Examination of the ears, nose, and throat provides information about their integrity and function, as well as the associated respiratory and digestive tracts. The special senses of smell, hearing, equilibrium, and taste are also associated with the ears, nose, and mouth.
Ears
- 1.
Inspect the auricles and surrounding area for:
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Size, shape, and symmetry
- •
Landmarks
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Color
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Position
- •
Deformities or lesions
- •
- 2.
Palpate the auricles and mastoid area for tenderness, swelling, and nodules.
- 3.
Inspect the auditory canal with an otoscope, noting:
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Cerumen
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Color
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Lesions
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Discharge
- •
Foreign bodies
- •
- 4.
Inspect the tympanic membrane for:
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Landmarks
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Color
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Contour
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Perforations
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Mobility
- •
- 5.
Assess hearing through responses to:
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Questions
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Whispered voice
- •
Tuning fork for air and bone conduction
- •
Nose and Sinuses
- 1.
Inspect the external nose, noting the shape, size, color, and nares.
- 2.
Palpate the bridge and soft tissues of the nose, noting:
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Tenderness
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Displacement of cartilage and bone
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Masses
- •
- 3.
Evaluate the patency of the nares.
- 4.
Inspect the nasal mucosa and nasal septum for:
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Color
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Alignment
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Discharge
- •
Swelling of turbinates
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Perforation
- •
- 5.
Inspect the frontal and maxillary sinus area for swelling.
- 6.
Palpate the frontal and maxillary sinuses for the tenderness or pain, and swelling.
Mouth
- 1.
Inspect and palpate the lips for symmetry, color, and edema.
- 2.
Inspect the teeth for:
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Occlusion
- •
Caries
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Loose or missing teeth
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Surface abnormalities
- •
- 3.
Inspect and palpate the gingivae and buccal mucosa for color, lesions, and tenderness.
- 4.
Inspect the tongue for color, symmetry, swelling, and ulcerations.
- 5.
Assess the function of cranial nerve XII (hypoglossal).
- 6.
Palpate the tongue.
- 7.
Inspect the palate and uvula.
- 8.
Elicit the gag reflex (cranial nerves IX and X).
- 9.
Inspect the oropharyngeal characteristics of the tonsils and posterior wall of the pharynx.
Anatomy and Physiology
Ears and Hearing
The ear is a sensory organ that identifies, localizes, and interprets sound and helps to maintain balance. It is divided into the external, middle, and inner ear ( Figs. 13.1 and 13.2 ).
The external ear, including the auricle (or pinna) and external auditory canal, is cartilage-covered skin. The auricle, extending slightly outward from the skull, is positioned on a nearly vertical plane. Note its structural landmarks in Fig. 13.3 .
The external auditory canal, an S-shaped pathway leading to the middle ear, is approximately 2.5 cm (1 in) long in adults. Its skeleton of bone and cartilage is covered with thin, sensitive skin. This canal lining is protected and lubricated with cerumen, secreted by the apocrine glands in the distal third of the canal. Cerumen provides an acidic pH environment that inhibits the growth of microorganisms.
The middle ear is an air-filled cavity in the temporal bone. It contains the ossicles, three small connected bones (malleus, incus, and stapes) that transmit sound from the tympanic membrane to the oval window of the inner ear. The air-filled cells of the mastoid area of the temporal bone are continuous with the middle ear. The tympanic membrane, surrounded by a dense fibrous ring (annulus), separates the external ear from the middle ear. It is concave, being pulled in at the center (umbo) by the malleus. The tympanic membrane is translucent, permitting the middle ear cavity and malleus to be visualized. Its oblique position to the auditory canal and conical shape account for the triangular light reflex. Most of the tympanic membrane is tense (the pars tensa), but the superior portion (pars flaccida) is more flaccid ( Fig. 13.4 ).
