Clinical examination-pcl 9

Physical examination
The ear
-Look at the pinna, noting its shape, size and any deformity. Gently pull on the pinna and ask if it is sore.
- Look at the size of meatus, if it is very wide, this suggests previous mastoid surgery. Note any discharge or colour change
-use an auriscope with the largest speculum that will comfortably fit the external auditory meatus, explain to the patient what you are going to do.
-gently pull the pinna upwards and backwards to straighten the cartilaginous external auditory meatus. Introduce the speculum and inspect the skin of external auditory meatus. Look at the tympanic membrane. You should see a cone of light as the concave surface of the tympanic membrane reflects the light forward.
-Note the pearly grey translucent appearance of the normal drum.

Whispered voice test
-stand behind patient
-start with your mouth open about 15cm from the ear you are testing
-mask hearing in the other ear by rubbing the tragus
-ask patient to repeat your words. Use combination of numbers and letters. Start at 15cm normal speaking voice to confirm that the patient understands the test.
- repeat, but this time at arm’s length from the patient’s ear. Typically, if a patient can hear a whispered voice at 60cm, this hearing is better than 30Db, that is normal.

Webers test
-hit prongs of the fork against hard surface to make it vibrate
-place the base of the vibrating tuning fork on the top of the patient’s head or in the middle of the forehead.
-ask patient where he hears the sound, normally this is in the middle or equally in both ears.
-note which side weber’s test lateralizes.

Abnormal findings
-in symmetrical hearing loss,the sound is also heard in the middle. It is heard loudest in the ear with conductive deafness, since there is no interference from extraneous noise. In unilateral sensorineural deafness the sound is loudest in the unaffected ears.

Rinne’s test
-hit the prongs and place the vibrating prongs at the patient’s external auditory meatus; ask if he can hear it
-place the still vibrating base on the mastoid process and whether it is louder in front or behind the ear.

Abnormal findings.
-if the sound is louder at the ear canal, the test is positive and air conduction is better than bone conduction; this is normal.
-if the sound is louder on the mastoid process, the test is negative; bone conduction is better than air conduction.
-Rinne’s test is negative in conductive deafness.


Testing vestibular function

Testing for nystagmus
-with the patient seated,hold your fingers an arm’s length away,level with the patients eyes.
-ask the patient to look at and follow the tip of your fingers as you slowly move it up and down and then side to side
-look at the patient’s eyes for any oscillations and note
• Whether they are horizontal,vertical or roatatory
• Which direction of gaze causes the most marked nystagmus
• In which direction the fast phase of jerk nystagmus occurs
• Whether jerk nystagmus changes direction when the direction of gaze changes

Unterberger’s test
-patients march on the spot with their eyes closed. They rotate to the side of the damaged labyrinth

Fistula test
-Repeatedly compress the tragus against the external auditory meatus to occlude the meatus, if this produces a sense of imbalance or vertigo with nystagmus, it suggest an abnormal communication between the middle ear and vestibular apparatus.