the client may
have.
As you prepare the client for the ear
examination, carefully note how she responds
to your explanations.
 EQUIPMENT

Watch with a second-hand for Romberg test

Tuning fork (512 or 1,024 Hz)

Otoscope
THE OTOSCOPE
EXTERNAL EAR STRUCTURES
 PROCEDURE NORMAL ABNORMAL
Inspect the auricle, Ears are equal in size Ears are smaller than 4
tragus, and lobule. Note bilaterally (nor- mally 4 cm or larger than 10 cm.
size, shape and position to 10 cm). Malaligned or low-set
The auricle aligns with ears may be seen with
the corner of each eye genitourinary disorders
and within a 10-degree or chromosomal defects
angle of the vertical
position.
Earlobes may be free,
attached, or sol- dered
(tightly attached to
adjacent skin with no
apparent lobe).
 CULTURAL CONSIDERATION
Most African Americans and Caucasians have
free lobes, whereas most Asians have at-
tached or soldered lobes although any type is
possible in all cultural groups (Overfield,
1995).
SPECIAL CONSIDERATION: OLDER
CLIENT (NORMAL)
The older client often has
elongated earlobes with linear
wrinkles.
SPECIAL CONSIDERATION: NEWBORN
(ABNORMAL)
Low-set ears with an alignment greater than a
10-degree angle suggest retardation or
congenital syndromes.
Abnormal shape may suggest renal disease
process, which may be hereditary.
Preauricular skin tags or sinuses suggest other
anomalies of ears or the renal system.
 PROCEDURE NORMAL ABNORMAL
Continue inspecting the The skin is smooth with Enlarged preauricular and
auricle, tragus, and lobule. no lesions, lumps, or postauricular lymph
Observe for lesions, nodules. nodes—infection
discolorations, and Color is consistent with Tophi (nontender, hard,
discharge. facial color. Darwin’s cream-colored nodules on
tubercle, which is a the helix or antihelix, con-
clinically insignificant taining uric acid crystals)—
projection, may be seen on gout
the auricle. Blocked sebaceous
No discharge should be glands—postauricular cysts
present. Ulcerated, crusted
nodules that bleed— skin
cancer (most often seen on
the helix due to skin
exposure)
Redness, swelling,
scaling, or itching— otitis
externa
Pale blue ear color—
frostbite
 PROCEDURE NORMAL ABNORMAL
Palpate the auricle and Normally the auricle, A painful auricle or tragus
mastoid process. tragus, and mastoid is associated with otitis
process are not tender. externa or a postauricular
cyst. Tenderness over the
mastoid process suggests
mastoiditis. Tenderness
behind the ear may occur
with otitis media.
ABNORMALITIES OF THE EXTERNAL
EAR AND EAR CANAL
INTERNAL EAR: OTOSCOPIC
EXAMINATION
 PROCEDURE NORMAL ABNORMAL
Inspect the external A small amount of Foul-smelling, sticky,
auditory canal. Use the odorless cerumen (ear yellow discharge— otitis
otoscope. wax) is the only discharge externa or impacted
Note any discharge along normally present. foreign body
with the color and Cerumen may be yellow, Bloody, purulent
consistency of cerumen (ear orange, red, brown, gray, discharge—otitis media
wax) or black and soft, moist, with ruptured tympanic
dry, flaky, or even hard. membrane
Blood or watery drainage
(cerebrospinal fluid)—skull
trauma (refer client to
physician immediately)
Impacted cerumen
blocking the view of the
external ear canal—
conductive hearing loss
 CULTURAL CONSIDERATION
Most Europeans and Africans, 97% or more,
have wet earwax; Asians and Native
Americans have dry, with transition in
southern Asia.
The gene accounting for this has been isolated
and is associated with lower sweat production
of the apocrine glands, possibly an adaptation
to cold (Wade, 2006).
 SPECIAL CONSIDERATION: OLDER
CLIENT (NORMAL)
In some older clients, harder, drier
cerumen tends to build as cilia in
the ear canal become more rigid.
Coarse, thick, wirelike hair may
grow at the ear canal entrance as
well.
This is an abnormal finding ONLY if
it impairs hearing.
 PROCEDURE NORMAL ABNORMAL
Observe the color and The canal walls should Reddened, swollen
consistency of the ear be pink and smooth and canals—otitis externa
canal walls and inspect without nodules. Exostoses
the character of any (nonmalignant nodular
nodules. swellings)
Polyps may block the
view of the eardrum
 PROCEDURE NORMAL
Inspect the tympanic The tympanic membrane
membrane should be pearly, gray,
(eardrum). Note shiny, and translucent with
color, shape, no bulging or retraction. It
consistency, and is slightly con- cave,
landmarks. smooth and intact. A cone-
shaped reflection of the
otoscope light is nor- mally
seen at 5 o’clock in the
right ear and at 7 o’clock in
the left ear. The short
process and handle of the
malleus and the umbo are
clearly visible
ABNORMAL
Red, bulging eardrum and
distorted, di- minished or absent
light reflex—acute otitis media
Yellowish, bulging membrane
with bub- bles behind—serous
otitis media