The middle ear mucosa produces a small amount of mucus that is rapidly cleared by the ciliary action of the eustachian tube, a cartilaginous, fibrous, and bony passageway between the nasopharynx and the middle ear. The eustachian tube drains into the posterior aspect of the inferior turbinate of the nose. Muscles briefly open this passage (during swallowing, yawning, or sneezing) to clear middle ear secretions and to equalize the middle ear pressure with atmospheric pressure. The equalized pressure in the middle ear permits the tympanic membrane to vibrate freely with sound waves.
The inner ear is a membranous, curved cavity inside a bony labyrinth consisting of the vestibule, semicircular canals, and cochlea. The cochlea, a coiled structure containing the organ of Corti, transmits sound impulses to the eighth cranial nerve. The semicircular canals contain the end organs for vestibular function. Equilibrium receptors in the semicircular canals and vestibule of the inner ear respond to changes in direction of movement and send signals to the cerebellum to maintain balance.
Hearing is the interpretation of sound waves by the brain. Sound waves travel through the external auditory canal, strike the tympanic membrane, and cause it to vibrate. The malleus, attached to the tympanic membrane, and the serially connected incus and stapes begin vibrating. The vibrations are passed from the stapes to the oval window of the inner ear (see Fig. 13.2 ). Oval window movement causes cochlear endolymph fluid motion to be transmitted to the round window, where it is dissipated. Hair cells in the organ of Corti detect sound vibrations and send the information to the auditory division of the eighth cranial nerve. These impulses are transmitted to the temporal lobe of the brain for interpretation. Sound vibrations may also be transmitted by bone directly to the inner ear.
Nose, Nasopharynx, and Sinuses
The nose and nasopharynx provide a passage for inspired and expired air; humidify, filter, and warm inspired air; identify odors; and provide resonance of laryngeal sound. The external nose is formed by skin-covered bone and cartilage. The nares, anterior openings of the nose, are surrounded by the cartilaginous ala nasi and columella. The frontal and maxillary bones form the nasal bridge ( Fig. 13.5 ).
The nasal floor is formed by the hard and soft palate, whereas the roof is formed by the frontal and sphenoid bone. The internal nose is covered by a vascular mucous membrane thickly lined with small hairs and mucous secretions. These hairs and mucus collect and carry debris and bacteria from the inspired air to the nasopharynx for swallowing or expectoration. The mucus contains immunoglobulins and enzymes that serve as a defense against infection. Receptors for smell are located in the olfactory epithelium.
The internal nose is divided by the septum into two anterior cavities: the vestibules. Inspired air enters the nose through the nares and passes through the vestibules to the choanae, posterior openings leading to the nasopharynx. The cribriform plate, housing the sensory endings of the olfactory nerve, lies on the roof of the nose. The Kiesselbach plexus, a convergence of small fragile arteries and veins, is located on the anterior-superior portion of the septum. The adenoids lie on the posterior wall of the nasopharynx ( Fig. 13.6 ).
Turbinates, parallel curved bony structures covered by vascular mucous membrane, form the lateral walls of the nose and protrude into the nasal cavity. They increase the nasal surface area to warm, humidify, and filter inspired air. A meatus below each turbinate is named for the turbinate above it. The inferior meatus drains the nasolacrimal duct, the middle meatus drains the paranasal sinuses, and the superior meatus drains the posterior ethmoid sinus.
The paranasal sinuses are air-filled, paired extensions of the nasal cavities within the bones of the skull. They are lined with mucous membranes and cilia that move secretions along excretory pathways. Their openings into the middle meatus of the nasal cavity are easily obstructed.
Only the maxillary and frontal sinuses are accessible for physical examination. The maxillary sinuses lie along the lateral wall of the nasal cavity in the maxillary bone. The frontal sinuses that develop during childhood are in the frontal bone superior to the nasal cavities. The ethmoid sinuses lie behind the frontal sinuses and near the superior portion of the nasal cavity. The sphenoid sinuses are deep in the skull behind the ethmoid sinuses ( Fig. 13.7 ).
