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P r o c e d u r e 4 . 2 Assessing the Ears 61

PROCEDURE 4.2
Assessing the Ears
OVERVIEW
● Plays an important role in the function of the ear as the sensory
organ for hearing and maintaining equilibrium.
● Can help determine if hearing, equilibrium, or even speech problems

stem from the ear, or if the neurologic system may be involved.

P R E PA R AT I O N
● Review related history that would give the examiner information
(past and present) regarding patient’s hearing and general ear con-
dition, including earaches, infections, tinnitus, vertigo, and speech-
development problems.
● Ask about the intake of ototoxic drugs such as aspirin, furosemide,

quinine, and aminoglycosides (gentamycin, vancomycin).

● Observe for signs of hearing loss during all interactions with the

patient.
● Adjust your examination for the developmental and cultural needs

of the patient.

Special Considerations
• Never insert a speculum if a foreign object is seen in the external
auditory canal.
Pediatric Patient
• In infants and children, otoscopic examination is best done at the end
of the complete assessment, because children tend to protest. Make
sure the child is securely restrained, preferably in the caretaker’s lap,
to prevent head movement during the examination. Remember to
pull the pinna straight down and back in children younger than 3
years old to match the direction of the ear canal. The tympanic mem-
branes of a child may appear reddened and swollen, especially after
crying. A pneumatic bulb may be used in children to introduce air
into the canal and examine the mobility of the tympanic membrane.
• Use developmental milestones to assess hearing in an infant. Loud,
sudden sound should produce:
• Newborn—startle reflex, acoustic blink reflex
• 3–4 months—acoustic blink reflex, infant stops movement
• 6–8 months—turns head toward sound, responds to own name
• Delayed speech development can indicate a hearing problem in
children.
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62 C h a p t e r 4 Physical Assessment

Elderly Patient
• Elderly patients may have more pendulous earlobes; men may have
coarse hairs present at the opening of the ear canal; the eardrum
may appear whiter, thicker, and more opaque than in younger
patients.
• Presbycusis, the hearing loss that occurs with aging, affects the high-
frequency tones.
• This condition may become apparent in the whispered test and in
difficulty hearing consonants during conversation.

R E L E VA N T N U R S I N G D I A G N O S E S
● Possible disturbed sensory perception: auditory

EXPECTED OUTCOMES
● Completion of the assessment, including examination of the external
ear, internal ear, hearing, and equilibrium while maintaining patient
comfort and safety
● Examination performed appropriately for age, and developmental

and educational levels

EQUIPMENT/SUPPLIES
Otoscope with bright white light
Pneumatic bulb attachment
(optional)
Tuning fork (512 or 1024 Hz)

FIGURE 4.2A Otoscope.

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P r o c e d u r e 4 . 2 Assessing the Ears 63

FIGURE 4.2B Tuning fork.

I M P L E M E N TAT I O N
➧ Inspect the external ear.
Provides information and evidence of infection, deformities, trauma, or sys-
temic problems.
● Note placement, size, shape, symmetry of placement, and skin color.
Abnormal size or placement of ears is associated with some genetic disor-
ders; reddened ears may indicate inflammation, whereas red-blue color indi-
cates frostbite. Ecchymosis behind the ear (Battle’s sign) may indicate basilar
skull fracture.
● Observe for drainage, swelling, lumps, and lesions.
These signs are often found in infection, dermatitis, or carcinoma.
➧ Palpate the external ear for nodules and tenderness.
Uncovers abnormalities that cannot be seen.
● Move the pinna, push on the tragus, and press on the mastoid
process.
These maneuvers elicit pain and tenderness with otitis externa, mastoiditis,
or trauma.
➧ Inspect the external auditory meatus noting the size of the opening,
any redness, swelling, or discharge
Cerumen may be present, but other discharge may indicate infection.
➧ Examine the ear canal and eardrum using the otoscope.
Provides a thorough examination of the ear that cannot be examined with
the naked eye
● Choose the largest speculum that will fit comfortably in the ear
canal. Slightly tilt the patient’s head to the opposite shoulder of
the ear that is being examined
This will provide the best view of the eardrum.
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64 C h a p t e r 4 Physical Assessment

