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10
Chapter 2
Primary Care Otolaryngology
larynx, hypopharynx, and nasopharynx. Fiberoptic instruments provide a
similar ability to examine these regions, but with superior optics.
The Ear
Assess the
external auricle
for congenital deformities, such as microtia,
promin auris, or preauricular pits. The external auditory canal should be
examined by
otoscopy
after being thoroughly cleaned if it is blocked by
cerumen. The canal should be assessed for swelling, redness (erythema),
narrowing (stenosis), discharge (otorrhea), and masses. The tympanic
membrane is normally pearly gray, shiny, translucent, and concave.
Changes in the appearance of the eardrum may indicate pathology in the
middle ear, mastoid, or eustachian tube. White patches, called
tympano-
sclerosis
, are often clearly visible and provide evidence of prior significant
infection. An erythematous, bulging, opacified tympanic membrane indi-
cates acute bacterial otitis media. A dull, retracted, amber eardrum can be
a sign of serous otitis. If a perforation is present, then the middle ear
mucosa may be viewed directly. Healed perforations are often more trans-
parent than the surrounding drum and may be mistaken for actual holes.
Pneumatic otoscopy
should be performed to observe the mobility of the
tympanic membrane with gentle insufflation of air. Mobility may be lim-
ited by scarring, middle ear effusion, or perforation. Eustachian tube func-
tion may be assessed by watching the eardrum as the patient executes a
gentle Valsalva.
Tuning forks
can be used to grossly assess hearing and to differentiate
between conductive and sensorineural hearing loss. A tuning fork placed in
the center of the skull (
Weber test
) will normally be perceived in the mid-
line. The sound will lateralize and be perceived as louder on the affected
side in cases of conductive hearing loss. If a sensorineural loss exists, the
sound will be perceived in the better or normal hearing ear. The tuning
fork is then placed just outside the external auditory canal
for the
Rinne’s
test
of air conduction hearing. Placing the base of the tuning fork over the
mastoid process allows bone conduction hearing to be assessed. In conduc-
tive hearing loss, the tuning fork is heard louder behind the ear (bone con-
duction is better than air conduction in conductive hearing losses).
A proper, complete assessment of hearing requires
audiometry
. This is
indicated in any patient with chronic hearing loss, or with acute loss that
cannot be explained by canal occlusion or middle ear infection. It is also
an integral part of the evaluation of the patient with vertigo.