Al-Zaytoonah University- School of Nursing

Physical Assessment Course/ Theory

5. Ears Assessment
Dr: Hasan Abualruz: RN, MSN, PhD
 Outline

• Structure and function of ears

• Subjective data
• Objective data
 Learning Outcomes

 To identify the structure and function of ears.

 To collect the subjective data related to ears assessment.
 To recognize common abnormalities.
 To discuss the correct steps of conducting physical
examination
for ears.
 Structure and Function of
the Ear
 The ear is the sensory organ for hearing and maintaining
equilibrium. It has three parts:
1. the external ear
2. the middle ear
3. the inner ear
 External Ear Structure
 The external ear is called the auricle or pinna
 The external auditory canal is 2.5 to 3 cm long in the
adult and terminates at the eardrum {tympanic
membrane (TM)}.
 The canal is lined with glands that secrete cerumen, a
yellow, waxy material that lubricates and protects the
ear. The wax forms a sticky barrier that helps keep
foreign bodies from entering and reaching the sensitive
tympanic membrane. The canal has a slight S-curve in
the adult.
 The TM separates the external and middle ear and is
tilted obliquely to the ear canal, facing downward and
somewhat forward. It is translucent with a pearly gray
color.
 Cerumen migrates out to the meatus by the
movements of chewing and talking.
 Tympanic membrane

 Separates the external and middle ear

 Is tilted obliquely to the ear canal, facing

downward and forward

 It is translucent with a pearly gray color and

a prominent cone of light in the
anteroinferior quadrant, which is the
(at 5
reflection of the otoscope light
o’clock position in R ear and
7 o’clock position in L ear)
 The Middle Ear
 It contains tiny ear bones, or auditory ossicles: the malleus, incus, and
stapes.
 Its opening to the outer ear is covered by the tympanic membrane.
 The openings to the inner ear are the oval window and the round
window.
 Another opening is the eustachian tube, which connects the middle
ear with the nasopharynx and allows passage of air.

 The middle ear has three functions:

1. Conducts sound vibrations from the outer ear to the central hearing
apparatus in the inner ear
2. Protects the inner ear by reducing the amplitude of loud sounds
3. Its eustachian tube allows equalization of air pressure on each side of
the tympanic membrane so the membrane does not rupture
 The Inner Ear
 It contains the bony labyrinth, which holds the
sensory organs for equilibrium and hearing.
 Within the bony labyrinth:

 The vestibule
 The semicircular canals
 The cochlea
 Hearing

 The ear transmits sound and converts its vibrations into

electrical impulses, which can be analyzed by the brain.
 The sound waves produce vibrations on your tympanic
membrane.
 These vibrations are carried by the middle ear ossicles to your
oval window.
 Then the sound waves travel through your cochlea.
 The electrical impulses are conducted by the auditory portion of
cranial nerve VIII 8 to the brainstem.
 Hearing Loss
 Anything that obstructs the transmission of sound impairs hearing.

1. Conductive hearing loss involves a mechanical dysfunction of the

external or middle ear.
 It is a partial loss.
 Conductive hearing loss may be caused by impacted cerumen,
foreign bodies, a perforated tympanic membrane, pus or serum in
the middle ear, and a decrease in mobility of the ossicles.

2. Sensorineural (or perceptive) loss signifies pathology of the inner

ear, cranial nerve VIII, or the auditory areas of the cerebral cortex.
 Sensorineural hearing loss may be caused by nerve degeneration
that occurs with aging and by ototoxic drugs.
3. Mixed loss is a combination of conductive and sensorineural types in
the same ear.
 Clues that suggest
hearing loss
1. Person lip-reads or watches your face and lips
closely rather than your eyes
2. Frowns or strains forward to hear
3. Postures 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
 Subjective Data

1. Earache (PQRST) Referred pain from a problem in

teeth or oropharynx.
Infection
Rupture in tymbanic membrane
2. Infections A history of chronic ear problems
alerts you to possible hearing loss.

