Ear Examination - Using an Otoscope - Ear Anatomy - Clinical Skills - Dr Gill

hello and welcome to another clinical skills uh session with myself dr james gill today we're going to be looking at pathologies and presentations of ear complaints and if i'm perfectly honest ear problems are a very high proportion of gp workload and hence i think it's a very useful topic for us to make sure that we're all okay with the examination of the ear but also what we might see during that examination but to appreciate what we find on the clinical examination of the year we need to understand some of the the anatomy behind it and then we're going to go on once we've had a look at what's going on inside your skull we're going to go on to actually have a look how we do the examination here and crucially one of the reasons i felt that we needed to address this was because i frequently see students in the general practice environment who are struggling with this examination because well it's actually quite intimate you know you're going to be taking the otoscope and you know putting a little bit of plastic into someone's ear and well wiggling it around to try and see what's going on in there the vast majority of the common examinations that we do respiratory examinations chest examinations they're normally pressing them putting hands on the patient but we're not really putting anything into them obviously that's not including the digital rectal examination when we do an abdominal examination but again this is quite an intimate examination and for anybody who's coming in with earache um putting you know a speculum inside the ear is unlikely to increase that discomfort so it's understandable this is quite a nerve-wracking examination for students and hopefully we'll be able to go through you know a couple of top tips on how to make this an easier examination both for yourselves and your patients at the end of the day that's what we're here for to help you and the patients you're going to serve right with that in mind let's look at the anatomy so here we have uh the ear the kind of flappy thing that we're gonna hear with but in terms of being the external ear we've actually got three parts we've got the pinner okay the actual ear to you and i we've got the external ear canal which also has two components to it we've got the cartilaginous one-third on the outside and then we've got the bony medial sort of two-thirds part further back into the skull and as the final part of the ear we've got the lateral the external surface of the tympanic membrane or the eardrum there are several features that we want to be able to identify on the tympanic membrane one can be seen here the presence of a light reflex which we should see reflecting the light from our otoscope we also need to be aware of the handle of the malleus and sometimes behind we can see the long process of the incus just behind here there are two sections of the tympanic membrane the pars tensor which is essentially the membranous area but also we have the past flaccida just at the top here this flaccid upper part is particularly important to pay attention to as here we may see changes from a cholesterol here an invasive collection of keratising squamous epithelium now the purpose of this is to take um sound funnel it into the ear what causes the tympanic membrane to vibrate this mechanical movement is transmitted by the ossicles the bones of the ear if we actually take the tympanic membrane out you can see the ossicles the the bones of the ear attached to the tympanic membrane and the purpose of these bones is to amplify the sound coming from the tympanic membrane into the cochlear where that movement stimulates the hair cells and that mechanical movement is translated into electrical signals which can then be heard by the brain whilst not visible on examination normally there is another nerve vessel that sits just behind the tympanic membrane this is the called a tympani and runs through the middle ear carrying taste fibers from the anterior two-thirds of the tongue this is why given the proximity to the facial nerve which also runs through the mastoid bone problems with the inner ear can end up affecting the facial nerve the inner ear contains our cochlear and vestibular systems the vestibular system contains the semicircular canals of which there are three the lateral the posterior and the semicircular canals these all sit at right angles to each other now allowing you to detect rotational movement in their fluid so endolymphatic tissue which will again allow you to determine that movement yourself and turning in your head if however there is an infection such as a vestibular neuronitis affecting these canals this will give rise to sensations of vertigo so the room's spinning around as opposed to the snail-like cochlear containing the hair cells that allow hearing to be transmitted down the cochlear part of the vestibular cochlear nerve the middle ear is sealed from the external ear canal however is still an air filled space behind the tympanic membrane and this air-filled space is contiguous with the back of the throat via the eustocian canal here which allows for changes in pressure behind the ear so it's important that the middle ear with its air space is contiguous with the back of the throat with those uh used tooth and tubes because when you go up in a plane the pressure decreases which means that the tympanic membrane bulges outwards because you're still pressurized for down below by popping your ears you're equilibrating the pressure