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Phys Dx
6/22/98
To review tests with her -- SIGN UP
Remember--she bases test on her study questions
--she asks definitions
EAR EXAM
Components
 Hx
 external ear
 middle ear
 inner ear
 nervous innervation
Why do -- Hx, complaints, risk factors
Hx--personal Hx, family Hx
complaints--ex--can’t hear as well
risk factors --job exposure
--music tastes/hobbies
--trauma (head, ear)
Reasons to do an ear exam
 part of a complete physical
 c/o hearing loss
(c/o= complaint of)
 vertigo/dizziness
 tinnitus--ringing in the ear
 otorrhea--discharge from the ear
 prutitis--itching
Risk factors
 head trauma
 whiplash
 job/environmental exposure
 medication toxicity (ex.-aspirin)
 water sports (dampness in ear)
 Hx of herpes (ex.-herpes simplex)
 wrestlers tend to get this around ear
 spreads rapidly once in ear canal
-can destroy tympanic membrane
-can mess up nerve
 headache
-can be sign of infections
Hearing loss
 unilateral or bilateral (may occur slowly or abruptly)
 when did it first appear
 what makes it better/worse
 past treatments
 family Hx
 transient?
 Medications
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some meds are ototoxic
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salicylates and diuretics
 transient hear loss possible
streptomycin and gentamicin
 can destroy hair cells
 can be permanent loss
cisplatin--ototoxic
cancer drugs
UNILATERAL HEARING LOSS--TRAUMA, INFECTION, WAX BUILDUP
BILATERAL HEARING LOSS--SYSTEMIC, MEDICATIONS
NOTE: IF YOU USE SAME SPECULUM FOR BOTH EARS AND CHANCE OF AN INFECTION IT
COULD SPREAD SO DO GOOD EAR FIRST OR USE SEPARATE SPECULUM.
Speculum--can get disposable ones or clean them with alcohol
If developed slowly, probably sensorineural
If developed suddenly, more likely to be meds, infection
Can put traction on nasopharyngeal portion of Eustachian tube from inside the mouth in an attempt to open
it up and get it to drain.
People with sensorineural losses tend to talk loudly
People with conductive losses tend to talk softly
Table 8-4 (IN LIBRARY) Common Causes of Deafness
Sound waves => tympanic membrane vibrates =>
=> ossicles => waves in endolymph/perilymph
=> distorts hair cells of organ of Corti
=> converts to chemical signals => cortex
Mastoid air cells--direct connection to tympanic membrane (why you can hear yourself talk even if ears are
blocked)
External otitis = swimmer’s ear
Cerumen = wax (made in distal 1/3 of canal)
 associated with hydration level
 if get dehydrated (ex.: too much Coke & Pepsi)
Eustachian tube blockage--can lead to pressure buildup
Viral meningitis--middle ear
Cholesteatoma--tumors (can rupture)
Otosclerosis--scarring of tympanic membrane or ossicles due to previous infection
Meniere’s Disease--inner ear
 considered idiopathic or autoimmune or viral (not really
known)
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 Dx by exclusion
 affects endolymph
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triad
 episodic vertigo
 fluctuating sensorineural hearing loss
 tinnitus (usually unilateral, often severe)
episodic--multiple episodes
in 1940-70 grouped with MS
 MS--different phases
 dizziness
 ringing in ears
 no fever
 eventually shows up in CSF or on an MRI
Tx--both MS & Meniere’s--PREDNISONE (steroid)
Acoustic neuroma--buildup of tissue along CN VIII
See text--conduction loss vs sensorineural
 conduction--minor sound distortion
 speak softly
 concentrate more if environmental noise
 any age
 sensorineural--more distortion of sound(esp. upper
 patient tends to speak loudly since can’t hear
 middle age or elderly
 problem is not visible
frequency)
own voice
Unilateral loss--may bend their ear toward you
 early years--turn bad ear your way
 later years--turn good ear toward you
Vertigo--sense of self spinning or room turning while in a resting position, usually associated with a loss of
equilibrium
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Subjective vertigo = sense of self spinning
Objective vertigo = sense of room spinning
Table 2.2 (text)
 consider onset, duration, course
 any vomiting, etc.
