Examination of the Ear

The following guide presents one structured approach to examining the ear. There are many valid techniques, and you should adapt this framework to suit your own style as you gain experience. This guide assumes a basic working knowledge of ENT anatomy. If you are uncertain about any of the underlying anatomy or pathology, the recommended texts are Key Topics in Otolaryngology or ENT Secrets — both are appropriate for SHO or ST-level ENT.

This guide has been written primarily for the examination setting, where you will be presenting your findings aloud to an examiner. The best candidates talk continuously throughout, narrating what they are doing and what they are seeing. This demonstrates both clinical competence and a systematic approach.

This page is part of Professor Vik Veer's free clinical education series for junior doctors.

Equipment

Before beginning, ensure you have the following to hand:

• Otoscope — the standard instrument for visualising the external auditory canal (EAC) and tympanic membrane (TM). Choose the correct speculum size for the patient (larger for adults, smaller for children). Some departments use a pneumatic otoscope, which has a bulb attached to assess TM mobility by varying pressure in the canal.
• 512 Hz tuning fork — used for Weber's and Rinne's tests. The 512 Hz frequency is preferred clinically as it is least affected by bone vibration artefact and corresponds to the speech range.
• Barany noise box (or Frenzel glasses) — used for masking the non-test ear during tuning fork tests when there is a significant asymmetry of hearing.
• Lack tongue depressor — occasionally useful for examining the oral cavity and post-nasal space at the end of the ear examination.

Step 1: Consent and Introduction

Always introduce yourself, confirm the patient's identity, and gain verbal consent before any examination.

"Is there any pain at all? And would it be all right if, while I am examining you, I speak to the examiner about my findings?"

Remember to wait for the patient's response before proceeding. In an exam setting, candidates who rehearse so thoroughly that they forget to wait for answers appear robotic and may miss important symptoms (such as ear pain, which would make pulling the pinna very uncomfortable).

Step 2: General Inspection from the Front

Stand in front of the patient and inspect both ears before moving closer.

"From the front, both ears appear to be of symmetrical shape and position, with no obvious asymmetry or structural deformity."

It is good practice to examine the normal (or better-hearing) ear first. This allows you to establish what is normal for that patient before examining the pathological side. The examiner may ask you to start with the affected ear — be ready to adapt.

Step 3: Inspection of the External Ear

For each ear, systematically inspect three areas before picking up the otoscope:

Post-auricular, Mastoid, and Pre-auricular Areas

"On inspection, the post-auricular, mastoid, and pre-auricular areas appear normal, with no evidence of scars, erythema, swelling, pits, or sinuses."

The mastoid is the bony prominence immediately behind the ear. Erythema, swelling, or a displaced pinna (pushed forwards) over the mastoid suggests acute mastoiditis — a surgical emergency. Pre-auricular pits (small skin-lined pits just in front of the tragus) are developmental remnants that can become infected.

The Pinna

"The pinna appears normal, with no obvious scars, skin changes, inflammation, or structural deformity."

Look for: cauliflower ear (haematoma organisation following blunt trauma), gouty tophi (urate crystal deposits — small white nodules on the helix), perichondritis (diffuse erythema and swelling of the pinna), or any skin lesions (basal cell carcinoma is common on the pinna in sun-exposed patients).

Ask About Pain Again Before Palpation

Always re-check for pain before you touch the ear. Palpation with an undiagnosed perichondritis or acute otitis externa can be extremely uncomfortable.

"Palpation of the post-auricular, mastoid, and pre-auricular areas is also normal, with no tragal tenderness, pinna tenderness, mastoid tenderness, or palpable masses."

Tragal tenderness (pain on pressing the tragus inwards) is a hallmark of acute otitis externa (infection of the EAC). Mastoid tenderness is a sign of mastoiditis.

Step 4: Otoscopy

To straighten the external auditory canal for otoscopy, pull the pinna superiorly, laterally, and posteriorly simultaneously in adults. In children under approximately 2 years of age, pull the pinna inferiorly and posteriorly, as the canal curves in the opposite direction at that age.