between the external environment and your internal previously sealed middle ear that allows the pressure to reduce and the tympanic membrane drops back into position or should i say stop bulging with that increased pressure going out the inverse is true when you go diving water goes into your ears and presses on the tympanic membrane pushing it in again causing a degree of discomfort but if you press down and force a bit of air pressure up the eustressing tubes that again causes the pressure to equilibrate and that discomfort goes away in some unfortunate patients the ustocian tube can become affected with either with infections or can be blocked by secretions which can mean the patient is unable to balance the pressure in the ears causing a lot of discomfort that can be seen in glue ear this can sometimes be treated by using a nasal balloon i'll be honest i've always found the concept of the nasal balloon to be quite entertaining in its brilliance we all know what it's like you blow up a balloon and sometimes uranus will pop but that's random based upon the pressure that it takes to blow up that balloon with a nasal balloon you're actually going to put it up your nose you'll cover one nostril and blow up the balloon using your nose and this balloon is specifically designed with a pressure equal to that of most people's eustusian tubes so by inflating that with your nose it should mean that you're able to push that same air pressure back up your nostril forcing open the eusteusen tube which can help equilibriate that pressure and take away the discomfort that you may be getting from that blocked ear now it's not going to sort the infection or whatever has triggered that blockage in the first place but it can bring some symptomatic relief which is really important for the vast majority of patients with middle ear problems in terms of actually performing the examination we want to have a quick look at how the patient's ear is sitting on the side of the head so for example do we have evidence of a small ear are there any scars before and around the ear bear mind if they've had operations to the mastoid or the inner ear we may see a scar behind the ear we also want to consider the position of the ear if we have a mastoid itis so an infection going backwards the bone here that can shift the ear down and backwards similarly we can have low set small ears which can be seen in down syndrome other things that we want to have a look for are straightforward scarring to the pinna itself so rugby players are quite um accustomed to having damaged hematomas to the pinna resulting in a cauliflower ear if this is not drained another thing that we will need to be looking for is any bruising around the base of the skull in a trauma victim that may indicate there's been severe trauma resulting in a base of skull fracture which we would see with the bruising here in terms of the examination we want to take our otoscope and we're going to use the right hand to examine the patient's right ear holding the ear back with the left hand and we're going to use our left hand to examine the patient's left ear again pulling the pinner back with the right we need to select the correct size speculum for the patients here so using nice large speculum for adults all the way through to very small speculate for children in terms of our examination we want to observe the patient's ear as mentioned for position for scarring for bruising we want to press over the tragus and pull down on the pinner to see if there's pain and now we're going to pull back the pinner before inserting the speculum in and we're going to need to perhaps rest our finger just on the side of the patient's cheek to in order to avoid brushing or banging into them with the speculum at which point we'll move the speculum around in order to ensure that we get a good view of the canal and the tympanic membrane as with all such head and neck examinations we're going to want to make sure we adequately assess the patient's lymph nodes so checking for pre-auricular lymph nodes in front of the air checking for post auricular nodes behind the ear along with the tonsilla mandibular underneath the jaw for the submental i'm checking down the neck for the deep and superficial cervical chains as well at the back of the head to check for any occipital lymph nodes that may be present and there we have it so there's a very simple overview of using the otoscope to have a look inside the air and assess the external air the ear canal and the tympanic membrane as a taster for what's coming up next in the coming week we're going to be filming the vestibular cochlear system assessment not the cranial nerve per se but what we're going to do for that hearing assessment with the ever popular abbey tut with this video today we're trying something slightly different in terms of blending some of the examination demonstration with some of the anatomy and background that's needed so drop us a comment down below which you prefer the straightforward demonstration video where we follow up with a deeper dive or this slightly more blended approach where we're giving little bits of information as well whilst doing the examination if you've uh if you've enjoyed the video please consider giving it a thumbs up liking the video and if you've not joined us please subscribe to the channel and join the community we've got going here with that in mind take care please make sure you keep wearing your masks and get your vaccine for when you get the opportunity uh through the post take care see you