1. PHYSICAL EXAMINATION

2.  Examination of the ear and related head and neck structures should be performed in a systematic and consistent manner so that no part of the exam is neglected

3. EXTERNAL AUDITORY CANAL (EAC)  composed of cartilage covered by skin  outer 1/3 cartilaginous (mobile) - inner 2/3 bony  with narrowing at the bone-cartilage junction (narrowest area)  skin lining cartilaginous portion is thicker

4.  Bony portion of the EAC is the only structure in the body where there is skin directly overlying bone with no subcutaneous tissue  area is very sensitive and swelling is very painful as there is no room for expansion

6. AURICLE OR PINNA - A complex cartilaginous structure that is covered with skin -Has a variety of folds which are generally consistent but vary slightly from individual to individual -Important to know the embryology of the auricle in understanding the different pathological conditions

7.  Development of the auricle embryologically is complicated, sometimes resulting in developmental anomalies including pre auricular skin tags, and small accessory auricles

8.  Cosmetically pleasing auricle is generally positioned with the concha at a 90 degree angle lateral to the head  helix and antihelix must be well formed

9.  Noticeable differences, even if minor, between an individuals right and left auricles are abnormal and should suggest a pathological process

11. INSTRUMENTS USED IN DOING OTOSCOPY  Penlight  Aural speculum  Otoscope  Appropriate source of illumination – floor lamp, head mirror, head light

12.  Ear Examination Instruments  -penlight - may be used to examine external ear and ear canal  - ear speculum - utilized to widen the opening of the ear canal  - floor lamp - necessary for viewing the external and middle ear using a head mirror

13.  Head Mirror - used together with a floor lamp and ear speculum to view external and middle ear  Otoscope - used in place of a head mirror - does not require use of a floor lamp because of its built - in light source

14.  Select correct size of speculum  examine ear canal for inflammation, redness of skin, secretions, impacted cerumen or ear wax  always disinfect speculum to avoid cross- contamination

15. OTOSCOPY  Adequate examination of the external auditory canal requires proper positioning of the patient  Patient’s head must be tilted towards the opposite shoulder

16.  Since tilting the head is a position the patients do not normally assume, you should explain to them why you are doing this

17. Otoscopy  Examining an adult  Examining a child/infant

18.  In adults, the tragus should be gently pulled anteriorly and the pinna lifted in the postero superior direction to straighten the ear canal

19.  In infants and young children, the pinna should be pulled inferiorly because of the downward curvature of the normal infantile EAC

20.  In many individuals, the EAC is sufficiently large that drawing the tragus anteriorly and lifting the auricle upwards and posteriorly opens the meatus sufficiently wide to give us a good view of the EAC and tympanic membrane (TM).

21.  If not, a nonreflective aural speculum can be used to control the soft tissues of the lateral EAC and thus facilitate visualization o the medial EAC and TM.  The largest speculum that will fit comfortably gives the best exposure

22.  Use your non dominant hand to hold speculum so the dominant hand can be left free for instrumentation

23. INSERTING THE SPECULUM  The hand holding the speculum should gently rest against the patient’s head so that inadvertent movement by the patient will move the head and speculum together and prevent accidental injury to the EAC or TM.

24.  Speculum should not be inserted past the cartilaginous portion as this is the only part which is mobile or stretchable  Contact with the inner bony 1/3 of the canal is painful and does nothing to enhance visualization

25. Otoscope Advantages: Advantages: - handheld, portable - quick and easy to use - with good magnification - easily available and cheaper Limitation: - absence of binocular vision - absence of binocular vision

26. Microscope Advantages: -allows binocular vision, maximum illumination and magnification, -leaves the dominant hand free for effective and relatively easy instrumentation Limitation: Limitation: -availability and cost

27. CERUMEN  Typical pH of cerumen is 6.1  Conveyed along the EAC by the normal movements of the lower jaw while eating, yawning, and talking

28. CERUMEN  Consists of a combination of desquamated epithelium, thick sebaceous gland secretions, and thinner apocrine gland secretions  Water resistant, traps debris

29.  With both bacteriostatic and bactericidal activity due to the presence of saturated fatty acids, lysozymes and low pH

30. CERUMEN CERUMEN

32. METHODS IN CLEANING THE EAR  Should always be done under direct visualization using a cerumen spoon  Using a handheld otoscope with magnifying lens (operating otoscope)

33.  Aural Irrigation with warm water (not to be performed among patients with perforated TM’s, had otologic surgery, otitis externa, and with acute episodes of vertigo)

