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Assessing the Ear and Hearing

is the sensory organ for hearing and equilibrium.

Assessment of the ear includes:

- direct inspection and palpation of the
external ear
- inspection of the remaining parts of the
ear by an otoscope
- determination of auditory acuity
Anatomic Structure of the Ear
3 Parts of the Ear
I - External ear
a. Auricle/ Pinna
= consists of movable cartilage and

Landmarks of the Auricle

- lobule (earlobe)
- helix
- antihelix
- tragus
- triangular fossa
- external auditory meatus
b. External auditory canal

= is curved, is about 2.5 cm long in the

adult, and ends at the tympanic membrane

= is covered with skin that has many fine

hairs and nerve endings.

= also lined with glands that secrete cerumen

The canal has a slight S-curve in the adult.

The outer 1/3 of the canal is cartilage and

curves up and toward the back of the head.

The inner 2/3 angles down and forward

toward the nose.

The curvature of the external ear canal differs

with age.
- infant and toddler - upward curvature
- by age 3 assumes the more downward
curvature of adulthood
c. eardrum/ tympanic membrane
= separates the external and middle ear and
is tilted obliquely to the ear canal, facing
downward and somewhat forward.

= is a translucent membrane with a pearly

gray color and a prominent cone of light
in the antero-inferior quadrant, which is
the reflection of the otoscope light.
II - Middle Ear
= is a tiny air-filled cavity inside the temporal
bone that starts at the tympanic membrane.

= contains three (3) ossicles (bone of transmission)

1. malleus (hammer)
2. incus (anvil)
3. stapes (stirrups)
Eustachian tube
= another part of the middle ear connecting the middle
ear to the nasopharynx.

= stabilizes the air pressure between the external

atmosphere and the middle ear, thus preventing rupture
of the tympanic membrane discomfort produced by
marked pressure differences.
Functions of the Middle Ear

conducts sound vibrations from the outer ear to the central

hearing apparatus in the inner ear.

protects the inner ear by reducing the amplitude of loud


its eustachian tube allows equalization of air pressure on

each side of the tympanic membrane so that the membrane
does not rupture, e.g. during altitude changes in an airplane.
III Inner Ear
= contains the bony labyrinth, which holds the
sensory organs for equilibrium and hearing.

* Within the bony labyrinth, are the vestibule and

the semi-circular canals (the organs of
equilibrium) and the cochlea (Latin for snail
shell), the central hearing apparatus.
Process of Sound Transmission
Air-conducted Transmission

1. A sound stimulus enters the external canal and reaches

the tympanic membrane.
2. The sound waves vibrate the tympanic membrane and
reach the ossicles.
3. The sound waves travel from the ossicles to the opening
in the inner ear (oval window).
4. The cochlea receives the sound vibrations.
5. The stimulus travels to the auditory nerve (the 8 th cranial
nerve) and the cerebral cortex.
Bone-conducted transmission
= occurs when skull bones transport the sound
directly to the auditory nerve.
Audiometric evaluations, which measures hearing at
various decibels, are recommended for children and

A common hearing deficit with age is loss of ability to

hear high frequency sounds, such as f, s, sh, and ph.
This neurosensory hearing deficit does not respond
well to use of a hearing aid.
Types of Hearing Loss
1. Conduction hearing loss
= is the result of interrupted transmission of sound
waves through the outer and middle ear structures.
= possible causes:
- tear in the eardrum or obstruction
- swelling or other causes, in the auditory canal
2. Sensorineural hearing loss
= is the result of damage to the inner ear, the auditory
nerve, or the hearing center in the brain.
3. Mixed hearing loss
= is a combination of conduction and sensorineural
Procedure in Assessing the Ear and Hearing

- It is important to conduct the ear and hearing exam.
in an area that is quiet. In addition, the location should
allow the client to be positioned sitting or standing at
the same level as the nurse.

Equipment: Otoscope with several sizes or ear specula


1. Explain to the client what you are going to do, why it is
necessary, and how he or she can cooperate. Discuss how
the results will be used in planning further care or treatments.

2. Wash hands and observe appropriate infection control


3. Provide for client privacy.


4. Inquire if the client has any history of the following:

family history of hearing problems or loss; presence
of any ear problems; medication history, especially if
there are complaints of ringing in ears; any hearing
difficulty: its onset, factors contributing to it, and how
interferes with ADL; use of a corrective hearing device:
when and from whom it was obtained.

5. Position the client comfortably, seated if possible.

6. Inspect the auricles for color, symmetry of size, and position.
To inspect position, note the level at which the superior
aspect of the auricle attaches to the head in relation to the

7. Palpate the auricles for texture, elasticity, and areas of

* Gently pull the auricle upward, downward & backward.
* Fold the pinna forward (it should recoil).
* Push in on the tragus.
* Apply pressure to the mastoid process.
8. Using an otoscope, inspect the external ear for cerumen,
skin lesions, pus, and blood.


- Attach a speculum to the otoscope. Use the largest diameter
that will fit the ear canal without causing discomfort. This
achieves maximum vision of the entire ear canal and eardrum.

- Tip the clients head away from you, and straighten the ear
canal. For an adult, straighten the ear canal by pulling the
pinna up and back.
- Hold the otoscope either
a. right side up, with your fingers between the otoscope
handle and the clients head
b. upside down, with your fingers and the ulnar surface
of your hand against the clients head.

- Gently insert the tip of the otoscope into the ear canal,
avoiding pressure by the speculum, against either side of the
ear canal.
9. Inspect the tympanic membrane for color and gloss.


10. Assess clients response to normal voice tones. If client has
difficulty hearing the normal voice, proceed with the
following tests.

10A. Perform the watch tick test. The ticking of a watch has
a higher pitch than the human voice.
- Have the client occlude one ear. Out of the clients
sight, place a ticking watch 2 to 3 cm (1 to 2 in.) from
the unoccluded ear.
- Ask what the client can hear. Repeat with the other ear.
* Webers test done to assess bone conduction by
examining the lateralization (sideward
transmission) of sounds.

- Hold the tuning fork at its base. Activate it by tapping

the fork gently against the back of your hand near the
knuckles or by stroking the fork between your thumbs
and index fingers. It should be made to ring softly.

- Place the base of the vibrating fork on top of the

clients head and ask where the client hears the noise.
* Rinne test compares air conduction to bone conduction.

- Ask the client to block the hearing in one ear inter-

mittently by moving a fingertip in and out of the ear

- Hold the handle of the activated tuning fork on the

mastoid process of one ear until the client states that the
vibration can no longer be heard.

- Immediately hold the still vibrating fork prongs in front

of the clients ear canal. Push aside the clients hair if
necessary. Ask whether the client now hears the sound.
Sound conducted by air is heard more readily than sound
conducted by bone. The tuning fork vibrations conducted by
air are normally heard longer.
11. Document findings in the client record using forms or
checklists supplemented by narrative notes when

- Perform a detailed follow-up examination of the neurologic
system based on findings that deviated from expected or
normal for the client. Relate findings to previous assessment
data if available.

- Report significant deviations from normal to the primary

care provider.