Mouth and Oropharynx
The mouth and oropharynx release air for vocalization and for expiration. They also provide passage for food, liquid, and saliva (either swallowed or vomited); initiate digestion by solid food mastication and salivary gland secretion; and identify taste. The oral cavity is divided into the mouth and the vestibule, the space between the buccal mucosa and the outer surface of the teeth and gums. The mouth, housing the tongue, teeth, and gums, is the anterior opening of the oropharynx. The bony arch of the hard palate and the fibrous soft palate form the roof of the mouth. The uvula hangs from the posterior margin of the soft palate ( Fig. 13.8 ).
Loose, mobile tissue covering the mandibular bone forms the floor of the mouth. The tongue is anchored to the back of the oral cavity at its base and to the floor of the mouth by the frenulum. The dorsal surface of the tongue is covered with thick mucous membrane supporting the filiform papillae. Fungiform papillae (taste receptors) are scattered throughout the filiform papillae of the tongue, and specific areas are sensitive to the five basic taste sensations of sour, sweet, salty, bitter, and umami (savory). The ventral surface of the tongue has visible veins and fimbriated folds (fringelike projections of thin mucous membrane) ( Fig. 13.9 ).
The parotid, submandibular, and sublingual salivary glands are located in tissues surrounding the oral cavity. The secreted saliva initiates digestion and moistens the mucosa. Stensen ducts are parotid gland outlets that open on the buccal mucosa opposite the second molar on each side of the upper jaw. Wharton ducts open on each side of the frenulum under the tongue. They drain saliva from the submandibular and sublingual glands to the sublingual caruncle at the base of the tongue. The sublingual glands have many ducts opening along the sublingual fold (see Fig. 13.9 ).
The gingivae, fibrous tissue covered by mucous membrane, are attached directly to the teeth and the maxilla and mandible. The roots of the teeth are anchored to the alveolar ridges of the maxilla and mandible. The enamel-covered crown is visible to examination. Adults generally have 32 permanent teeth ( Fig. 13.10 ).
The oropharynx, continuous with but inferior to the nasopharynx, is separated from the mouth by bilateral anterior and posterior tonsillar pillars. The tonsils, lying in the cavity between these pillars, have crypts that collect cell debris and food particles.
Swallowing is initiated when food is forced by the tongue toward the pharynx. Muscles in the pharynx contract and prevent movement of the food into the nasopharynx, and respiration is inhibited as the epiglottis closes. Food is then propelled into the esophagus.
Infants and Children
Because development of the inner ear occurs during the first trimester of pregnancy, an insult to the fetus during that time may impair hearing. The infant’s external auditory canal is shorter than the adult’s and has an upward curve. The infant’s eustachian tube is wider, shorter, more horizontal, and less stiff than the adult’s, which allows easier reflux of nasopharyngeal secretions. As the child grows, the eustachian tube lengthens and its pharyngeal orifice moves inferiorly. Growth of lymphatic tissue, specifically the adenoids, may occlude the eustachian tube and interfere with aeration of the middle ear, predisposing young children to develop middle ear effusion.
Although the maxillary and ethmoid sinuses are present at birth, they are very small. The sphenoid sinuses are present by 5 years of age. The frontal sinuses begin to develop at about 7 to 8 years of age and complete development during adolescence. Infections of the paranasal sinuses can occur during childhood.
Salivation increases by the time the infant is 3 months old, and the infant drools until swallowing is learned. The 20 deciduous teeth usually erupt between 6 and 24 months of age (see Fig. 13.10 ). The permanent teeth begin forming in the jaw by 6 months of age. Pressure from these teeth causes resorption of the deciduous teeth roots until the crown is shed. Eruption of the permanent teeth begins about 6 years of age and is completed around 14 or 15 years of age in most races/ethnicities. Tooth eruption timing may be delayed in cases of poor nutritional status and chronic conditions.
