Term
1. Earache.
Any
earache
or other pain in ears?
• Location—feel close to the surface or deep in the head?
• Does it hurt when you push on the ear?
• Character—dull, aching or sharp, stabbing? Constant or come and go? Is it affected by changing position of head?
• Any accompanying cold symptoms or sore throat? Any problems with sinuses or teeth?
• Ever been hit on the ear or on the side of the head or had any sport injury? Ever had any trauma from a foreign body
• What have you tried to relieve pain?
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Definition
Otalgia
may be directly due to ear disease or may be referred pain from a problem in teeth or oropharynx.
Virus/bacteria from upper respiratory infection may migrate up the eustachian tube to involve the middle ear.
Trauma may rupture the tympanic membrane (TM).
Assess effect of coping strategies.
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Term
2. Infections.
Any ear
infections?
As an adult, or in childhood?
• How frequent were they? How were they treated?
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Definition
A history of chronic ear problems suggests possible sequelae.
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Term
3. Discharge.
Any
discharge
from your ears?
• Does it look like pus, or is it bloody?
• Any odor to the discharge?
• Any relationship between the discharge and the ear pain?
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Definition
Otorrhea
suggests infected canal or perforated eardrum, such as:
External otitis
—purulent, sanguineous, or watery discharge.
Acute otitis media with perforation
—purulent discharge.
Cholesteatoma
—dirty yellow/gray discharge, foul odor.
Typically with perforation—ear pain occurs first, stops with a popping sensation, then drainage occurs.
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Term
4. Hearing loss.
Ever had anytrouble hearing?
• Onset—did the loss come on slowly or all at once?
• Character—has all your hearing decreased, or just on hearing certain sounds?
• In what situations do you notice the loss: conversations, using the telephone, listening to TV, at a party?
• Do people seem to shout at you?
• Do ordinary sounds seem hollow, as if you are hearing in a barrel or under water?
• Recently traveled by airplane?
• Any family history of hearing loss?
• Effort to treat—any hearing aid or other device? Anything to help hearing?
• Coping strategies—how does the loss affect your daily life? Any job problem? Feel embarrassed? Frustrated?
How do your family, friends react? |
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Definition
Presbycusis
is gradual onset over years, whereas a trauma hearing loss is often sudden. Refer any sudden loss in one or both ears
not
associated with upper respiratory infection (URI).
Loss shows with competition from background noise, as at a party.
Recruitment
—a marked loss when speech is at low intensity, but sound actually becomes painful when speaker repeats in a loud voice.
Character of hearing loss when cerumen expands and becomes impacted, as after swimming or showering.
Hearing loss can cause social isolation and lessen pleasure of leisure activities.
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Term
Note to examiner
—during history, note these clues from normal conversation that indicate possible hearing loss. |
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Definition
1 Person lip reading or watching your face and lips closely rather than your eyes
2 Frowning or straining forward to hear
3 Posturing of head to catch sounds with better ear
4 Misunderstands your questions or frequently asks you to repeat
5 Acts irritable or shows startle reflex when you raise your voice (recruitment)
6 Person's speech sounds garbled, possibly vowel sounds distorted
7 Inappropriately loud voice
8 Flat, monotonous tone of voice |
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Term
5. Environmental noise.
Any loud noises at home or on the job?For example, do you live in a noise-polluted area, near an airport or busy traffic area? Now or in the past?
• Are you near other noises such as heavy machinery, loud persistent music, gunshots while hunting?
• Coping strategies—any steps to protect your ears, such as headphones or ear plugs? |
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Definition
| Old trauma to hearing initially goes unnoticed but results in further decibel loss in later years. |
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Term
6. Tinnitus.
Ever felt ringing, crackling, or buzzing in your ears? When did this occur?
• Seem louder at night?
• Are you taking any medications? |
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Definition
Tinnitus
originates within the person; it accompanies some hearing or ear disorders.
Tinnitus seems louder with no competition from environment noise.
Many medications have ototoxic sequelae:
aspirin, aminoglycosides (streptomycin, gentamicin, kanamycin, neomycin), ethacrynic acid, furosemide, indomethacin, naproxen, quinine, vancomycin. |
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Term
7. Vertigo.
Ever felt
vertigo;
that is, the room spinning around or yourself spinning? (Vertigo is a true twirling motion.)
• Ever felt dizzy, like you are not quite steady, like falling or losing your balance? Giddy, light-headed? |
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Definition
True rotational spinning occurs with dysfunction of labyrinth.
Objective vertigo—feels like room spins.
Subjective vertigo—person feels like he or she spins.
Distinguish true vertigo from dizziness or light-headedness. |
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Term
8. Self-care behaviors.
How do you clean your ears?
• Last time you had your hearing checked?
• If a hearing loss was noted, did you obtain a hearing aid?
How long have you had it? Do you wear it? How does it work?
Any trouble with upkeep, cleaning, changing batteries? |
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Definition
Assess potential trauma from invasive instruments.
Cotton-tipped applicators can impact cerumen, causing hearing loss.
Prescribe frequency of hearing assessment according to person's age or risk factors. |
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Term
INSPECT AND PALPATE THE EXTERNAL EAR
Size and Shape
The ears are of equal size bilaterally with no swelling or thickening.
Ears of unusual size and shape may be a normal familial trait with no clinical significance. |
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Definition
Microtia
—ears smaller than 4 cm vertically;
macrotia
—ears larger than 10 cm.
