Ear exam method

2021-01-31 12:00 AM

Use your thumb to press on classic points such as cymbals, cymbals, cymbals, ear caps to find pain points. Notice the grimace when you press the sick ear.

Asked the disease

Exploit the following symptoms: ear pain, hearing loss, tinnitus, ear discharge, dizziness, and facial paralysis.

Time of appearance, progression, the relationship of symptoms to each other, with the whole body with other organs. Functional symptoms such as pain, hearing loss, tinnitus, dizziness that the patient tells, need analysis to see if it is correct? because the patient may use words that are not synonymous with the physician. For example, there are patients who complain of dizziness, but when asked closely what dizziness is, they say that every time they get up quickly, their eyes turn dark with fireflies. We call this phenomenon dizziness, not dizziness.

In addition, we have to learn more about pathological phenomena in other organs such as the heart, blood vessels, lungs, gastrointestinal tract ... all of these symptoms will help us much in the diagnosis of the whole. pathogen.

Systemic condition of the patient: bacterial infection, debilitating state.

Have any drug treatment yet? Previous treatment methods, has surgery yet? Who is the operator, where does it operate? ...

Disorders of other organs such as: nervous, digestive (ask the patient if there is a digestive disorder, have rheumatism? , dizziness ...

Questions about history: need to ask about personal history, family, living factors, occupation, habits such as smoking, drinking, drug allergy, premature birth ...

Physical examination

Ear exam tools

Clar lights.

Frontal mirror.

Speculum of different sizes.

Hooked up.

Tuning fork.

Siègle earoscope.

Cotton swab.

Elbow.

Air pump ball ...

External examination

Observe and detect changes in the morphology of the skin, deformations in the ear (congenital), cases of lymphadenitis due to pimples or mastoid fistula. We observe the ear rim, the ear door to see the skin in front of the ear and behind the ear.

Palpation of the cymbals, earcups for pain points and swelling distinguishing pure otitis media, has a better prognosis than mastitis.

Use your thumb to press on classic points such as cymbals, cymbals, cymbals, ear caps to find pain points. Notice the grimace when you press the sick ear.

For young children, we should not rely entirely on the response of the child because wherever we feel pain or cry out loud. On the contrary, we appreciate the grimace of pain when we press the diseased ear.

The hand helps to detect the cake behind the ear or swollen glands in the front of the ear.

Look for signs of the mastoid reaction.

Ear and eardrum microscopy

Patient posture

If a child is looking at the ear, he should urinate before the examination, the woman holds the child on her lap. If the child is fussy, squirm, curl the baby into a towel, a head holder, a shoulder and hand holder, and a lower limb holder. Or the mother has to hold the baby on her lap and hug the baby to her chest to reduce fear and struggle.

If the patient is an adult let them sit across from the physician. The patient turns his head, ear direction is examined opposite to the physician, pay attention to check the good ear first, the sick ear after.

Use of the endoscope

The head physician wears a Clar lamp or a frontal mirror that focuses light on the rear door. One handle above the earcup pulls slightly up and back. With the other hand holding the bronchoscope with two thumbs and index fingers, gently and slightly rotate the bronchoscope inwards and select the bronchoscope to fit the ear canal.

Tools should be warmed (cold season) before putting them in the ears. When placing the ear canal, it should not be pushed straight from the outside but in the direction of the curvature of the ear canal, to avoid damaging the wall of the ear canal.

If there is wax or pus in the ear canal, the pus must be cleaned or cleaned before the examination.

To see the top of the eardrum, it is necessary to point the bronchoscope upwards and forward.

Watch from the outside to the inside

See if the outer ear canal has leaks, boils, ulcers, scratches, foreign bodies, or buttons?

The tympanic membrane examination: must know the shape, color, inclination of the eardrum, the shape of the anatomical markers, the concave, swelling, puncture, and tear? for the diagnosis of otitis media.

Image of normal eardrum: the eardrum is oval in shape, shiny white like a garlic bulb. In adults, the eardrum is tilted 45 ° outward from the vertical axis of the outer ear canal. In children, this angle is above 60o. Therefore, the eardrum is difficult to see in this type of patient.

The eardrum is divided into 2 parts, the stretch membrane, and the slack membrane. The boundary between the two membranes is the anterior hammer ligament and the posterior hammer atrial ligament. In the middle of the stretch membrane, there is a concave point, that is the eardrum corresponding to the lower pole of the hammer handle. The hammer hilt is a longitudinal ridge that goes from the upper edge of the diaphragm down to the umbilical eardrum, it is tilted slightly forward about 15 degrees. At the upper end of the hammer, there is a convex point equal to the tip of a pin, called the short jaw of the hammer bone. On the lower and anterior sides of the eardrum, there is a triangular bright area. It is the reflection of the light due to the glossy surface of the eardrum (called the light cone). The sagging membrane starts above the hammer atrial ligament, the eardrum is pink here, easily confused with the skin of the ear canal.

While examining the eardrum we should ask the patient to cover their nose, close their mouth and swallow their saliva (the Toyenbée test) to see if the eardrum is mobile? We can replace this test by pumping air into the ear canal with the Siègle ear canal and observing the eardrum movement.

Anatomical landmarks

Hammer short: small as a pin, protruding and exposed through the eardrum.

Hammered hammer is a white fold, going downwards and backward to the middle of the stretch membrane.

