Introduction 

1. Greet patient and introduce yourself 
2. Confirm patient details ✍ 
3. Briefly explain examination in a patient friendly manner 
4. Get patient consent ✅ 
5. Ask patient to sit 
6. Wash hands ✋ 
7. Check the patient is not in any pain  

Inspection  

Identify any objects or equipment that may be clinically relevant: 

👂 Mobility aids: indicates patient’s mobility status (vestibulocochlear nerve pathology can lead to hearing and balance issues) ♿ 

👂 Hearing aids: ask patient to remove hearing aids 

Hearing assessment: 

Preparation:  

👂 Ask if patient has noticed any changes in hearing ❓ 

👂 Tell patient you will say 3 words/numbers and that they should repeat them back to you 

1. Stand 60cm from ear and whisper a number or word 
2. Rub the tragus of the opposite ear to mask it, and shield their eyes 👁
3. Ask patient to repeat it back to you 
4. If they get two-thirds or more correct, it indicates 12db hearing level or lower ⬇ 
5. If you need to use a conversational volume, it indicates 34db hearing level 
6. If you need to use a loud voice, it indicates 76db hearing level or higher ⬆ 
7. If the patient does not repeat the word/number at any volume, move 15cm closer and repeat 
8. If they repeat when you whisper, it indicates 34db hearing level 
9. If they repeat when using a conversational volume, it indicates 56db hearing level 
10. Repeat the assessment for the other ear 👂

Weber's test 

1. Tell patient you will test hearing using a tuning fork 
2. Tap a 512Hz tuning fork and position it in the midline of the patient’s forehead 
3. Ask patient where they hear the sound👂
4. Consider results alongside those of Rinne’s test 

👂 Normal hearing: sound heard equally in the 2 ears👂

👂 Sensorineural deafness: sound heard louder on unaffected side 

👂 Conductive deafness: sound hear louder on affected side 

Rinne’s test 

1. Place vibrating 512Hz tuning fork on mastoid process to test bone conduction 
2. Ask patient to inform you when they can no longer hear the tuning fork 
3. When patient cannot hear it, move tuning fork in front of external auditory meatus 
4. Ask patient if they can hear it again or not, if they can it indicates air conduction is superior to bone conduction (positive result, identified in healthy individuals) 

👂 Normal: Rinne’s positive result ✅ 

👂 Sensorineural deafness: Rinne’s positive result, both air and bone conduction equally reduced ✅ 

👂 Conductive deafness: Rinne’s negative result (bone conduction is superior to air conduction) ❌ 

What is conductive hearing loss ❓ 

👂 Sound cannot effectively transfer at any point between outer ear, external auditory canal, tympanic membrane and middle ear 👂

👂 Causes: ear wax, otosclerosis, perforated tympanic membrane, otitis media, otitis externa 

What is sensorineural hearing loss ❓ 

👂 Cochlea dysfunction and/or vestibulocochlear nerve ❌ 

👂 Caused by ageing, excessive noise exposure, ototoxic agents, genetic mutations, viral infections 

External Ear 

Inspect the pinnae: 

👂 Scars: indicates prior surgery 🏨

👂 Ear piercings: can cause infection/allergy/trauma 🏨

👂 Skin lesions: pre-malignant/malignant skin changes 

👂 Deformity: acquired or congenital 

👂 Erythema/oedema: associated with otitis externa 

👂 Asymmetry: identify unilateral pathology 

Inspect the mastoid area: 

👂 Scars: indicate prior surgery 🏨

👂 Erythema and swelling: associated with mastoiditis 

Inspect the pre-auricular region: 

👂 Lymphadenopathy: associated with ear infection 

👂 Pre-auricula sinus/pit: congenital deformity (dimple) which can become infected and require drainage 

Inspect conchal bowl: 

👂 Erythema: sign of infection 

👂 Purulent discharge: sign of infection  

Palpate tragus: 

👂 Identify tenderness, indicates otitis externa 

Palpate regional lymph nodes: 

👂 Pre and post auricular lymph nodes 

What is cauliflower ear ❓ 

👂 Caused by repeated blunt ear trauma, which causes blood to collect beneath the perichondrium of the pinna 

👂 This destroys the cartilage of the ear as its nutrient supply, from the perichondrium is lost 

What is congenital ear deformity ❓ 

👂 Microtia: underdeveloped pinna 

👂 Anotia: pinna absence 

👂 Low-set ears: ears lower than normal, due to genetic disorders such as Down’s syndrome or Turner’s syndrome 

Otoscopy 

Insertion of the otoscope: 

1. Apply sterile speculum to otoscope 
2. Lift pinna of the better ear up and back, then use your other hand to straighten the external auditory canal 👂
3. Place the otoscope at the external auditory meatus 
4. Advance the otoscope slowly  

Inspect external auditory canal: 

👂 Discharge: suggests otitis externa or media  

👂 Excess ear wax: causes conductive hearing loss 👂

👂 Foreign bodies: such as cotton buds/insects etc. 

👂 Erythema/oedema: otitis externa 

Inspect the 4 quadrants of the tympanic membrane (TM): 

👂 Colour: healthy TM should be grey/translucent, erythema indicates inflammation caused by acute otitis media 

👂 Shape: healthy TM should be flat, bulging TM indicates raised middle ear pressure due to acute otitis media with effusion whilst reduced TM indicates reduced middle ear pressure to to pharyngotympanic tube dysfunction 

👂 Light reflex: cone shaped light reflection, visible when light is shone onto TM, absence/distortion indicates otitis media  

👂 Perforation: assess size and location of TM perforations, caused by infection/trauma/tympanostomy tube insertion/cholesteatoma  

👂 Scarring: tympanosclerosis can cause significant hearing loss, often caused by otitis media or tympanostomy tube insertion 

Otoscopy completion: 

1. Carefully withdraw otoscope 
2. Repeat assessment on other ear for comparison 👂
3. Appropriately discard of speculum after first ear if infected or after second if not 

What is acute otitis media ❓ 

👂 Inflammation of middle ear 👂

👂 Due to viruses/bacteria 

👂 Bulging red, yellow or cloudy TM 

👂 May be auditory canal discharge if TM is perforated 

What is otitis externa ❓ 

👂 Inflammation of outer ear 👂

👂 Affects auricle, external auditory canal, and TM external surface 

👂 Caused by bacteria 

👂 Erythema, pain and possible oedema of auditory canal 

Completion 

1. Tell the patient that the examination is now complete
2. Thank the patient
3. Dispose of PPE appropriately
4. Wash your hands
5. Summarise what the examination revealed

Summary:

1. Greet patient and explain the procedure
2. Inspect the patient to identify anything relevant such as hearing aids or mobility aids
3. Perform a hearing test
4. Perform Weber's test and Rinne's test to identify sensorineural deafness or conductive deafness
5. Inspect and palpate the outer ear
6. Inspect the otoscope to inspect the inner ear
7. Complete the procedure by thanking the patient