Describe the clinical examination of the ear.

History and Inspection

• The history should establish — deafness (which ear, onset, progression, fluctuation, effect on telephone use and on conversation in noise); discharge (otorrhoea), and crucially whether it is mucoid or foul-smelling and scanty; pain (otalgia), and whether the ear looks normal, which suggests referred pain; tinnitus; vertigo; and facial weakness
• The character OF the discharge IS the single most useful historical point: profuse, mucoid and odourless discharge suggests safe (tubotympanic) disease.
• Ask about the past — ear surgery, trauma, noise exposure, ototoxic drugs (aminoglycosides, loop diuretics, cisplatin), meningitis, and family history of deafness

Otoscopy and Further Assessment

• Otoscopy technique — use the largest speculum that fits comfortably; pull the pinna upward and backward in an adult and backward and downward in an infant; hold the otoscope like a pen, resting the hand on the patient’s head so that it moves with any sudden movement — which matters greatly in a child
• Examine the canal first — wax, debris, discharge, oedema, furuncle, granulation, exostoses, foreign body — then the drum. The canal must be cleared before any statement about the drum is made
• Examine the drum systematically: colour and translucency; position (retracted, neutral, bulging); the handle and lateral process of the malleus; the cone of light; any perforation with its site, size and whether the margin is central or marginal; and the attic.
• Pneumatic (SIEGLE) otoscopy assesses mobility and is the most useful single addition to otoscopy: reduced mobility indicates fluid, adhesions or a stiff drum, and it also demonstrates the fistula sign
• The fistula test — pressure applied to the canal produces vertigo and nystagmus when there is a labyrinthine fistula, eroding the lateral semicircular canal in cholesteatoma. A false-negative occurs when the labyrinth is already dead, which is an important qualification
• Tuning fork tests with a 512 Hz fork are performed at the bedside — RINNE, WEBER and absolute bone conduction — and give the type of hearing loss before any audiometry
• Examine the nose, postnasal space and throat IN every ear patient. The ear is not an isolated organ: referred otalgia arises from the pharynx, larynx and teeth; Eustachian dysfunction arises in the nose and nasopharynx; and a unilateral effusion in an adult demands the postnasal space be seen
• Complete the examination with the facial nerve, the other cranial nerves, the neck, and vestibular assessment (nystagmus, head impulse, Romberg, gait) where there is vertigo