Reference:
- Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh (Ch. 59, pp. 1935-1963)
The ears are located on either side of the cranium at approximately eye level. Assessment involves inspection of the external, middle, and inner ear. Gross hearing acuity is also measured in every physical examination.
External Ear
While simple, this is often overlooked. The external ear consists of the auricle (pinna) and the external auditory canal, and is separated from the middle ear by the tympanic membrane. Utilize inspection and direct palpation for assessment.
- Inspect and palpate the auricle and surrounding tissues for masses, lesions, deformity, and placement, as well as size, symmetry, and angle of attachment to the head.
- Move the auricle and press on the tragus to check for pain. Manipulation normally does not produce pain. If so, acute external otitis is suspected.
- Tenderness of the mastoid may indicate acute mastoiditis or inflammation of the postauricular node.
- Assess for discharge from the ear.
- Occasionally, sebaceous cysts and tophi form on the pinna. A flaky scaliness on or behind the auricle usually indicates seborrheic dermatitis and can be present on the scalp and facial structures as well.
Internal Ear
Assessment of the inner ear requires otoscopic examination (sometimes inverted).
- Ear Canal: normally pink and intact.
- Cerumen (ear wax) is normal to an extent, but may become impacted; Impacted Cerumen.
- Check for Erythema and Edema
- Check for Tenderness
- Tympanic Membrane: normally pearly gray, semi-transparent, and intact. With partial transparency, some inner structures may be visible like the long process of the incus and the opening of the eustachian tube. The handle of the malleus, which extends downwards and backwards, is a reliable landmark.
Gross Auditory Acuity (Hearing Assessment)
Whisper Test
Test hearing acuity.
- Procedure: stand 1 to 2 feet to the side or behind the patient. Instruct the patient to obstruct the contralateral ear. The nurse whispers words with two distinct syllables (e.g., baseball, cellphone, pencil), and asks the patient to repeat the words spoken. They should be able to repeat the spoken words. This is done for both ears.
- Interpretation: if the patient is able to repeat the words, they pass. Failure requires more specific assessments and audiometry.
Weber Test
This test differentiates conductive from sensorineural hearing.
- Procedure: strike a (512 Hz, ideally) tuning fork softly, and place it on the patient’s head (on top, or by the forehead).
- Interpretation: Ask the patient if they hear the sound on both sides equally. This is normal, and the patient may describe it as “inside their head”. If the sound undergoes “lateralization”, it is abnormal. If the sound is stronger on the “poor” ear, then it demonstrates conductive hearing loss. If it is stronger on the good ear, then it demonstrates sensorineural hearing loss. Sensorineural hearing loss manifests as the sound being heard better in the normal ear, because the bypassed conductive parts of the ear did not impact the patient’s ability to hear. If conductive hearing loss is present, then bypassing them with bone conduction allows the patient to hear better in the otherwise-affected ear.
| Interpretation | Weber | Rinne |
|---|---|---|
| Normal | Sound is heard equally in both ears. | Air conduction is audible longer than bone conduction in both ears |
| Conductive Hearing Loss | Sound is heard best in affected ear (hearing loss). | Sound is heard as long or longer in affected ear (hearing loss). |
| Sensorineural Hearing Loss | Sound is heard best in normal hearing ear. | Air condition is audible longer than bone conduction in affected ear. |
Rinne Test
This test compares air and bone conduction to identify conductive or sensorineural hearing loss.
- Procedure: the same process as Weber, but the base of the tuning fork is placed on the mastoid bone (for bone conduction). Ask them to state when the sound is no longer heard (note the duration/time interval). Repeat the test, but while holding the tuning fork next to the auditory meatus, about two inches away (for air conduction). Alternatively, allow the patient to identify which “sounds louder” instead of using time.
- Interpretation: Ask them to state when the sound is no longer heard (note the duration/time interval). Normally, the patient should hear air conduction better than and longer than bone conduction, and this is documented as a positive Rinne test. In conductive hearing loss, bone conduction is better heard than air conduction (same or longer time interval), and is documented as a negative Rinne test. If the patient displays hearing loss, but air conduction remains superior to bone conduction, suspect sensorineural hearing loss.
| Result | Interpretation |
|---|---|
| Air Conduction is louder/lasts longer than Bone Conduction | (+) Positive; Normal |
| Air Conduction is shorter than or equal to Bone Conduction | (-) Negative; Conductive Hearing Loss |
| Air Conduction is louder/lasts longer than Bone Conduction | (+) False Positive; Sensorineural Hearing Loss |