● Pull the pinna up and back in

an adult using your nondomi-
nant hand. Maintain this
position until the otoscope
is removed.
Pulling the pinna up and back
in the adult helps to straighten
the ear canal.
● Hold the otoscope in your
dominant hand in an upside-
down position with the back
of your hand braced on the
patient’s cheek.
This position helps to prevent
forceful insertion and also
stabilizes your hand in case
the patient’s head moves.
● Insert the speculum slowly, FIGURE 4.2C Otoscope in sertion.
avoiding the medial wall, which is sensitive to pain. Observe the
canal for redness, swelling, discharge, foreign bodies, and lesions.
Redness, swelling, and purulent discharge suggests otitis externa or otitis
media with a ruptured eardrum. Frank blood or clear, watery fluid following
trauma is associated with basal skull fracture.
● Inspect the eardrum, noting the color, contour, and integrity of the
eardrum.
Normally the eardrum is shiny, translucent, pearl-gray. Other colors indicate
infection, or the accumulation of serous fluid behind the eardrum. A perfo-
rated eardrum presents as a dark oval area or a larger opening on the drum.
● Observe the umbo, the handle of the malleus, and the cone of light
(noted at 5 o’clock in the right drum and at 7 o’clock in the left
drum.
Absent or distorted landmarks indicate fluid accumulation or a ruptured
eardrum.

pars
flaccida
malleous
umbo

cone of pars
light tensa

FIGURE 4.2D Eardrum.

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P r o c e d u r e 4 . 2 Assessing the Ears 65

➧ Clean off any discharge or change the speculum, and repeat the
procedure for the other ear.
Helps to prevent contamination of the other ear with possibly infectious
material.

➧ Test hearing acuity.

Tests conductive hearing as well as cranial nerve VIII.

➧ Voice Test (Whisper Test)

Tests gross acuity of hearing.
● Direct patient to occlude one ear by placing his or her finger on
the tragus and rapidly push it in and out of the auditory meatus.
This will mask the hearing in that ear while hearing is tested in the other ear.
● Have the patient repeat each word after you say it.
Verifies that the patient correctly heard the whispered word.
● Repeat for the other ear.
Tests gross acuity in both ears.

➧ Weber Test
Tests lateralization of sound.
● Gently strike the tines of a
tuning fork against your
other hand.
Sets the tuning fork vibrating.
● Place the vibrating tuning
fork on the midline of the
patient’s skull. Ask the patient
where the tone is heard: left
ear, right ear, or both.
Tests bone conduction through
the skull; it should sound equally
loud in both ears.

FIGURE 4.2E Weber test.

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66 C h a p t e r 4 Physical Assessment

➧ Rinne Test
Compares air conduction
and bone conduction of sound.
● Place the base of a vibrating
tuning fork on the patient’s
mastoid process; have the
person signal when the
sound is no longer heard.
Determines the length of
bone conduction.
● When the tone is no longer FIGURE 4.2F Rinne test.
heard, quickly move the fork
so that the tines are near the ear canal. Ask the patient if the
tone is heard, and direct him or her to signal when it ends.
Determines the length of air conduction.
● Compare the time of bone conduction to the time of air
conduction.
Normally, air conduction is twice as long as bone conduction; variations
from normal may indicate a conductive or sensorineural hearing loss.

➧ Perform the Romberg test.

Tests the ability of the vestibular apparatus in the inner ear to help maintain
standing balance.
● Direct the patient to stand with feet together and arms at the
sides, then have the person close his or her eyes and hold the
position.
Normally, the patient is able to maintain this position without sway-
ing or falling for at least 20 seconds. A positive Romberg test (loss
of balance) may indicate inner-ear problems or a problem with the
cerebellum.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Refer patient to an audiologist or physician for further testing and
evaluation of abnormal findings if needed