Pregnant Patients
Elevated levels of estrogen cause increased vascularity of the upper respiratory tract. The capillaries of the nose, pharynx, and eustachian tubes become engorged, leading to symptoms of nasal stuffiness, decreased sense of smell, epistaxis, a sense of fullness in the ears, and impaired hearing. Increased vascularity and proliferation of connective tissue of the gums also may occur. Hormone-induced laryngeal changes may lead to hoarseness, deepening or cracking of the voice, vocal changes, or persistent cough.
Older Adults
About two-thirds of adults aged 70 years and older have a hearing loss that affects their daily living ( Contrera et al, 2016 ). Age-related hearing loss is associated with degeneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive membrane, and decreased vascularity in the cochlea. Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of high-frequency sounds usually interferes with the understanding of speech and localization of sound. Conductive hearing loss may result from cerumen impaction and tympanosclerosis or otosclerosis caused by calcification of tissues in the middle ear.
Deterioration of the sense of smell results from loss of olfactory sensory neurons beginning at about 60 years of age. The sense of taste begins deteriorating at about 50 years of age as the number of papillae on the tongue and salivary gland secretion decrease, reducing the perception of sweet sensations ( Huether, 2014 ). However, a wide variation in rate of smell and taste deterioration occurs.
Cartilage formation continues in the ears and nose, making the auricle and nose larger and more prominent. The soft tissues of the mouth change as the granular lining on the lips and cheeks becomes more prominent. The gingival tissue may recede and be more vulnerable to trauma, allowing teeth to erode more easily at the gum line. The tongue becomes more fissured. The older adult may have altered motor function of the tongue, leading to problems with swallowing. Saliva production may decrease as a result of disease or medications taken (e.g., anticholinergics and diuretics). Lost teeth may contribute to diet changes or malocclusion and difficulty chewing. Sensitivity to odors and taste declines.
Review of Related History
For each of the conditions discussed in this section, selected topics to include in the history of the present illness are listed. Responses to questions about these topics help fully assess the patient’s condition and provide clues for focusing the physical examination. Questions regarding medication use (prescription and over the counter) as well as complementary and alternative therapies are relevant for each area.
History of Present Illness
Ear Pain
- •
Onset, duration, and course
- •
Concurrent upper respiratory infection, frequent swimming, head trauma; related complaints in the mouth, teeth, sinuses, throat, or temporomandibular joint
- •
Associated symptoms: pain, fever, discharge (e.g., waxy, serous, mucoid, purulent, sanguinous); itchiness; reduced hearing, ringing in ear, vertigo; association with diving or flying
- •
Method of ear canal cleaning; prior cerumen impactions
- •
Medications: antibiotics, ear drops (e.g., acetic acid, anesthetic, topical steroids, cerumen softeners)
Hearing Loss: One or Both Ears
- •
Onset: sudden (may indicate vascular or autoimmune process), over a few hours or days (may indicate viral infection), slow or gradual
- •
Hears best: on telephone, in quiet or noisy environment; all sounds reduced or some sounds garbled; inability to discriminate words; complains about people mumbling
- •
Speech: soft or loud, articulation of speech sounds
- •
Associated symptoms: tinnitus, ear pain, foreign body, prior cerumen impactions
- •
Management: hearing aid, when worn, battery change frequency; lipreading, sign language used
- •
Ototoxic medications: aminoglycosides (gentamicin), chemotherapy (cisplatin), antimalarial (quinine), salicylates, and furosemide
Adults
- •
Exposure to industrial or recreational noise
- •
Genetic disease: Ménière disease
- •
Neurodegenerative and autoimmune disorders
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Syphilis