Edema with infection or trauma. |
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Term
Skin Condition
The skin color is consistent with the person's facial skin color.
The skin is intact, with no lumps or lesions.
On some people you may note Darwin's tubercle, a small, painless nodule at the helix.
This is a congenital variation and is not significant (Fig 15-6). |
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Definition
Reddened, excessively warm skin with inflammation (see Table 15-1, Abnormalities of the External Ear, p. 341).
Crusts and scaling occur with otitis externa, eczema, contact dermatitis, seborrhea.
Enlarged, tender lymph nodes in the region indicate inflammation of the pinna or mastoid process.
Red-blue discoloration with frostbite.
Tophi, sebaceous cyst, chondrodermatitis, keloid, carcinoma (see Table 15-2, Lumps and Lesions on the Ear, pp. 342-343). |
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Term
Tenderness
Move the pinna and push on the tragus.
They should feel firm, and movement should produce no pain.
Palpating the mastoid process should also produce no pain. |
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Definition
Pain with movement occurs with otitis externa and furuncle.
Pain at the mastoid process may
indicate mastoiditis or enlarged posterior auricular node. |
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Term
The External Auditory Meatus
Note the size of the opening to direct your choice of speculum for the otoscope.
No swelling, redness, or
Some cerumen is usually present.
The color varies from gray-yellow to light brown and black, and the texture varies from moist and waxy to dry and desiccated.
A large amount of cerumen obscures visualization of the canal and drum. |
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Definition
A sticky, yellow discharge accompanies otitis externa or may indicate otitis media if the drum has ruptured.
Impacted cerumen is a common cause of conductive hearing loss. |
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Term
The External Canal
Note any redness and swelling, lesions, foreign bodies, or discharge.
If any discharge is present, note the color and odor.
(Also, clean any discharge from the speculum before examining the other ear to avoid contamination with possibly infectious material.)
For a person with a hearing aid, note any irritation on the canal wall from poorly fitting ear molds. |
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Definition
Redness and swelling occur with otitis externa; canal may be completely closed with swelling.
Purulent otorrhea suggests otitis externa or otitis media if the drum has ruptured.
Frank blood or clear, watery drainage (cerebrospinal fluid [CSF]) after trauma suggests basal skull fracture and warrants immediate referral.
CSF feels oily and is positive for glucose on TesTape.
Foreign body, polyp, furuncle, exostosis (see Table 15-3, Abnormalities in the Ear Canal). |
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Term
The Tympanic Membrane
Color and Characteristics.
Systematically explore its landmarks (
Fig. 15-9
). The normal eardrum is shiny and translucent, with a pearl gray color.The cone-shaped light reflex is prominent in the anteroinferior quadrant (at the 5 o'clock position in the right drum and the 7 o'clock position in the left drum).This is the reflection of your otoscope light.Sections of the malleus are visible through the translucent drum: the umbo, manubrium, and short process.(Infrequently, you also may see the incus behind the drum; it shows as a whitish haze in the upper posterior area.)At the periphery, the annulus looks whiter and denser. |
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Definition
Yellow-amber drum color occurs with otitis media with effusion (serous).
Red color with acute otitis media.
Absent or distorted landmarks.
Air/fluid level or air bubbles behind drum indicate otitis media with effusion (see Tables 15-4, Abnormal Views on Otoscopy, and 15-5, Abnormal Tympanic Membranes). |
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Term
Position.
The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). You may elicit these maneuvers to assess drum mobility.Avoid them with an aging person because they may disrupt equilibrium.Also avoid middle ear insufflation in a person with upper respiratory infection because it could propel infectious matter into the middle ear. |
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Definition
Retracted drum from vacuum in middle ear with obstructed eustachian tube.
Bulging drum from increased pressure in otitis media.
Drum hypomobility is an early sign of otitis media (see Table 15-5). |
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Term
Integrity of Membrane.
Inspect the eardrum and the entire circumference of the annulus for perforations.
The normal tympanic membrane is intact.
Some adults may show scarring, which is a dense white patch on the drum.
This is a sequela of repeated ear infections. |
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Definition
Perforation shows as a dark oval area or as a larger opening on the drum.
Vesicles on drum (see Table 15-5). |
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Term
Whispered Voice Test
Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. This is done by placing one finger on the tragus and rapidly pushing it in and out of the auditory meatus. Shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the “good” ear. With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly a set of 3 random numbers and letters, such as “5, B, 6.” Normally, the person repeats each number/letter correctly after you say it. If the response is not correct, repeat the whispered test using a different combination of 3 numbers and letters. A passing score is correct repeating of at least 3 out of a possible 6 numbers/letters.2 Assess the other ear using yet another set of whispered items. |
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Definition
| The person is unable to hear whispered items. A whisper is a high-frequency sound and is used to detect high-tone loss. |
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Term
The Aging Adult
An aging adult may have pendulous earlobes with linear wrinkling because of loss of elasticity of the pinna.
Coarse, wiry hairs may be present at the opening of the ear canal.
During otoscopy, the eardrum normally may be whiter in color and more opaque, duller than in the younger adult.
It also may look thickened.
A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging.
This condition is revealed in difficulty hearing whispered words in the voice test and in difficulty hearing consonants during conversational speech.
The aging adult feels that “people are mumbling” and feels isolated in family or friendship groups. |
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Definition
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