ST.

ANTHONY’S COLLEGE
San Jose, Antique

ASSESSING EARS

Definition:

The ear and hearing examination is to evaluate the condition of the external ear, the condition and
patency of the ear canal, the status of the tympanic membrane, bone and air conduction of sound vibrations,
hearing acuity, and equilibrium.

Goal:

Perform a physical assessment of the ears and hearing ability using the correct techniques. Differentiate
between normal and abnormal findings of the ear and hearing.

Equipment:

• Snellen or E chart
• Hand-held Snellen card or near-vision screener
• Penlight
• Opaque cards
• Ophthalmoscope
• Disposable gloves

Step
Preparation
1. Introduce self and verify client’s identity.
2. Explain the procedure to the client.
3. Perform hand hygiene and observe other
appropriate infection prevention procedures.
4. Gather the equipment and bring them to
bedside.
5. Provide for client’s privacy.
6. Position the client appropriately.
Rationale/Findings
 Establishes rapport and ensures correct patient.
 Providing information fosters cooperation, trust,
understanding, and participation in care.
 Prevents transmission of microorganisms.
 Organization facilitates accurate skill performance
 Maintains privacy.
 To promote patient’s comfort and safety and
effectiveness of the procedure.

External Ear Structures

7. Inspect the auricle, tragus, and lobule for size
and shape, position, lesions/discoloration, and
discharge.
 Ears are equal in size bilaterally (normally 4–10 cm).
The auricle aligns with the corner of each eye and
within a 10-degree angle of the vertical position.
Earlobes may be free, attached, or soldered.
 The skin is smooth, with no lesions, lumps, or nodules.
Color is consistent with facial color.
 Darwin’s tubercle, which is a clinically insignificant
projection, may be seen on the auricle.
 No discharge should be present.
 Ears are smaller than 4 cm or larger than 10 cm.
 Malaligned or low-set ears may be seen with
genitourinary disorders or chromosomal defects.
 Some abnormal findings suggest various disorders,
including:
• Enlarged preauricular and postauricular lymph
nodes—infection
• Tophi (nontender, hard, cream-colored nodules
on the helix or antihelix, containing uric acid
crystals)—gout
• Blocked sebaceous glands—postauricular cysts
• Ulcerated, crusted nodules that bleed—skin
cancer (most often seen on the helix due to skin
 ST. ANTHONY’S COLLEGE
San Jose, Antique
8. Palpate the auricle and mastoid process for
tenderness.
Otoscopic Examination
9. Inspect the external auditory canal with the 
otoscope for discharge, color and consistency of
cerumen, color and consistency of canal walls,
and nodules.
10. Inspect the tympanic membrane, using the
otoscope, for color and shape, consistency, and
landmarks.
exposure)
• Redness, swelling, scaling, or itching—otitis
externa
• Pale blue ear color—frostbite
 Normally the auricle, tragus, and mastoid process are
not tender.
 A painful auricle or tragus is associated with otitis
externa or a postauricular cyst.
 Tenderness over the mastoid process suggests
mastoiditis.
 Tenderness behind the ear may occur with otitis
media.
A small amount of odorless cerumen (earwax) is the
only discharge normally present. Cerumen color may
be yellow, orange, red, brown, gray, or black.
Consistency may be soft, moist, dry, flaky, or even
hard.
 The canal walls should be pink and smooth, without
nodules.
 Abnormal findings associated with specific disorders
include:
• Foul-smelling, sticky, yellow discharge—otitis
externa or impacted foreign body
• Bloody, purulent discharge—otitis media with
ruptured tympanic membrane
• Blood or watery drainage (cerebrospinal fluid)—
skull trauma (refer client to physician
immediately)
• Impacted cerumen blocking the view of the
external ear canal—conductive hearing loss
• Refer any client with presence of foreign bodies
such as bugs, plants, or food to the health care
practitioner for prompt removal due to possible
swelling and infection. If the object in the ear is a
button-type battery, medical attention is urgent as
leaking chemicals can burn and damage the ear
canal even within 1 hour.
 Abnormal findings in the ear canal may include:
• Reddened, swollen canals—otitis externa
• Exostoses (nonmalignant nodular swellings)
• Polyps may block the view of the eardrum
 The tympanic membrane should be pearly, gray, shiny,
and translucent, with no bulging or retraction. It is
slightly concave, smooth, and intact. A cone-shaped
reflection of the otoscope light is normally seen at 5
o’clock in the right ear and 7 o’clock in the left ear.
The short process and handle of the malleus and the
umbo are clearly visible.
 Abnormal findings in the tympanic membrane may
include:
• Red, bulging eardrum and distorted, diminished,
or absent light reflex—acute otitis media
• Yellowish, bulging membrane with bubbles
behind—serous otitis media
• Bluish or dark red color—blood behind the
eardrum from skull trauma
• White spots—scarring from infection
• Perforations—trauma from infection
 ST. ANTHONY’S COLLEGE
San Jose, Antique
Hearing and Equilibrium Tests
11. Perform the whisper test by having the
client place a finger on the tragus of one ear.
Whisper a two-syllable word 30.4–60.9 cm (1–2 
ft) behind the client. Repeat on the other ear.
12. Perform the Weber test by using a tuning
fork placed on the center of the head or
forehead and asking whether the client hears the 
sound better in one ear or the same in both ears.
13. Perform the Rinne test by using a tuning
fork and placing the base on the client’s mastoid
process. When the client no longer hears the
sound, note the time interval, and move it in
front of the external ear. When the client no
longer hears a sound, note the time interval.
14. Perform the Romberg test to evaluate
equilibrium. With feet together and arms at the
side, close eyes for 20 seconds. Observe for
swaying.
Completing the examination
15. Makes the client comfortable.
16. Tells the client the results of the
examination and asks if there are any questions.
17. Washes hands (alcohol or soap)..
• Prominent landmarks—eardrum retraction from
negative ear pressure resulting from an obstructed
eustachian tube
• Obscured or absent landmarks—eardrum
thickening from chronic otitis media.
 Able to correctly repeat the two-syllable word as
whispered.
Unable to repeat the two-syllable word after two tries
indicates hearing loss and requires follow-up testing by
an audiologist.
 Vibrations are heard equally well in both ears. No
lateralization of sound to either ear.
With conductive hearing loss, the client reports
lateralization of sound to the poor ear—that is, the
client “hears” the sounds in the poor ear. The good ear
is distracted by background noise and conducted air,
which the poor ear has trouble hearing. Thus the poor
ear receives most of the sound conducted by bone
vibration.
 With sensorineural hearing loss, the client reports
lateralization of sound to the good ear. This is because
of limited perception of the sound due to nerve damage
in the bad ear, making sound seem louder in the
unaffected ear.
 With conductive hearing loss, bone conduction (BC)
sound is heard longer than or equally as long as air
conduction (AC) sound (BC ≥ AC).
 Conductive hearing loss occurs when sound is not
conducted through the outer ear canal to the eardrum
and ossicles of the middle ear. Possible causes include:
fluid in middle ear, middle-ear infection (otitis media),
allergies (serous otitis media), eustachian tube
dysfunction, perforated eardrum, benign tumors,
impacted cerumen, infection in the ear canal (external
otitis) or presence of a foreign body.
 Air conduction sound is normally heard longer than
bone conduction sound (AC > BC).
 With sensorineural hearing loss, air conduction sound
is heard longer than bone conduction sound (AC > BC)
if anything is heard at all.
 Sensorineural hearing loss occurs with damage to the
inner ear (cochlea), or to the nerve pathways between
the inner ear and brain. This is the most common type
of permanent hearing loss. It decreases one’s ability to
hear faint sounds. Even loud speech may be muffled.
Causes include: ototoxic drugs, genetic hearing loss,
aging, head trauma, malformation of the inner ear, and
loud noise exposure.
 Client maintains position for 20 seconds without
swaying or with minimal swaying.
 Client moves feet apart to prevent falls or starts to fall
from loss of balance. This may indicate a vestibular
disorder.
 To provide comfort and safety to the patient.
 To keep the patient informed of her situation and give
chance to answer questions and clarifications.
 Prevents transmission of microorganisms.
 ST. ANTHONY’S COLLEGE
San Jose, Antique

