Examination of the ear includes :
1. Pinna,
2. External auditory meatus,
3. Tympanic membrane,
4. Middle ear,
5. Tests for the function of Eustachian tube,
6. Tests of hearing,
7. Tests of balance,
8. Eyes.
9. Cranial nerves
10. Post aural area (Mastoid process), and lymph nodes.
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OTOSCOPY:
Methods:
- Indirect illumination using a head mirror. Difficult.
- Electric Otoscope: It consists of a speculum, handle and a magnifying
attachment (1.5-2 x).
Technique:
- The pinna is pulled upwards, backwards and outwards.
- The speculum of appropriate size is introduced along the axis of the meatus with a
rotating motion using the left hand for the right ear and the right hand for the left ear.
The wall of the bony meatus must not be irritated as it is very sensitive.
- One hand is left free for instrumentation.
- In infants and young children the pinna is pulled downwards and backwards to straighten
the meatus.
- Wax and other debris must be removed for adequate examination.
Mistakes:
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Examination of the
Pinna:
- Shape,
- Size,
- Symmetry,
- Signs of inflammation,
- Ulcers.
Examination of the
External Auditory Meatus:
- Patency: Atresia, stenosis
- Swelling: Inflammatory, neoplastic.
- Discharge: Wax, mucoid, purulent, haemorrhagic, watery.
- Tragal tenderness.
- Sagging of the postero-superior meatal wall.
Tympanic membrane: (Using naked
eye, otoscope, and otomicroscope)
- Position,
- Colour: Hemorrhage, dullness, blue, bullae
- Ossicles
- Perforations: Marginal and Central, site, size.
- Mobility: (Retractions) by using a pneumatic otoscope, or
Siegle's speculum.
Middle ear:
- Can be examined through a perforation. Look at the colour of
mucosa, edema, discharge, polyps, promontory.
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Tests for Eustachian tube functions
Qualitative
Methods:
i] Valsalva Maneuver:
Principle: Demonstration of tubal patency without external aids.
Method: After taking a deep breath, the patient pinches
his nose and closes his mouth in an attempt to blow air in his ears. Otoscopy shows
movement of the drum. Auscultation reveals crackling.
Note: Failure of this test does not prove pathologic
occlusion of the tube.
This maneuver in the presence of nasal and nasopharyngeal infection
carries the danger of transmission of infection to the ear.
ii]Toynbee's test:
Principle: It is safer
and confirms normal tubal function.
Method: The nose is closed and the patient swallows.
There is in drawing of the tympanic membrane, confirmed by otoscopy and on auscultation
when a noise is heard.
iii]Politzer's test:
Principle: When the soft palate is elevated the pressure in the
nasopharynx is increased which opens the tube.
Method: The doctor occludes one of the patient's nostrils
with the olive of a rubber balloon and pinches the other nostril tightly. The patient
elevates the palate by swallowing or saying "Kay, Kay". At the same time air
pressure in the closed nasal cavity is increased by pressing the Politzer's bag. The
doctor can hear the rush of air into the middle ear by auscultation using a tube. Optical
assessment can also be used.
iv]Tubal Catheterization
Principle: It is to artificially blow air through the tubal opening.
Method: A silver catheter with an angulated tip is passed
through the nose to engage the tubal opening. Air is forced into the ear by connecting the
catheter to a balloon.
Complications: Tubal otitis media, rupture of an atrophic
drum, nasal bleeding, damage to tubal ostium.
Quantitative Methods:
1. Manometry
2. Sonomanometry,
3. Acoustic impedance, and
4. Tympanometry.
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Tests of Balance
Romberg
test
Method:
-
Patient stands upright with the feet parallel and close together, eyes closed ,and the
arms folded in front of the chest or outstretched.
- Blindfold gait and walking a straight
line.
Results:
- Unilateral
peripheral lesion or a unilateral cerebellar lesion, the patient tends to sway towards the
affected side.
- Central lesions give irregular pattern of sway.
- The patient deviates towards the side of the lesion, in gross
lesions.
- Quantitative assessment may be carried out using a Balance Platform.
Unterberger's Stepping test
Method:
Stepping on one spot with the eyes closed.
Result:
Peripheral lesions- rotation of the body axis to the side of the labyrinthine
lesion.
Central disorders- the deviation is irregular.
Deviations of greater than 40 degree are
significant.
Positional tests
1. Spontaneous deviation
reaction:
Method: The arms are held horizontal in the
supine position with the patient sitting.
Result: Both arms are deviated in
parallel to the side of the lesion.
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2. Spontaneous tone reaction:
Method:
With the patient sitting and the arms stretched in front of him.
Result: The arm on the side of cerebellar lesion sinks as a
result of loss of tone of the muscles.
Finger-nose pointing test:
Method: The index finger of the outstretched hand is brought to the point
o the nose with the eyes closed.
Result: Ataxia and disorders of coordination
indicate an ipsilateral cerebellar lesion or a disorder of positional sense.
Gait
High
Stepping Gait; Loss of proprioception as in tabes dorsalis or in sensory neuropathy.
Hemiplegic
gait; Dragging of the leg and flexion of the
affected arm.
Shuffling
gait; Parkinsonism.
Head bent.
Ataxic
gait; Midline cerebellar
dysfunction
TESTS FOR EYE
MOVEMENTS:
Nystagmus
Nystagmus
should be sought with the head in the :
i. primary position.
ii. when flexed, extended, laterally inclined and rotated. These
constitute the cervical postural tests (Barany Halpike).
Method: ( With the head in neutral position)
Patient
looking to the front. Observer viewing from the side. Visual fixation is obtained by
placing a finger central to the eyes and at least 45 cm from the nose. The presence or
absence of nystagmus is noted, and then the finger is moved 30° to either side asking the
patient to follow the finger without moving the head.