Bluish or dark red color—blood
behind the eardrum from skull
trauma
White spots—scarring from
infections
Perforations—trauma from
infection
Prominent landmarks—eardrum
retraction from negative ear
pressure resulting from an
obstructed eustachian tube
Obscured or absent landmarks—
eardrum thickening from chronic
otitis media
SPECIAL CONSIDERATION: OLDER
CLIENT (NORMAL)
The older client’s eardrum may
appear cloudy. The landmarks
may be more prominent because
of atrophy of the tympanic
membrane associated with the
normal process of aging.
ABNORMALITIES OF THE TYMPANIC
MEMBRANE
HEARING AND EQUILIBRIUM TESTS
 SPECIAL CONSIDERATION: OLDER
CLIENT (NORMAL)
• In general, African Americans have slightly
better hearing at low and high frequencies
(250 and 6000 Hz); Caucasians have better
hearing at middle frequencies (2000 and 4000
Hz). African Americans are less susceptible to
noise-induced hearing loss (Overfield, 1995).
SPECIAL CONSIDERATION: NEWBORN
(NORMAL)
• A newborn will exhibit the startle (Moro)
reflex and blink eyes (acoustic blink
reflex) in response to noise. Older infant
will turn head.
 WEBER TEST
Strike a tuning fork softly with the back of
your hand and place it in the center of the
client’s head or forehead .
Centering is the important part.
Ask whether the client hears the sound better
in one ear or the same in both ears.
 NORMAL FINDINGS
Vibrations are heard equally well in
both ears. No lateralization of sound
to either ear.
 ABNORMAL FINDINGS
Conductive hearing loss the client reports
lateralization of sound to the poor ear—that is, the
client “hears” the sounds in the poor ear. The good ear
is distracted by background noise, conducted air, which
the poor ear has trouble hearing. Thus the poor ear
receives most of the sound conducted by bone
vibration.
Sensorineural hearing loss the client reports
lateralization of sound to the good ear. This is because
of limited perception of the sound due to nerve
damage in the bad ear, making sound seem louder in
the unaffected ear.
SPECIAL CONSIDERATIONS: OLDER
CLIENT
Presbycusis, a gradual sensoneural hearing loss
due to degeneration of the cochlea or
vestibulocochlear nerve, is common in older
(over age 50) clients. The client with presbycusis
has difficulty hearing consonants and whispered
words; this difficulty increases over time.
The older client may have had a bad experience
with certain hearing aids and may refuse to wear
one. The client may also associate a negative self-
image with a hearing aid.
SPECIAL CONSIDERATIONS: OLDER
CLIENT
Conductive hearing impairment is not
uncommon in the older client due to greater
incidence of cerumen buildup and/or atrophy
or sclerosis of the tympanic membrane. A
condition called otosclerosis often occurs with
aging as the auditory ossicles develop a
spongy consistency that results in conductive
hearing loss.
 RINNE TEST
The Rinne test compares air and bone conduction
sounds.
Strike a tuning fork and place the base of the fork
on the client’s mastoid process.
Ask the client to tell you when the sound is no
longer heard.
Move the prongs of the tuning fork to the front of
the external auditory canal.
Ask the client to tell you if the sound is audible
after the fork is moved.
 NORMAL FINDINGS ABNORMAL FINDINGS
Air conduction sound is normally With conductive hearing loss,
heard longer than bone conduction bone conduction sound is heard
sound (AC BC). longer than or equally as long as air
conduction sound (BC AC).
With sensorineural hearing loss,
air conduction sound is heard longer
than bone conduction sound (AC
BC) if anything is heard at all. c
 ROMBERG TEST
This tests the client’s equilibrium.
Ask the client to stand with feet together and
arms at sides and eyes open and then with the
eyes closed.
Put your arms around the client without
touching him or her to prevent falls.
 NORMAL FINDINGS ABNORMAL FINDINGS
Client maintains position Client moves feet apart
for 20 seconds without to prevent falls or starts
swaying or with minimal to fall from loss of
swaying balance. This may
indicate a vestibular
disorder
SPECIAL CONSIDERATIONS:NEWBORN
The inner ear develops during the first
trimester of gestation. Therefore, maternal
problems during this time, such as rubella,
may impair hearing.
Newborns can hear loud sounds at 90 decibels
and react with the startle reflex.
They respond to low-frequency sounds, such
as a heartbeat or a lullaby, by decreasing
crying and motor movement.
They react to high-frequency sounds with an
alerting reaction. In infants, the external
auditory canal curves upward and is short and
straight.
Therefore, the pinna must be pulled down and
back to perform the otoscopic examination.
The eustachian tube is wider, shorter, and
more horizontal, increasing the possibility of
infection rising from the pharynx.