Introduction
Ear examination is a common OSCE station in ENT, GP, and paediatric circuits. You must demonstrate safe otoscopy technique, interpret tuning fork tests correctly, and characterise hearing loss as conductive or sensorineural. These are consistently tested because the interpretation requires active clinical reasoning.
💎 Clinical Pearl
Pull the pinna upward and backward in adults, downward and backward in young children, to straighten the external auditory canal before inserting the otoscope.
Preparation
- Introduce yourself, confirm patient identity
- Explain the examination and obtain verbal consent
- Ensure adequate lighting; have a 512 Hz tuning fork available
- Examine the normal ear first
External Ear Inspection
| Finding | Significance |
|---|---|
| Pinna: erythema, swelling | Otitis externa, pinna cellulitis, perichondritis |
| Pre-auricular sinus | Congenital remnant — can become infected |
| Post-auricular erythema or swelling | Mastoiditis (serious complication of otitis media) |
| Tophi (chalk-white nodules) | Gout |
| Discharge from canal | Otitis externa, otitis media with perforation, cholesteatoma |
Otoscopy Technique
- 1Select the largest speculum that fits comfortably
- 2Hold the otoscope like a pen between thumb and index finger; rest your little finger on the patient's cheek (prevents sudden movement from pushing the scope in)
- 3Pull the pinna up and back (adult) to straighten the canal
- 4Insert the speculum gently, angling anteriorly and inferiorly
- 5Inspect in order: external canal, tympanic membrane
External Auditory Canal
- Wax (cerumen): type and amount
- Erythema, oedema, discharge: otitis externa
- Foreign body
Tympanic Membrane — Normal Anatomy
| Feature | Normal appearance |
|---|---|
| Colour | Pearly grey |
| Light reflex | Cone of light at 5 o'clock (right) or 7 o'clock (left) |
| Handle of malleus | Visible as white stripe |
| Annulus | Rim of fibrocartilage |
| Pars flaccida | Upper portion (site of cholesteatoma) |
| Pars tensa | Larger inferior portion |
Otoscopy Findings
| Finding | Diagnosis |
|---|---|
| Red, bulging, loss of landmarks, no light reflex | Acute otitis media |
| Amber or blue-black fluid level behind TM | Glue ear (otitis media with effusion) |
| Perforation of pars tensa | Chronic suppurative otitis media |
| White pearlescent mass in pars flaccida | Cholesteatoma |
| Retracted drum, handle of malleus prominent | Negative middle ear pressure, eustachian tube dysfunction |
| Erythematous, thickened canal | Otitis externa |
⚠️ Red Flag
Cholesteatoma (white mass in pars flaccida) is a surgical emergency referral — it is locally destructive and can erode the ossicles, mastoid, facial nerve canal, and semicircular canals.
Tuning Fork Tests (512 Hz)
Rinne Test
Strike the tuning fork and place it on the mastoid process (bone conduction). When the patient can no longer hear it, move it to 2 cm from the external meatus (air conduction).
| Result | Interpretation |
|---|---|
| Rinne positive: AC > BC | Normal OR sensorineural hearing loss |
| Rinne negative: BC > AC | Conductive hearing loss |
🧠 Mnemonic
Rinne Positive = Normal / sensorineural. Rinne Negative = Conductive loss.
Positive = good (air > bone, as expected). Negative = problem with conduction pathway.
Weber Test
Strike the tuning fork and place it on the vertex (centre of forehead).
| Result | Interpretation |
|---|---|
| Centralises (heard equally) | Normal or symmetrical loss |
| Lateralises to the WORSE ear | Conductive hearing loss in that ear |
| Lateralises to the BETTER ear | Sensorineural hearing loss in the worse ear |
🧠 Mnemonic
Weber lateralises to the WORSE ear in conductive loss.
In conductive loss, the worse ear cannot hear background noise — so the bone-conducted sound seems louder there.
Summary Table: Interpreting Combined Results
| Condition | Rinne (affected ear) | Weber |
|---|---|---|
| Normal | Positive (AC > BC) | Centralises |
| Conductive loss | Negative (BC > AC) | Lateralises to affected ear |
| Sensorineural loss | Positive (AC > BC) | Lateralises to better ear |
Causes of Hearing Loss
| Type | Causes |
|---|---|
| Conductive | Wax, otitis externa, otitis media, glue ear, ossicular chain disruption, otosclerosis |
| Sensorineural | Presbycusis (age), noise-induced, Meniere's disease, acoustic neuroma, ototoxic drugs (aminoglycosides, loop diuretics), sudden sensorineural loss |
| Mixed | Chronic otitis media with inner ear involvement |
Free Field Hearing Tests
If formal audiometry is unavailable:
- Whisper test: stand 60 cm behind the patient (masking the other ear), whisper a number — ability to repeat suggests hearing is adequate
- Voice test: test at conversational, loud, and whispered voice levels
"How do you interpret Rinne and Weber together?"
In conductive hearing loss: Rinne negative on the affected side (BC > AC) and Weber lateralises to the worse (affected) ear. In sensorineural hearing loss: Rinne positive on both sides (AC > BC) and Weber lateralises to the better (unaffected) ear. In a normal patient: Rinne positive bilaterally and Weber centralises.
"What is the correct otoscopy technique in an adult versus a child?"
In an adult, pull the pinna upward and backward to straighten the cartilaginous external auditory canal. In a young child (under 2-3 years), pull the pinna downward and backward. Hold the otoscope like a pen with the little finger resting on the patient's cheek to prevent sudden movements from injuring the canal.
"What is cholesteatoma and why does it matter?"
Cholesteatoma is a destructive accumulation of squamous epithelium in the middle ear, typically arising from the pars flaccida. It appears as a white pearly mass on otoscopy. It is locally destructive: it can erode the ossicles (causing conductive hearing loss), invade the mastoid, damage the facial nerve, and cause labyrinthitis. It requires surgical excision (mastoidectomy) and urgent ENT referral.
"What is the difference between otitis externa and otitis media on otoscopy?"
Otitis externa (infection of the external canal) shows erythema, oedema, and debris in the canal, with a normal tympanic membrane if it is visible. Otitis media (middle ear infection) shows a normal or hyperaemic external canal but a red, bulging tympanic membrane with loss of the light reflex and landmarks. The Rinne test may be negative in otitis media (conductive loss) but normal in uncomplicated otitis externa.
Related guides: Ophthalmology History OSCE | Cranial Nerve Examination OSCE | Paediatric History Taking OSCE