Insert the otoscope speculum gently into the outer third of the EAC only — never force it deeper, as this is painful and risks damaging the thin skin of the deeper meatal wall.

External Auditory Canal

"The conchal bowl and external auditory canal appear normal, with healthy skin, no erythema, no oedema, no discharge, no foreign body, and no masses. A small amount of normal cerumen (ear wax) is present."

Look for: wax (may be impacted, obstructing the view of the TM), otitis externa (erythematous, oedematous, tender canal with discharge), furunculosis (localised boil in the outer EAC — exquisitely tender), polyps, or exostoses (smooth, bony lumps narrowing the canal — seen in cold-water swimmers).

Tympanic Membrane — Systematic Description

Describe the tympanic membrane in an orderly sequence. Do not simply say "the drum looks normal" — work through the anatomical landmarks one by one.

"The pars flaccida appears normal, with no evidence of a retraction pocket, keratin accumulation, or any other abnormality."

The pars flaccida is the upper, loosely attached portion of the TM above the lateral process of the malleus. Retraction pockets here can harbour cholesteatoma (a destructive epidermal cyst of the middle ear), which is a dangerous diagnosis to miss.

"The pars tensa has an intact annulus with no marginal perforations. Moving to the landmarks: I can see a normal umbo and the long process of the malleus. The short process of the malleus is visible in the anterior-superior quadrant. In the posterior-superior quadrant, I can identify the long process of the incus. The anterior and posterior malleolar ligaments, along with the chorda tympani nerve (which courses across the middle ear), are visible and have normal appearances."

The pars tensa is the larger, lower portion of the TM. The annulus is the fibrocartilaginous ring anchoring the TM to the bony canal. A marginal perforation (one that involves the annulus) is more clinically significant than a central perforation, as it is associated with cholesteatoma.

"The pars tensa has a typical appearance, with no bulging (which would suggest acute otitis media with effusion under pressure) and no retraction. The light reflex (cone of light) is present in the anterior-inferior quadrant, as expected. The membrane colour and vascularity are normal."

The cone of light (light reflex) is the triangular reflection of the otoscope light seen in the anterior-inferior quadrant of a healthy TM. Its absence, distortion, or displacement indicates abnormal TM position or texture.

If you cannot visualise the whole tympanic membrane:

"I am unable to see the entire tympanic membrane due to a prominent anterior bulge of the inferior canal wall, or wax obscuring the view. I can see [describe what is visible]."

Describing Pathological Findings

Perforations: State whether the perforation is central (within the pars tensa, not involving the annulus) or marginal (involving the annulus). Describe which quadrant it occupies and estimate its size as a percentage of the pars tensa: e.g., "There is a 20% central posterior-inferior perforation of the pars tensa." If you can see into the middle ear, describe any visible structures — the promontory (medial wall), the round window niche, ossicular remnants, or any discharge.

Retraction pockets: State the location (pars flaccida or pars tensa), whether it is self-cleaning (epithelial migration keeps it clear) or whether epithelial debris or keratin is accumulating within it — the latter is the hallmark of cholesteatoma.

Tympanosclerosis: White, chalky plaques within the pars tensa representing calcification within the fibrous layer of the TM — usually following previous otitis media. Describe the position and extent. Usually clinically insignificant unless it involves the ossicular chain.

Posterior Tympanic Membrane and Middle Ear

"Behind the tympanic membrane, there are no obvious masses and no collection of fluid or glue visible. There is no amber discolouration or air-fluid level suggestive of a middle ear effusion."

A middle ear effusion (glue ear) appears as an amber or yellowish discolouration behind the TM, often with a visible air-fluid level or the appearance of bubbles. The TM may be retracted.