34. CERUMEN  Ceruminolytics – also called “cerumen softeners” also called “cerumen softeners” –Hydrogen peroxide –Mineral oil, baby oil –Commercially prepared otic drops (Otosol, Auralgan) –Water

35. CERUMEN After complete cerumen removal, evaluate the size and shape of the EAC If the diameter of the EAC is less than 4 mm., it is considered stenotic

36. TYMPANIC MEMBRANE  Eardrum-divides external from middle ear  conical structure with the point of the cone, umbo, directed medially  outer -epidermal layer; middle- fibrous layer; and an inner mucosal layer  fibrous layer is absent above the lateral process of malleus making it flaccid - Sharpnell’s membrane

37.  Take note of the color of the tympanic membrane  Normally it is grayish with variable transparency  Covered by smooth squamous epithelium  “cone of light” is seen at the anterior inferior quadrant

40.  The tympanic membrane is mobile and to perform its function, it should be able to vibrate  Restrictions in movement may be due to effusion in the middle ear  Ask patient to do Valsalva Maneuver to test mobility or use a pneumatic otoscope

41. ANCILLARY PROCEDURES

42. IMAGING STUDIES  Radiographic X-rays – done to visualize the middle ear structures, should always compare both sides, gives limited information –Schullers View – demonstrates mastoid air cells –Stenvers View –demonstrates petrous ridge and apex

43. COMPUTERIZED TOMOGRAPHY  For temporal bone imaging  With the ability to define specific bone structures  Axial and coronal cuts

45. MAGNETIC RESONANCE IMAGING  Best for detecting tumors, suspected vascular lesions  Less superior than CT in defining bony structures

46. CLINICAL HEARING TESTS

47. TUNING FORK TESTS  Goal: to differentiate between conductive and sensorineural hearing loss  CONDUCTIVE Hearing Loss (CHL)- caused by diseases of the external auditory canal or middle ear  SENSORINEURAL Hearing Loss(SNHL) – caused by problems in the cochlea and inner ear

48.  512 Hz TF - most commonly used  Can use a TF that vibrates between 250 and 800 Hz  Lower frequencies are avoided due to interference from perception of low frequency vibrations

49. - The TF should have a broad base -The base of the TF should be pressed firmly against the cranial bone inorder to transmit the vibrations to the bone and overcome dampening by the skin

50. WEBER TEST  The TF is placed in the midline of the skull, (vertex or forehead), vibration is transmitted by bone conduction to cochlea  When hearing is normal, vibrations are perceived equally loud on both sides (midway between the ears)  Comparing the right and left ear

52. Weber Test (con’t)  When hearing is abnormal, sound will lateralize to one side  SNHL – lateralizes to the better hearing ear  CHL- sound lateralizes to the poorer hearing ear because the vibrational energy is more poorly transmitted from the cochlea through the middle ear and would be harder for the sounds to reach the cochlea

53. RINNE TEST  In Rinne, we compare the levels of air and bone conduction in the same ear  Air conduction (AC) – tested by holding the TF just outside the ear canal without touching it  Bone conduction (BC) – tested by pressing the TF base firmly against the mastoid bone

56. Rinne Test (con’t)  Patient is asked to compare loudness in the 1 st position( AC) with the 2 nd position (BC)  Rinne Test Positive – AC > BC and lasts at least 15 seconds longer  Rinne Test Negative – AC< BC

57. BASIC AUDIOMETRY  Audiometry – measurement of auditory functions  Goals: - detection -lateralization -lateralization -quantification of a hearing disorder -quantification of a hearing disorder

58.  Human ear can perceive sound between 20 - 20, 000 Hz 20, 000 Hz  Velocity of sound ranges from 340m/s in air to approximately 5000 m/s in solid media such as bone  Noise- most common acoustic stimulus  Voice- most important sound source in humans ( approx. 100Hz- males, 200Hz- females) ( approx. 100Hz- males, 200Hz- females)

59. Classification of Hearing Loss by Severity (Quantification)  Normal hearing - < 20 db  Mild hearing loss – 20-40 db  Moderate hearing loss – 40-60 db  Severe hearing loss - 60-90 db  Profound hearing loss – 90-and above

60.  Congenital deafness - refers to the absence of hearing; failure of speech development  Acquired deafness – loss of sense of hearing; loss of speech comprehension; have developed speech and language development depending on age when this occurred