- •
Ototoxic medication use
Infants and Children
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Prenatal factors: perinatal infection, irradiation, drug abuse
- •
Assisted ventilation for more than 14 days, hyperbilirubinemia requiring exchange transfusion, or extracorporeal membranous oxygenation ( Kraft et al, 2014 )
- •
Infection: bacterial meningitis, recurrent episodes of acute otitis media or otitis media with effusion
- •
Cleft palate, craniofacial abnormalities, syndromic conditions associated with hearing loss (e.g., Alport, Down, Treacher Collins)
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Ototoxic medications
- •
Head trauma
- •
Hypoxic episode
- •
Family history of child with permanent hearing loss
Vertigo (A False Sense of Motion)
- •
Time of vertigo onset, time of day, duration, circumstances, past episodes
- •
Description of sensation (to-and-fro movement or rotary motion—room moving around patient or patient spinning), change of sensation with turning over in bed or head turning, any position better than others
- •
Associated symptoms: nausea, vomiting, tinnitus, hearing loss or change, headache, double vision, ear fullness
- •
Unsteadiness, loss of balance, falling
- •
Medications: ototoxic medications such as aminoglycosides (gentamicin), gentamicin, streptomycin, quinine, chemotherapy (cisplatin), antimalarial (quinine), salicylates, and furosemide; salt-retaining medications such as corticosteroids
Nasal Discharge
- •
Character (e.g., watery, mucoid, purulent, crusty, bloody); odor, amount, duration, unilateral or bilateral
- •
Associated symptoms: sneezing, nasal congestion or stuffiness, itching, habitual sniffling, nasal obstruction, mouth breathing, malodorous breath, sore throat, eye burning or itching, cough
- •
Seasonality of symptoms; allergies or concurrent upper respiratory infection; frequency of occurrence
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Tenderness over face and sinuses, postnasal drip, daytime cough, face pain, headache, recent injury
Snoring
- •
Change in snoring pattern, complaints of snoring loudness by partner, periods of apnea (pauses in breathing)
- •
Daytime sleepiness (associated with obstructive sleep apnea)
- •
Nosebleed
- •
Frequency, duration, amount of bleeding, nasal obstruction, treatment, difficulty stopping the bleeding
- •
Predisposing factors: concurrent upper respiratory infection, dry heat, nose picking, forceful nose blowing, trauma, use of anticoagulants, allergies, dry air or climate
- •
Site of bleeding: unilateral or bilateral, alternating sides
Sinus Pain
- •
Fever, malaise, cough, headache, maxillary toothache, eye pain
- •
Nasal congestion, colored nasal discharge
- •
Pain: tenderness or pressure over sinuses, pain increases when bending forward
- •
Medications: change in symptoms with decongestants
Dental Problems
- •
Pain: with chewing, localized to tooth or entire jaw, severity, interference with eating, foods no longer eaten; tooth grinding; associated with temporomandibular joint problems
- •
Swollen or bleeding gums, mouth ulcers or masses, tooth loss
- •
Dentures or dental appliances (e.g., braces, retainers): snugness of fit, areas of irritation, length of time dentures or appliances worn daily
- •
Malocclusion: difficulty chewing, tooth extractions, previous orthodontic work
- •
Medications: phenytoin, cyclosporine, calcium channel blockers, mouth rinses
Mouth Lesions
- •
Intermittent or constantly present, duration, painful or painless; excessive dryness of mouth; halitosis
- •
Associated with stress, foods, seasons, fatigue, tobacco use, alcohol use, dentures
- •
Variations in tongue character: swelling, size change, color, coating, ulceration, difficulty moving tongue
- •
Mucosal lesions elsewhere (e.g., vagina, urethra, anus)
- •
Medications: mouth rinses
- •
Tobacco use: cigarettes, cigars, pipes, chewing tobacco, snuff; risk increases with frequency and duration of tobacco use
- •
Alcohol use: heavy consumption has higher risk, especially when combined with tobacco use
- •
Oral infection with human papilloma virus (type HPV 16)
- •
Older than 55 years
- •
Gender: higher rate in men than women
- •