3. Discharge Otorrhea suggests infected canal or

perforated eardrum

4. Hearing loss Gradual vs sudden

A trauma hearing loss is often
sudden
 Subjective Data

5. Environmental noise
Exposed to loud sound, Noise
protection
6. Tinnitus Occurs with sensorineural hearing loss,
Ringing, roaring, or buzzing in your ears cerumen impaction, middle ear infection,
and other ear disorders
Ototoxic drugs
7. Vertigo Feeling of spinning of person (subjective
vertigo) or the objects around person
(objective vertigo).
8. Patient-centered care
Clean your ears Frequency of
hearing assessment
 Objective
Data/Physical
Examination
 Inspection and Palpation of the
External Ear
 Size and shape :
Equal size bilaterally with no swelling or thickening
 Skin Condition :
-Color consistent with facial skin color
-Intact skin, with no lump or lesions.
 Tenderness:
-move the pinna & push the tragus (should feel firm
with no pain )
 External auditory meatus :
Some cerumen -color varies from gray-yellow to light
brown and black; may be moist and waxy to dry
Inspection of Ears Using
Otoscope

➢Tilt person’s head slightly away from

you toward the opposite shoulder
➢ Pull the pinna up and back on an
adult
➢ Pull the pinna down and back for a
child < 3 yrs
➢ Hold the otoscope upside down
➢ Insert the speculum slowly and
carefully
➢ Once in place, rotate the otoscope
slightly
The Tympanic
Membrane

 Color: shiny and translucent with a

pearl gray color.
 Cone-shaped light reflex: prominent in
the anteroinferior quadrant
 Position : The eardrum is flat and
slightly pulled in at the center
 Integrity of membrane : intact
 Hearing Acuity ( Assess CN VIII )

 Your screening for a hearing deficit

begins during the history; “Do you
have difficulty hearing now?” If the
answer is yes, perform audiometric
testing or refer for audiometric
testing. If the answer is no, screen
using the whispered voice test
described as follows.
Hearing Acuity

 audiometer gives a precise quantitative measure of

hearing by assessing the person's ability to hear
sounds of varying frequency. This is a battery-
powered, lightweight, handheld instrument that is
available in most outpatient settings. With the
patient sitting, prop his or her elbow on the armrest
of the chair with the hand making a gentle fist.
 Tell the patient, “You will hear faint tones of different
pitches. Please raise your finger as soon as you hear
the tone; then lower your finger as soon as you no
longer hear the tone.”
 Choose tones of random loudness in decibels on the
audioscope. Each tone is on for 1.5 seconds and off
for 1.5 seconds. Test each ear separately and record
 Whispered Voice Test

 Stand arm's length (2 feets) behind the person.

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 pushing it in and out of
the auditory meatus. Move your head to 1 to 2
feet from the person's ear. Exhale fully 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 repetition of 4 of a
possible 6 numbers/letters. Assess the other ear
using yet another set of whispered items “4, K,
 Tuning Fork Tests

 It is measure hearing by air conduction (AC) or bone

conduction (BC), in which the sound vibrates through
the cranial bones to the inner ear.
 The AC route through the ear canal and middle ear is
usually the more sensitive route. If hearing loss is
identified by history or whispered voice test, tuning fork
tests traditionally were used to distinguish conductive
loss from sensorineural loss.. The Rinne (pronounced
RIN-neh) test is more accurate in detecting conductive
hearing loss.
 Be aware that neither test can distinguish normal
hearing from a sensorineural loss in both ears —you
should rely on audiometry.
Tuning Fork tests: Weber test

 Place TF in the midline of the skull or

mid forehead and ask whether the
sounds the same in both ears or
better in one.

 Normal; should hear BC and the

sound is equally loud in both ears
 Tuning Fork tests: Rinne
test
 Place the stem of TF on the mastoid
process and ask the client to signal
when the sound goes away.
 Invert the fork so the ends near the
ear canal.
 Normal; Positive AC:BC 2:1
 Romberg Test
 The Romberg test assesses the ability of the
vestibular apparatus in the inner ear to help
maintain standing balance.
 Ask patient to stand up with feet together and
arms at side. When stable have client close eyes
wait about 30 -60 seconds; slight swaying may
occur
 proprioception; sensation of position with visual
information is blocked.
 Positive Romberg ’s ; loss of balance that occurs
when closing eyes.
 Thank You