1- Ears (Investigations and examination findings)

Question 1

How to use an otoscope

Answer 1

• Gently pull the pinna upwards and backwards to straighten the ear canal to best visualise the tympanic membrane. In children, pulling the pinna downwards and backwards may provide better visualisation
• Hold the otoscope like a pencil and use your little finger as a fulcrum against the cheek to avoid injury should the patient move suddenly
• Inspect systematically
  Looking at: external auditory canal, tympanic membrane, ossicles

Question 2

Normal auditory canal

Answer 2

• Some hair
• Often with yellow to brown
• Cerumen

Question 3

Normal tympanic membrane

Answer 3

• Pinkish grey (pearly grey) in color, translucent and in neutral position
• Malleus lies in oblique position behind the upper part of the drum
• Mobile with air inflation

Question 4

colour of TM

Answer 4

Colour
- A healthy TM should appear pearly grey and translucent.
- Erythema suggests inflammation of the TM which can occur in conditions such as acute otitis media.

Question 5

shape of TM

Answer 5

• A healthy TM should appear relatively flat.

Bulging of the TM suggests increased middle ear pressure
- acute otitis media (there is

Retraction of the TM suggests reduced middle ear pressure
- pharyngotympanic tube dysfunction secondary to upper respiratory tract infections and allergies
- otitis media with effusion

Question 6

Light reflex

Answer 6

• If a TM is healthy, the cone-shaped reflection of light should appear in the anterior inferior quadrant.
• In the left ear, the light reflex should be positioned at approximately 7 o’clock to 8 o’clock.
• In the right ear, the light reflex should be positioned at approximately 4 o’clock to 5 o’clock.
• Absence or distortion of the light reflex is associated with otitis media (due to bulging of the TM).

Question 7

Perforations

Answer 7

• Size and position
• Cause: infection, trauma, cholesteatoma (superior part of TM), tympanostomy tube insertion

Question 8

Scarring

Answer 8

• Scarring of the TM is known as tympanosclerosis and can result in significant conductive hearing loss if it is extensive.
• Tympanosclerosis often develops secondary to otitis media or after the insertion of a tympanostomy tube.

Question 9

what is this?

Answer 9

cholesteatoma

Question 10

what is this?

Answer 10

chronic supporative otitis media

Question 11

what is this?

Answer 11

external auditory canal bleeding

Question 12

what is this?

Answer 12

impacted cerumen

Question 13

what is this?

Answer 13

otitis media with effusion

otitis

Question 14

what is this?

Answer 14

tympanic membrane calcification

Question 15

what is this?

Answer 15

tympanic membrane calcification

Question 16

what is this?

Answer 16

otitis externa

Question 17

what is this?

Answer 17

acute otitis media

Question 18

Pneumatic otoscopy

Answer 18

Pneumatic otoscopy- can be used to assess tympanic membrane (this modified otoscope has an air-tight seal when placed in the ear canal and a rubber bulb (similar to that of a sphygmomanometer) which the user can squeeze which alters the pressure within the ear canal)

Question 19

Hearing tests in order

Answer 19

• Field speech testing
• Webers and rinnes tests
• Pure tone audiogram

Question 20

free field speech testing

Answer 20

• Free field testing is a good screening tool for hearing loss
• Use of masking improves the accuracy of testing:
  o Rub the tragus of the contralateral ear whilst performing this to prevent sound being heard in the contralateral non-test ear
• Use polysyllabic phrase (number or letter) e.g. ‘C5’, ‘37’ or motivational phrases in children e.g. ball, sweets, crisps
• Test normal ear first.
• Perform, in order of intensity at 60cm (arms length) and 15cm: whisper, conversational speech, loud voice.
• Patient should be able to repeat >50% of the letters/numbers correctly.

Question 21

Webers and Rinnes test

Answer 21

Webers and Rinnes test
These tests assess air conduction (AC) and bone conduction (BC) and are used to help delineate whether hearing loss is sensorineural (SNHL)or conductive (CHL) in origin.

Question 22

Webers test

Answer 22

• Vibrating 512Hz tuning fork applied firmly to the midline of the forehead, apex of head
• Ask the patient if they can hear a tone in the right ear, left ear or centre of the head
• The “louder” ear may be due to conductive hearing loss in that ear (sound travels through the bone), or sensorineural hearing loss in the other ear
• You can work out which this is by performing Rinne’s test

Question 23

Rinnes test

Answer 23

• Place vibrating tuning fork with base on mastoid process (position 1, testing bone conduction).
• Then move the tuning fork so its prongs are adjacent to (but not touching) the external auditory meatus (position 2, testing air conduction).
• Ask patient to tell you which is louder, when the fork is placed behind the ear or in front of the ear
• Position 2 is louder than position 1 in the normal ear (Positive Rinne), as an intact hearing apparatus of the external and middle ear amplifies sound.
• When position 2 is quieter than position 1, (Negative Rinne), this indicates external or middle ear disease affecting the air conduction

Question 24

intepreting Webers and Rinnes

Answer 24

Question 25

Pure tone audiometry

Answer 25

is a subjective test that aims to evaluate the quietest sound that can be heard with each ear at various frequencies i.e. the hearing threshold.

Hearing is usually reported on the decibel scale, which is a logarithmic scale.

In general, a whisper from 1m has an intensity of 30dB, normal conversational voice is 60dB, shouting equates to about 90dB and discomfort can be felt at around 120dB.

Question 26

Normal hearing is defined to be

Answer 26

20dB or better

Question 27

Hearing Disability is defined as:

Answer 27

• Mild hearing loss is between 21-40dB.
• Moderate hearing loss is between 41-70dB.
• Severe hearing loss is considered to be 71-90dB.
• Profound hearing loss is worse than 90dB.

Question 28

pure tone audiometry technique

Answer 28

Technique
- The audiometer is a machine which provides pure tone sounds at varying frequencies
- The test must be conducted in a soundproof room and the subject should not be able to see the machine or the tester adjusting the controls as this may influence the results.
- Before conducting the test, the ears must be examined to exclude an active infection, foreign body or occluding wax. The patient then wears headphones to test air conduction followed by a bone vibrator placed on the mastoid process to test bone conduction
- Air conduction is tested at 250, 500, 1000, 2000, 4000 and 8000 Hz while bone conduction is tested at 500-4000 Hz.
- Masking helps to deal with cross hearing, which occurs from bone conduction to the contra-lateral cochlea.
o It involves presenting a sound to the non-test ear (masking noise) to prevent it from detecting the sound being presented to the test ear

Question 29

normal audiometry graph

Answer 29

all >20dB

Question 30

audiogram form

Answer 30

Question 31

diagnosis?

Answer 31

Question 32

diagnosis?

Answer 32