 alcohol intoxication
 TIA (transient dizziness with decreased strength, hearing, and visual disturbances
 drug toxicity
True Vertigo--problems with
 CN VIII
 vestibular canals
 temporal cortex
 Causes
 Meniere’s
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otitis media
Herpes Zoster
Herpes simples
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tumors
otosclerosis
obstructed Eustachian tube
vestibular neuronitis
drug toxicity (esp. hard liquors)
 alcohol (also toxic to eyes)
 opiates
 diuretics
motion sickness (problem between optic and oto apparatuses)
diplopia--abnormal input
circulatory--TIA’s
neurogenic
MS
skull fractures
encephalitis
meningitis
tumors of pons
leukemias
myelomas
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Benign positional vertigo
 rolling over in bed
 turning to look at someone
 turning head to back up car
ARTICLE--JMPT-1991 Cervicogenic Vertigo-Fitzgibbon
Chiro Report-David Chapman Smith
Dr. Cyriac tapes on spinal manipulation
 one of past foremost authorities on allopathic care
 still seen as an authority
 did not like chiro
Vestibular neuronitis--acute labyrinthitis
 drugs--streptomycin (ototoxic)
Tumors--can affect CN 5,6,7 as well as 8 (variable symptoms)
Table 8.6 Tinnitus (IN LIBRARY)
 sensation of buzzing or ringing in the ears in the absence of environmental input
 can be pulsatile/clicking or monpulsatile (doesn’t help in differentiation)
 external ear
 infection/inflammation
 occlusion
 bullous myringitis--fluid bubbles in TM
 foreign bodies--cerumen
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middle ear
 otitis media
 vascular anomalies
 neoplasm
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 otosclerosis
 Eustachian tube dysfunction
inner ear
 Meniere’s
 labyrinthitis
 drug toxicity
 presbycussis
CNS
 vascular
 hypertension
 syphilis
 degenerative disease
 cerebral atherosclerosis
drugs
 aspirin
 antidepressants (even for CTS, etc)
 anti hypertension
 caffeine
 pain meds (ex.: Flexoril)
 anti-inflammatory (at least 11 of these)
otorrhea (discharge from ear)
 often due to infection of trauma
 clear & watery--CSF--skull fracture
 bloody--carcinoma or trauma
 pus--bacterial
 ask about
 any dryness
 any pain
 any use of ear drops
 any sore throat
 swimming recently
Otalgia--ear pain MOST COMMON CAUSE => INFECTION
 external otitis and otitis media
 referred pain from teeth, pharynx, C-spine, TMJ
 inflammation, trauma, or neoplasm anywhere along course of CN V,VII,VIII,IX,X or cervical nerves
C2
or C3
 CN V-tensor tympani muscle-sensory to external ear
 CN VII-stapedius muscle
 CN VIII-semicircular canals and cochlea
 CN IX-sensory to TM
 CN X-sensory to inner canal
Pruritis—itching
 Disease of external auditory canal
 Discharge from middle ear infections
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Systemic disease
 Diabetes
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 Hepatitis
 Lymphoma 
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usually general itching
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Exam
 External ear
 Symmetry
 Helix—smooth and round—check for any nodules
 Check behind ear
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Otoscopic exam—canal and tympanic membrane (TM)
 Use otoscope
 Look at
 Hairs, wax
 Color of drum
 Position of drum
 Light reflection
 Look for perforations
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Auditory exam
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Ear—auricle—cartilage covered by skin
 Bony part—covered by skin
 Sebaceous glands in distal 1/3
Middle ear
 3 bones
 air filled mastoid cells
 tympanic membrane
 Eustachian tube—regulates atmospheric pressures
Inner ear
 Semicircular canal
 Cochlea
 Vestibule
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Innervations— CN V, VII, VIII, IX, X
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External ear
 Look for discharge, lesions, cysts, tophi, etc.
 Look for swollen lymph nodes esp. if chronic infections present
 DO NOT SQUEEZE SEBACEOUS CYSTS
 Could lead to infection of fascial planes
 Use cool, moist cloth to decrease inflammation then warm, moist cloth
Keloids—scar tissue
Tophi
 Uric acid crystals (gout)
 Hard, painful
 May open up and discharge white chalky crystals
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