61. BEHAVIORAL AUDIOMETRY  Based on an active and usually voluntary response from the test object -Pure – tone audiometry -Speech audiometry -Response audiometry

62. OBJECTIVE AUDIOMETRY  Based on objectively measured parameters that represent an involuntary physiologic response - tympanometry -otoacoustic emissions -auditory evoked brain-stem potentials (ABR, BAER)

63. PURE TONE AUDIOMETRY  Calibrated AC and BC stimuli are presented thru standard acoustic transducers (TDH- 39) or thru insert phones (ER-3A)  Signals are steady or pulsed and has a frequency range of 125 Hz to 8000Hz for AC and 250 Hz – 4000 Hz for BC  Signal levels are expressed in decibels (db)

64.  Makes use of an audiometer which is an electronic instrument to test hearing  Done in a sound treated room  Audiogram –graphic representation of the individual’s sensitivity for pure tones  Red circle- refers to the right ear  Blue or black X refers to the left ear

65.  Always test better ear first  Assessing the threshold – (weakest level at which a person will respond 50% of the time ) for each frequency  Start with 1KHz, 2KHz,4KHz,8KHz, re-check 1KHz,500Hz, 250Hz, 125 Hz

66. Tones are presented to one ear at a time Test for AC first using headphones or insert phones Prevent cross-hearing by masking Test BC thresholds by using a vibrator pressed against the mastoid bone ( set the skull into vibration to transmit sound into the inner ear)

67. AUDIOGRAM  Sensorineural hearing loss – no significant threshold differences between AC and BC thresholds  Conductive hearing loss –if AC is higher than BC by more than 10 db  Mixed type of hearing loss – greater air conduction compared with bone conduction but both abnormal

69. SPEECH AUDIOMETRY  Measures the recognition and understanding of speech rather than the threshold  Speech material is available in standardized form on compact discs and is presented at designated levels using an audiometer

70.  Speech audiogram indicates the percentage of syllables, words or sentences that the subject has heard correctly

71. TYMPANOMETRY (Impedance Audiometry)  Sound vibrations are reflected in the eardrum and sensitive electrical equipment records objectively the mobility of the drum  This test may show eustachian tube problems, middle ear disease, or a perforated drum

72.  Tympanogram – graphic results of an immitance test  Type A tympanogram has a prominent, sharp peak between –100- 100 mmH20  Type B tympanogram is flat or has a very low, rounded peak. This indicates immobility of the drum which may be due to fluid in the middle ear

73.  Type C tympanogram has a peak in the negative pressure region below –100 mmH20 consistent with impaired middle ear ventilation

75. AUDITORY EVOKED POTENTIALS (ABR,BAER)  May be used in the diagnosis of neurologic diseases  Done to differentiate a cochlear froma retrocochlear lesion  Important for threshold testing in pediatric audiology

76. OTOACOUSTIC EMISSIONS  Clinically important in screening the function of the cochlea in infants, newborns and small children  Provides a fast and simple way without sedation or anesthesia thus facilitating early detection of hearing problems

77.  Can also be used to investigate non-organic hearing loss, assess cochlear functions in high risk group and objectify audiometric findings in adults

78. VESTIBULAR TESTS

79.  HISTORY most important diagnostic tool

80. Quality Temporal Course – speed of onset, duration Associated symptoms Exacerbating factors

81. Chronology General Pattern Auditory Symptoms – hearing loss, tinnitus ear disease ear disease Ocular problems CNS - ataxia, dysequilibrium

82. Vestibular Examination TWO PRINCIPAL COMPONENTS Eye Movement Examination Balance and Coordination examination

83. NYSTAGMUS repetitive to and fro movement of the eyes with a fast and a slow component brought about by the imbalance of the tonic activity of the vestibular system

84.  This involves carefully observing the eye movements  Has a slow component and a fast recovery phase

85. NYSTAGMUS  CAN BE: –spontaneous –Provoked –induced

89. CALORIC TEST  Each ear is irrigated for a fixed duration of 30-40 seconds  Constant flow rate of water with a temperature of 7 degrees below body temperature (30 degrees) and 7 degrees above (44 degrees)  Supine position with the head tilted 30 degrees forward  Eyes open behind frenzel glasses,total darkness

91. Romberg’s Test  Patient stands still with eyes closed  Clasp hands together and pull apart inorder to divert attention (Jendrasik Maneuver)  20-30 seconds  Positive Romberg’s - fall on either side

92. THANK YOU