Hearing assessment and otoscopy frequently appear in OSCEs and you should feel confident in carrying out an examination of the ears. You’ll be expected to pick up the relevant clinical signs using your examination skills. Technique is very important to this station, so ensure you’ve practiced how to hold and use an otoscope before your exam.
Examining normal ears will make detecting pathology much easier. Often there is no pathology to see and the examiners will fabricate a hearing loss to be picked up using the objective tests below.
This ear examination guide provides a clear step by step approach to the station. Check out the Hearing assessment and Otoscopy OSCE mark scheme here.
Confirm patient details – name / DOB
“Today I’d like to examine your ears, this will involve me having a look inside your ears using a special piece of equipment known as an otoscope. In addition, I’ll also be assessing your hearing using a number of different tests“
Gain consent “Does everything I’ve said make sense?“ “Are you happy for me to go ahead?“
Gross hearing assessment
Ask the patient if they have noticed any change in their hearing recently.
Explain that you’re going to say 3 words or 3 numbers and you’d like them to repeat them back to you (choose two-syllable words or bi-digit numbers).
1. Approximately 60cm from the ear, whisper a number or word.
2. Mask the ear not being tested by rubbing the tragus. Do not place your arm across the face of the patient when rubbing the tragus, it is far nicer to occlude the ear from behind the head. If possible shield the patient’s eyes to prevent any visual stimulus.
3. Ask the patient to repeat the number or word back to you. If they get 2/3 correct then their hearing level is 12db or better. If there is no response use a conversational voice (48db or worse) or loud voice (76db or worse).
4. If there is no response you can move closer and repeat the test at 15cm. Here the thresholds are 34db for a whisper and 56db for a conversational voice.
5. Assess the other ear in the same way.
Explain to the patient that you are going to test their hearing using a tuning fork.
1. Tap a 512Hz tuning fork and place in the midline of the forehead. The tuning fork should be set in motion by striking it on your knee (not the patient’s knee or a table).
2. Ask the patient “Where do you hear the sound?“
- Normal – sound is heard equally in both ears
- Sensorineural deafness – sound is heard louder on the side of the intact ear
- Conductive deafness – sound is heard louder on the side of the affected ear
We use 512Hz as this gives the best balance between time of decay and tactile vibration. Ideally, you want a fork that has a long period of decay and cannot be detected by vibration sensation.
1. Place a vibrating 512 Hz tuning fork firmly on the mastoid process (apply pressure to the opposite side of the head to make sure the contact is firm). This tests bone conduction.
2. Confirm the patient can hear the sound of the tuning fork and then ask them to tell you when they can no longer hear it.
3. When the patient can no longer hear the sound, move the tuning fork in front of the external auditory meatus to test air conduction.
4. Ask the patient if they can now hear the sound again. If they can hear the sound, it suggests air conduction is better than bone conduction, which is what would be expected in a healthy individual (this is often confusingly referred to as a “Rinne’s positive” result).
Summary of Rinne’s test results:
- Normal result: Air conduction > Bone conduction (Rinne’s positive)
- Sensorineural deafness: Air conduction > Bone conduction (Rinne’s positive) – both air and bone conduction reduced equally
- Conductive deafness: Bone conduction > Air conduction (Rinne’s negative)
Ask the patient if they have any ear discomfort (if so examine the non-painful side first).
Ask the patient which is their “better” ear. Always examine the better ear first to act as a marker for comparison.
Test your otoscope to check that it is working and commence inspection.
If the patient has an infection in one ear, you should change the speculum on the otoscope before examining the other ear.
Inspect the pinnae:
- Compare symmetry with the other side
- Ear piercings
- Signs of active infection
Inspect behind the pinnae (mastoid):
- Skin changes
- Scars (previous surgery)
- Ask about any pain in this region
Pre-auricular area (in front of the ear):
Conchal bowl – look for signs of active infection
Ear canal / tympanic membrane
Ensure the light is working on the otoscope and apply a sterile speculum (the largest that will comfortably fit in the external auditory meatus).
Make sure to compare both ears.
1. Pull the pinna upwards and backwards with your other hand to straighten the external auditory meatus.
2. Position otoscope at the external auditory meatus:
- Otoscope should be held in your right hand for the patient’s right ear and vice versa
- Hold the otoscope like a pencil and rest your hand against the patient’s cheek for stability. This will also stop damage to the ear if there is any sudden movement.
3. Advance the otoscope under direct vision. Be gentle with the otoscope and ensure movements are slow and considered otherwise you will cause the patient pain.
4. Look for any wax, swelling, erythema, discharge, foreign bodies or bony swellings.
5. Examine the tympanic membrane (think of it as having 4 quadrants which you should systematically examine to avoid missing pathology):
- Colour – pearly grey and translucent (normal) / erythematous (inflammation)
- Erythema or bulging of the membrane – inspect for a fluid level e.g. otitis media
- Perforation of the membrane – note the size of the perforation
- Light reflex – absence/distortion may indicate ↑ inner ear pressure e.g. otitis media
- Scarring of the membrane – tympanosclerosis – can result in significant hearing loss
- Cholesteatoma – around the superior part of the eardrum
6. Withdraw the otoscope carefully
7. Discard the otoscope speculum into a clinical waste bin
To complete the examination
Suggest further assessments and investigations
- Cranial nerve examination, paying particular attention to the facial nerve
- Audiometry and tympanometry
Mr Krishan Ramdoo
ENT Registrar (ST6)
Mr Ben Cosway
ENT Registrar (ST5)
1. By Michael Hawke MD [CC BY 4.0 (https://creativecommons.org/licenses/by/4.0)], from Wikimedia Commons