Step 5: Pneumatic Otoscopy

"Normally I would use a tympanogram to assess the compliance (mobility) of the tympanic membrane. However, I can perform pneumatic otoscopy to assess this directly — by attaching a pneumatic bulb to the otoscope and gently varying the air pressure within the sealed external auditory canal. A healthy TM moves briskly inward with gentle positive pressure and outward with release. Reduced or absent movement suggests a middle ear effusion, a thick scarred membrane, or perforation. Alternatively, Valsalva's manoeuvre (forced exhalation against a pinched nose) applies positive pressure from the nasopharyngeal side and can demonstrate TM movement in co-operative patients."

Step 6: Fistula Test

The fistula test is performed if there is any suspicion of a perilymphatic fistula (an abnormal communication between the middle ear and inner ear) or erosion of the lateral semicircular canal by cholesteatoma.

Apply tragal pressure firmly enough to occlude the external auditory canal. Observe the patient's eyes for a nystagmus response — conjugate deviation of the eyes away from the examined side, with the fast phase of nystagmus directed towards the diseased side. A positive fistula test (Hennebert's sign) suggests either a fistula or erosion of the bony labyrinth.

Step 7: Hearing Tests

Free-Field Speech Testing

This is a quick bedside test of functional hearing. Stand approximately 60 cm (roughly arm's length) from the tested ear, and occlude the non-tested ear by pressing the tragus against the canal. Use bisyllabic words (spondees — words with equal stress on both syllables) such as "oatmeal," "popcorn," "cowboy," "railway," or numbers such as 21, 98, or 48. Test in order of increasing voice level: whispered voice, conversational voice, and then loud voice.

A person with normal hearing should repeat correctly at least 50% of whispered words at 60 cm. Failure at whisper but success at conversational voice suggests a mild-to-moderate hearing loss; failure even at loud voice indicates a severe loss.

Tuning Fork Tests

Use a 512 Hz tuning fork — strike it lightly on your elbow or knee so it vibrates at a moderate level (you should barely hear it at arm's length).

Weber's test: Place the base of the vibrating tuning fork firmly on the midline of the forehead (or any midline bony prominence equidistant from both ears, such as the vertex or upper incisor teeth). Ask the patient: "Do you hear the sound in one ear, both ears equally, or in the middle of your head?" A normal result is equal perception bilaterally. Lateralisation (hearing it more in one ear) indicates either a conductive hearing loss on the same side as lateralisation, or a sensorineural hearing loss on the opposite side — Weber's alone cannot distinguish between these possibilities.

Rinne's test: Place the base of the vibrating tuning fork firmly on the mastoid process (bone conduction, BC). When the patient can hear the sound, immediately move the vibrating prongs to 2 cm from the external auditory meatus (air conduction, AC) and ask: "Which is louder — here [mastoid] or here [beside the ear]?" Normally, air conduction is better than bone conduction (AC > BC), which is described as a "positive" Rinne's. If bone conduction is louder (BC > AC), this is a "negative" Rinne's and suggests a conductive hearing loss on that side. However, beware the false-negative Rinne's: in a patient with a profound sensorineural hearing loss on one side, the vibration crosses the skull (via bone conduction) and is perceived in the better ear — giving a falsely "negative" result. Masking of the contralateral ear with a Barany noise box is required in this situation.

"Weber's test showed no lateralisation — the sound was heard equally in both ears. Rinne's test was positive bilaterally, indicating air conduction is better than bone conduction — consistent with no significant conductive hearing loss."

Note: the terminology "positive" Rinne's equating to a normal result is counterintuitive and frequently confuses candidates. It is safer to simply state your findings: "Air conduction was louder than bone conduction" rather than relying on the positive/negative shorthand.

Step 8: Completing the Examination

"I would now move on to examination of the cranial nerves, paying particular attention to the facial nerve (CN VII) — including assessment of facial symmetry, motor function, and taste sensation (chorda tympani branch). I would also examine the post-nasal space, including the Eustachian tube openings, using a flexible nasendoscope. Finally, I would palpate the neck for lymphadenopathy — particularly the pre-auricular, post-auricular, and upper jugular nodal groups."

"With all these patients I would, following my examination, request a pure-tone audiogram and tympanogram to provide a more objective and quantitative assessment of hearing function and middle ear compliance."