UV light exposure associated with cancer of the lip
- •
Weakened immune system: HIV infection, previous malignancy, graft versus host disease
- •
Inherited genetic syndromes: Fanconi anemia, dyskeratosis congenita
Sore Throat
- •
Pain with swallowing, associated with upper respiratory infection; exposure to group A streptococcus, gonorrhea, or Epstein-Barr virus; postnasal drip, mouth breathing, fever
- •
Exposure to dry heat, smoke, or fumes
- •
Medications: antibiotics, nonprescription lozenges or sprays
Hoarseness
- •
Onset: acute, chronic
- •
Change in voice quality (e.g., breathy, pitch alteration); need to clear throat frequently
- •
Associated problems: overuse of voice, allergies, inhalation of smoke or other irritants, gastroesophageal reflux, recent surgery requiring intubation or intensive care treatment
Difficulty Swallowing
- •
Solids, liquids, or both; progressive difficulty
- •
Feeling of food in throat, tightness, or substernal fullness
- •
Drooling, swallowed liquids coming out of nose, coughing or choking when swallowing
Past Medical History
- •
Systemic disease: hypertension, cardiovascular disease, diabetes mellitus, nephritis, bleeding disorder, gastrointestinal disease, reflux esophagitis, asthma
- •
Ear: frequent ear infections during childhood; trauma; surgery; labyrinthitis; antibiotic use, dosage, and duration
- •
Nose: trauma, surgery, chronic nosebleeds
- •
Sinuses: chronic postnasal drip, recurrent or chronic sinusitis, allergies
- •
Throat: frequent documented streptococcal infections, tonsillectomy, adenoidectomy
Family History
- •
Hearing problems or hearing loss, Ménière disease
- •
Allergies
- •
Hereditary renal disease
Personal and Social History
- •
Environmental hazards: exposure to loud, continuous noises (factory, airport, music through headphones—associated with hearing loss); use of protective hearing devices
- •
Nutrition: excessive sugar intake, foods eaten (associated with caries)
- •
Oral care patterns: tooth brushing and flossing; last visit to and frequency of dental care; current condition of teeth; braces, dentures, bridges, crowns, mouth guard use
- •
Tobacco use: pipe, cigarettes, cigars, smokeless; amount, number of pack-years (associated with oral cancer)
- •
Alcohol use
- •
Intranasal cocaine use
Infants and Children
- •
Prenatal: perinatal infection (e.g., toxoplasmosis, cytomegalovirus, syphilis), irradiation, alcohol and drug abuse, hypertension, Rh incompatibility, diabetes
- •
Prematurity: birth weight less than 1500 g, assisted mechanical ventilation for more than 14 days, anoxia, ototoxic medication use
- •
Hyperbilirubinemia requiring exchange transfusion
- •
Infection: meningitis, encephalitis, recurrent episodes of acute otitis media with or without tympanostomy tube placement, prolonged episodes of otitis media with effusion, unilateral mumps, persistent nasal discharge or cough for 10 days or greater
- •
Secondary tobacco smoke exposure, out-of-home child care (associated with occurrence of otitis media), siblings in the home
- •
Congenital abnormalities and syndromes: cleft palate, choanal atresia or stenosis, other craniofacial abnormality; syndromic condition associated with hearing loss (Waardenburg, Treacher Collins); renal anomalies (Branchio-Oto-Renal syndrome)
- •
Snoring and daytime somnolence (associated with obstructive sleep apnea)
- •
Playing with small objects (foreign body in nose or ears)
- •
Behaviors indicating hearing loss: no reaction to calling name or caregiver’s voice, language delay such as no babbling after 6 months of age, no communicative speech and reliance on gestures after 15 months of age, inattention compared with children of the same age
- •
Failure on language domain of developmental screening tool; failure on newborn hearing screen or screening in childhood
- •
Dental care: fluoride supplementation or fluoridated water; sleeps with bottle; when first tooth erupted; number of teeth present; thumb sucking, pacifier use
Pregnant Patients
- •
Weeks of gestation or postpartum
- •
Presence of symptoms before pregnancy
- •
Pattern of dental care
- •
Exposure to infection
Older Adults
- •
Hearing loss causing any interference with daily life
