1. Ear Exam and Hearing

1. Inspect the auricles and the surrounding tissue for skin changes, nodules, and deformities.
2. Grasp the helix superiorly between the thumb and forefinger one at a time and gently pull up and backward to check for discomfort anywhere in the external ear.
3. Palpate the tragus and mastoid process for tenderness.
4. Perform the whispered voice test for auditory acuity.
   1. Make certain that the room is quiet.
   2. Stand 2 ft behind the seated patient so your face is not visible.
   3. Gently press and rub a finger against the tragus of the non-test ear, so it can detect no other sounds.
   4. Exhale completely and whisper a combination of 3 numbers and letters.
   5. Ask the patient to repeat them back before duplicating the process with a different combination for the opposite ear. Correctly reporting all 3 numbers and letters constitutes a normal test. If the patient makes any mistakes, repeat the test on that side. The test is still considered normal if the patient correctly reports at least 3 out of the 6 numbers and letters per side.
5. If the patient fails the whispered voice test, conduct a tuning fork test to help determine whether the hearing loss is conductive or neurosensory.
   1. Set a 256- or 512-Hz tuning fork vibrating by tapping it sharply against your knuckles or palm.
   2. Check for lateralization (Weber test): Firmly place the non-vibrating base of the turning fork midline on the patient's head. Normally, the vibration is heard centrally or in both ears equally. In unilateral neurosensory hearing loss, sound is localized to the good ear, whereas in unilateral conductive hearing loss, sound is localized to the impaired ear.
   3. Compare bone vs. air conduction (Rinne test): Place the base of the vibrating tuning fork on the mastoid process. At the moment the patient can no longer hear the vibration sound, quickly transfer the vibrating end of the tuning fork close to the external canal. Since air conduction exceeds bone conduction, sound is normally still detectable. In conductive hearing loss, however, bone conduction equals or exceeds air conduction, so the patient may report hearing no further sound once the tuning fork is moved. In neurosensory hearing loss, the opposite is true: the patient may report hearing sound after the transfer. Repeat the test on the opposite side. To avoid false positive results, it is best to avoid the Weber and Rinne tests in patients who pass the whispered voice test.

2. Otoscopic Exam

1. Turn on the otoscope and select the brightest setting.
2. Attach the largest ear speculum that comfortably fits the patient's auditory canal.
3. When examining the patient's right ear, hold the otoscope in your right hand, as if holding a pencil.
4. Stabilize the otoscope by resting your fourth and fifth fingers on the patient's cheek, so the otoscope follows any unexpected movements.
5. Using your left hand, pull the auricle slightly up and back to help straighten the auditory canal, and establish a clear line of sight to the tympanic membrane.
6. As this is done, gently insert the speculum into the canal, directing it slightly forward and down.
7. Ask the patient to report any discomfort. Take care not to insert the speculum too deeply, as this may reach the bony canal and cause severe pain.
8. If cerumen obstructs the view, do not attempt to remove it with a swab or sharp instrument. Instead, irrigate the canal with warm water using a plastic syringe, which is generally a safer and more effective approach.
9. Resist the urge to direct immediate attention to the tympanic membrane, and examine the canal first, noting any redness, discharge, swelling, or masses.
10. Gently readjust the angle of the speculum as necessary to view the entire tympanic membrane.
11. Orient yourself by first identifying the cone of light as it spreads anteriorly and inferiorly from umbo near the center.
12. At the origin of the cone of light, look for the handle of the malleus and the short process above. From there, identify the superior pars flaccida and the much larger inferior pars tensa. The incus may or may not be visible just posterior to the handle of the malleus. The stapes and the opening to the Eustachian tube are not visible.
13. Check for membrane redness, retraction, bulging, perfusion, or opacity; dull or absent cone of light; and serous or purulent middle ear effusions. If any abnormalities are seen, consider using a pneumatic otoscope equipped with an insufflator to assess membrane mobility.