When inserting the otoscope into the ear canal which direction should you pull the pinna on an adult patient?

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves

Approach the examination in a systematic way, starting from the outer parts of the ear before moving to the inner parts of the ear; be prepared to be instructed to move on quickly to certain sections by any examiner.

Pinna and Post Auricular Area

Inspect the pinna and the mastoid:

• Obvious deformities or abnormal cartilaginous fragments
• Scars or skin changes
  • Including for skin malignancies
• Signs of inflammation
  • An inflamed mastoid may push the pinna forward

Palpate the lymph nodes and pinna, specifically:

• Pre- and post-auricular lymph nodes
• Tragus
  • Tragal tenderness is a sign of otitis externa

Figure 1 – A basal cell carcinoma located on the posterior aspect of the outer ear

External Ear Canal

Inspect the outer aspect of the external ear canal using the otoscope as a light source

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

Look for signs of:

• Wax or a foreign body
• Skin changes or erythema
• Discharge

Tympanic Membrane

Hold the otoscope like a pen between thumb and index finger, left hand for left ear and right hand for right ear, resting your little finger on the patient’s cheek – this acts as a pivot.

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

For a normal tympanic membrane, you should be able to observe*:

• Lateral process of malleus
• Cone of light
• Pars tensa and pars flaccida

*The cone of light can be used to orientate; it is located in the 5 o’clock position when viewing a normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic membrane.

Adapted from work by Michael Hawke MD [CC BY 4.0], via Wikimedia Commons

Figure 2 – A normal right tympanic membrane

For an abnormal tympanic membrane, common signs may include:

• Perforations
• Tympanosclerosis
• Red and bulging membrane
• Retraction of the membrane

Ensure to check the function of the facial nerve

By Michael Hawke MD / CC BY (https://creativecommons.org/licenses/by/4.0)

Figure 3 – A traumatic perforation of the left tympanic membrane

Assessment of Hearing

Rinne Test

Strike the tuning fork (512Hz) against your elbow and place against the mastoid process (bone conduction), then once patient stops hearing it, hold it near the external ear canal (air conduction)

• For normal hearing or sensorineural hearing loss, air conduction is heard better than bone conduction (Rinne positive)
• For conductive hearing loss, bone conduction is heard better than air conduction (Rinne negative)

Weber Test

Strike the tuning fork (512Hz) against your elbow and place on the patient’s forehead in the midline. Ask the patient whether the sound is heard in the midline or has lateralised

• For normal hearing, the sound is heard in the midline
• For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing deficit
• For sensorineural hearing loss, the sound is loudest on the contralateral side to the hearing deficit

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Tympanogram
• Pure tone audiometry

With any ear exam, you will want the patient to sit down and slightly tilt their head away from you, to obtain easier access to the ear.

Turn on the scope

Turn the scope on at full intensity.

Review your speculum options

Attach a new disposable ear tip or speculum. These come in a variety of styles and sizes; as a rule of thumb, use a 4.25 mm tip for adults/children and 2.5mm for infants. In certain situations, a special Instrumentation Tip can be used for foreign body or cerumen/ear wax removal.

Handling options

There are two common ways to hold the otoscope and it’s all a matter of preference.

Hammer Grip: Some clinicians choose to hold the otoscope like a hammer by gripping the top of the power handle between your thumb and forefinger, close to the light source.

Pencil Grip: For more control, some clinicians choose to hold the otoscope like a pencil, between the thumb and the forefinger, with the ulnar aspect of the hand resting firmly but gently against the patient’s cheek. With this technique, if the patient turns or moves, your steady hand can move with the patient’s head to help prevent injury.

Examine the patient’s good ear

It’s best practice to examine the healthy ear first. This allows you to see the patient’s normal ear anatomy and compare to the other ear, while helping to prevent the spread of infection.

Examine the external canal

Straighten the outer ear canal to make insertion of the speculum easier. For adults, retract the pinna upwards and backwards; for children under three, retract the pinna downwards and backwards.

Steer the scope into the canal as you look until you can see the tympanic membrane or anything that’s in the way.

Adjust the focus

The MacroView focusing wheel is in the default position when the green line, aligns the corresponding green dot on the side of the instrument. This allows you to focus for your own vision if needed using the wheel.

It may be necessary to adjust the position of the otoscope to get a complete view of the entire ear canal and all areas of the tympanic membrane.

Remove the speculum

After the examination, the used disposable speculum should be removed and discarded from the otoscope. Twist the speculum off by hand or rotate the MacroView ‘Tip Grip’ ring counter-clockwise to disengage the speculum.

Pnuematic Otoscopy

Using the insufflator bulb

To help determine if there is fluid behind the drum (a sign of infection), you can use an insufflator bulb to gently puff air at the thin membrane. A lack of movement may be a clue that the ear has fluid, which may not be visible otherwise. Wlech Allyn SofSeal™ tips can help better seal against the canal wall – making it easier to see TM movement of the tympanic membrane.