- •
Any physical disability: interference with oral care or denture care, problems operating hearing aid
- •
Deterioration of teeth, extractions, difficulty chewing
- •
Dry mouth (xerostomia)
- •
Medications decreasing salivation: anticholinergics, diuretics, antihypertensives, antihistamines, antispasmodics, antidepressants, tranquilizers; ototoxic drugs
Examination and Findings
Equipment
- •
Otoscope with pneumatic attachment
- •
Nasal speculum
- •
Tongue blades
- •
Tuning fork (512 and 1024 Hz approximate vocal frequencies)
- •
Gauze
- •
Gloves
- •
Penlight, sinus transilluminator, or light from otoscope
Ears and Hearing
External Ear
Inspect the auricles for size, shape, symmetry, landmarks, color, and position on the head. Examine the lateral and medial surfaces and surrounding tissue, noting color, presence of deformities, lesions, and nodules. The auricle should have the same color as the facial skin, without moles, cysts or other lesions, deformities, or nodules. No skin tags, openings, or discharge should be present in the preauricular area. A Darwin tubercle, a thickening along the upper ridge of the helix, is an expected variation. Preauricular skin tags and preauricular pits, found in front of the ear where the upper auricle originates, are other expected variations (see Fig. 13.13, A-C ).
The auricle color may vary with certain conditions. Blueness may indicate some degree of cyanosis. Pallor or excessive redness may result from vasomotor instability. Frostbite can cause extreme pallor.
An unusual size or shape of the auricle may be a familial trait or indicate abnormality. A cauliflower ear results from blunt trauma and necrosis of the underlying cartilage. Tophi—small, whitish uric acid crystals along the peripheral margins of the auricles—may indicate gout. Sebaceous cysts, elevations in the skin with a punctum indicating a blocked sebaceous gland, are common ( Fig. 13.11, D-F ).
To check the auricle’s position, draw an imaginary line between the inner canthus of the eye and the most prominent protuberance of the occiput ( Fig. 13.12 ). The top of the auricle should be at or above this line. Draw a vertical imaginary line perpendicular to the previous line just anterior to the auricle. The auricle’s position should be almost vertical, with no more than a 10-degree lateral posterior angle. A low-set position or unusual angle may indicate a genetic syndrome or be a clue to look for renal anomalies.
Inspect the external auditory canal for discharge and note any odor. A purulent, foul-smelling discharge is associated with otitis externa, perforated acute otitis media, or a foreign body. In cases of head trauma, a bloody or serous discharge is suggestive of a skull fracture.
Palpate the auricles and mastoid area for tenderness, swelling, or nodules. The consistency of the auricle should be firm, mobile, and without nodules. If folded forward, it should readily recoil to its usual position. Pull gently on the lobule; if pain is present, the external auditory canal may be inflamed. Tenderness or swelling in the mastoid area may indicate mastoiditis.
Otoscopic Examination
The otoscope is used to inspect the external auditory canal and middle ear (see Fig. 3.18 ). Select the largest speculum that will fit comfortably in the patient’s ear. Hold the handle of the otoscope between your thumb and index finger, supported on the middle finger (many examiners use the right hand for the right ear and the left hand for the left ear). Depending on your preference, the bottom of the handle may rest against the palm of the hand or space between the thumb and index finger. Use the ulnar side of your hand to rest against the patient’s head, stabilizing the otoscope as it is inserted into the canal. Examination of the tympanic membrane with the otoscope requires manipulation of the auricle. Use a firm but gentle grasp to avoid causing discomfort. Tilt the patient’s head toward the opposite shoulder, and as the speculum is inserted, pull the patient’s auricle upward and back to straighten the auditory canal for the best view ( Fig. 13.13 ).
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