- Observation with and without Frenzel's glasses.
- Examined in a dark room with + 15 diopter lenses which almost
completely suppress optical fixation.
- Examine with and without fixation for a Fixation nystagmus.
Result:
- Are noted on a Frenzel chart.
Positional testing ( Dix -
Halpike method).
Principle:
-
Screening test for Positional nystagmus.
- Nystagmus induced or aggravated by this test is attributable to
cervical proprioceptors and vertebral artery compression.
Method:
(With the head in different positions).
- The head is firmly grasped with the patient sitting on a couch.
- The patients head is rotated 45 to one side and then the other
while he is made to assume the supine position with the head hanging 30 below the edge of
the table. The head is kept in this position for some time.
- The eyes should be observed for nystagmus.
Caloric Labyrinthine Testing:
Principle:
- The LSCC is brought into a vertical position in the supine patient by
elevating the head 30° .
- The volume of endolymph is changed by cooling or
warming the labyrinthine capsule by irrigation with water at 30° and 44° C for 30-40
sec.
- This produce changes in volume of the endolymph
(previous concept was of currents) which deflects the cupula.
- In cases where tympanic membrane is perforated Air
Caloric test is carried out.
Result:
- Reduced excitability;
Partial loss of function
- Total absence of excitability; Complete loss of
function.
- Directional Preponderance; Indicates a difference
in spontaneous activity in the higher vestibular centers.
- Advantage: Each labyrinth can be examined
separately.
Fistula
test
Principle:
- In the presence of a fistula in the LSCC, or stapes or elsewhere in the
labyrinthine capsule caused by trauma, cholesteatoma, or lytic process, a sudden increase
in pressure in the EAM produces vertigo, nystagmus.
- The same symptom can occur in case of adhesions
between the membranous labyrinth and the stapes footplate. (Fistula test without a
fistula).
- Tullio's phenomenon:
A large defect in the tympanic membrane or in mastoid cavity, aspiration of
air leads to cooling of the LSCC producing a caloric labyrinthine reaction and thus
nystagmus. This always beats towards the sound ear for both compression and aspiration.
Technique:
*Tragal pressure.
* Politzer balloon with a perforated olive.
Result:
* Compression induces nystagmus towards the diseased ear.
* Aspiration towards the sound ear.
* Hennebert' sign:
Is a positive fistula test in the presence of a
normal tympanic membrane and no evidence of middle ear disease. Present in Congenital or
tertiary syphilis, Endolymphatic hydrops, third window due to osteitis, and adhesions in
vestibule.
Tests of Hearing:
- This requires a quiet room of about 6 m long since noise and poor
acoustic properties such as a narrow room with smooth walls produce echoes which falsify
the results.
- Each ear is tested separately.
- The better ear is tested first.
- The opposite ear is masked by a moist plug of cotton pressed into the
EAM moved in and out. (Wagener's vibration method of masking).
- In cases of severe unilateral deafness Barany's noise box has to be
used.
[I] Whisper test:
Two syllable words are
articulated at a decreasing distance from the patient until these words can be clearly
repeated
[II] Tuning Fork tests:
(A C1 fork of 512 Hz is used).
i) Weber's test:
Principle:
It is
dependent on binaural comparison of bone conduction.
Method:
- The tuning fork is placed in the
center of skull at the hairline.
- The patient with normal hearing will hear
equally in both ears.
- The patient with a unilateral conductive
hearing loss localizes the tone in the diseased ear.
- The patient with a unilateral
sensorineural loss will localize to the healthy ear.
ii)
Rinne's test:
Principle:
This test rests on monaural comparison to bone conduction.
Method:
The patient can tested in two ways; i) Duration, ii) Intensity.
The patient is asked whether the tuning fork placed in front of the ear
or behind the ear on the mastoid is heard better.
Results:
- If air conduction is better than
bone conduction, Rinne's test is positive. This is the finding in normal ear and in
sensorineural deafness.
- If bone conduction is better than air
conduction, Rinne's test is negative. This is found in conductive deafness.
iii)
Schwabach's test:
Depends
on comparison of the bone conduction of the patient with that of the examiner.
iv)
Gelle's test:
The air pressure in the EAM is altered by a Siegle's speculum
leading to increased stiffness of the ossicular chain. In the normal patient or in
sensorineural deafness bone conducted sound appears to be decreased in intensity. Whereas
in stapes fixation no alteration occurs.
v) Bing test:
Increased loudness for bone
conducted sound less than 2 kHz, occurs in the normal or sensorineural deafness when the
EAM is occluded without increasing the pressure ( As the masking effect of air conducting
sound is removed). There is no change in conductive deafness.
Tests for non-organic hearing loss:
Stenger test:
Principle:
If sounds of identical frequency but different
intensity are presented simultaneously to each ear, only louder sound will be perceived.
The test can be performed with tuning forks or a n audiometer.
Method:
- The examiner stands behind the patient.
- A tuning fork is struck and is held 20 cm from the good ear - the patient hears the
sound.
- The fork is then removed and placed 5 cm from the bad ear - patient 'denies' hearing
sound.
- Another fork is the held 15 cm from the good ear without the patient noticing.
- If there is genuine hearing loss patient will the fork in the good ear.
- But if there is non-organic loss the patient will be unable to hear the fork in the
good ear as the fork is closer in his 'bad' ear.
Chimani-Moos
test:
- Modification of Weber. When the fork is
placed on the vertex, the patient indicates that he is hearing the fork in the good ear
and not in the deaf ear.
- The meatus of the good ear is then blocked .
- A genuine deaf p[patient will still lateralize the sound to the
good ear, the malingerer will usually deny hearing any sound at all.
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