18. Document findings.  Documentation provides coordination of care.

Competency Performance Checklist

ASSESSING EARS
 ST. ANTHONY’S COLLEGE
San Jose, Antique

Name: ___________________________________________ Date: _____________________

Clinical Instructor/ Evaluator: ______________________________________________________

Skill Competency Demonstrated

Done Not Done
Preparation
1. Introduce self and verify client’s identity.
2. Explain the procedure to the client.
3. Perform hand hygiene and observe other appropriate infection prevention
procedures.
4. Gather the equipment and bring them
5. to bedside.
5. Provide for client’s privacy.
6. Position the client appropriately.
External Ear Structures
7. Inspect the auricle, tragus, and lobule for size and shape, position,
lesions/discoloration, and discharge.
8. Palpate the auricle and mastoid process for
tenderness.
Otoscopic Examination
9. Inspect the external auditory canal with the otoscope for discharge, color
and consistency of cerumen, color and consistency of canal walls, and
nodules.
10. Inspect the tympanic membrane, using the otoscope, for color and shape,
consistency, and landmarks.
Hearing and Equilibrium Tests
11. Perform the whisper test by having the client place a finger on the tragus
of one ear. Whisper a two-syllable word 30.4–60.9 cm (1–2 ft) behind the
client. Repeat on the other ear.
12. Perform the Weber test by using a tuning fork placed on the center of the
head or forehead and asking whether the client hears the sound better in one
ear or the same in both ears.
13. Perform the Rinne test by using a tuning fork and placing the base on the
client’s mastoid process. When the client no longer hears the sound, note the
time interval, and move it in front of the external ear. When the client no
longer hears a sound, note the time interval.
14. Perform the Romberg test to evaluate equilibrium. With feet together
and arms at the side, close eyes for 20 seconds.
15. Observe for swaying.
Completing the examination
16. Makes the client comfortable.
17. Tells the client the results of the examination and asks if there are any
questions.
18. Washes hands (alcohol or soap).
19. Document findings.
Final Score /19

Expected Level of Performance

15 to 19 items DONE: PASSED
Less than 15 items DONE: (Repeat Procedure to Pass)

___________________________________ ___________________________________
Student’s Signature Clinical Instructor’s Signature