Light triangle: from the center of the eardrum, a bright area emerges from the reflection of light on the face of the eardrum.

Hammer atrial ligaments anterior and posterior: going from the short jig of the hammer bone to the front and back.

Reticulum: above the hammock and the hammer atrial ligament (Shrapnell membrane).

Stretch membrane: under the slack membrane.

In the case of ear disease, we see a change in the color, gloss, and inclination of the eardrum. In the case of pus in the middle ear, the eardrum will be pushed outwards. The absence of a bright triangle and ridges would indicate edema to the eardrum. The eardrum may also be punctured or have thin, thick, sticky, or calcareous scarring.

If the eardrum is punctured, it is necessary to carefully see the hole, in the stretch or slack membrane, the pattern of the hole, a hole or many holes, the size and close to the skeleton? Are the holes smooth or rough, are there polyps? ...

Examination of the ear canal (Eustachi)

There are many ways we can try to see if the ear canal (Eustachi) is blocked?

Toynbée maneuver: tell the patient to cover their nose, close their mouth and swallow their saliva, if the patient hears the ear sound of the ear canal.

Valsalva test: ask the patient to close their nose, close their mouth, and blow very hard to inflate both cheeks, if the patient hears the ear that is the ear canal.

The Politzer test: tells the patient to take a mouthful of water, cover one of the nose, the physician uses a large rubber ball to pump air into the other nose while the patient swallows the water if the patient hears a cry in the ear, Eustachi tap open.

Vestibular examination

Spontaneous solutions

The balance solution:

 The Romberg test: patient stands up, legs together, eyes closed. if balance is disturbed the patient will fall or lean to one side.

Finger misalignment test: patient and physician sit opposite each other: patient straightens his arms forward, other fingers clasped except for the straight index finger. The physician curls his hands in front of his chest, holding the fingers except for the straightened thumb to face the patient's index finger several centimeters apart. The patient closes his eyes. If there is a disorder, the index finger will be skewed to one side (compared to the physician's thumb).

Babinsky-Weil star-shaped test: patient closes eyes, walks straight in front of 8-10 steps, then takes 8-10 steps backward. Attached physician to help when the patient falls. If there is a disturbance, the forward always deviates in one direction while back again, the directions will form a star.

If there is damage to the vestibule, it will tilt, skew the index finger or deviate to the diseased ear.

Spontaneous eye movement: patient opens wide eyes, follows physician's fingers, to a distance of 0.4 m, note only glancing at not moving his head. The physician places his finger, in front of the patient, then slowly moves sideways to an angle of about 600 and then moves his finger to the opposite side. Follow up to detect eye movements:

Eye movements: horizontal, standing, or rotating.

Eye movement direction: in the direction of a quick jerk.

Eye-level.

The solutions caused

Coldwater test: let the patient sit upright in a chair, pump 10 ml of cold water at a temperature of 250C into the ear. Only performed when the eardrum is not punctured.

Normally 20 seconds, appears eye contact and lasts for 60 seconds. If the duration is short and the eye movement lasts longer than 120 seconds, it is considered too stimulating. If the opposite is considered poor stimulation.

If no eye movement occurs after 60 seconds, refilling with water up to 100 ml, if still no eye movement is considered no response (vestibular destroyed).

Bench test.

Inflation test: if the air is pumped into the ear through the Siègle endoscope. Normally, there is only a slight sense of pressure due to the compression of the eardrum. If your eyes are moving sideways or turning toward the diseased ear, think of a transverse tube probe shrinkage (found in cholesteatoma mastitis or postoperative). The above phenomenon is called Lucae's symptom.

X-ray

When mastoid ear infections are suspected, it is necessary to have a scan of the lesion. Poses: Schuller, Chaussé III, Stenvers, Mayer.

Stenvers pose

This pose shows a projection of the entire rock bone on an X-ray film from the outer part to the inner tip of the rock bone. Study of traumatic brain injury causing horizontal fracture, osteomyelitis, tumors at the angle of the cerebellum (eg indirect image of nerve tumor VIII).

Patient posture

Lie on your stomach, head resting on the table along the banks of your eyes, cheekbones and nose. Thus, the vertical plane of the skull creates a vertical line of 450 chin not touching the table. The main beam axis in a posterior direction focuses on the lateral occipital region.

Standard

The two sides of the semi-annular tube stand on top of each other.

Result

Normal:

Parts of the inner ear, cochlea, vestibule, upper and outer tubes. Particularly the post-sale tube is not seen.

See the inner ear canal, rock bone.

Pathological:

Stone fracture: fracture line.

Nerve tumor VIII: the inner ear canal dilates.

There are also the Mayer postures, Chaussé III, which are indicated in specific pathologies.

Schuller posture (temples-atrium)

It is the most common and common posture. When mastoid ear infections are suspected, it is necessary to have a scan of the lesion.

The posture of the patient: lying on his side in a tilted skull scan. The source of the main ray is 250-300 compared to the binaural axis, i.e. the center of the source is 7 cm above the opposite ear canal and the ray penetrates the side ear canal. The right ear cup should fold forward so that the image does not overlap the mastoid bone.

Standard

Visible jaw joint.

The outer ear canal and inner ear canal coincide, level with the temporal joint.

Result

Normal: clearly visible cells and septum

Pathological:

Fuzzy cells, unknown septum in acute mastoiditis.

Translucent cells, the septum is lost in chronic mastitis.

On the base of the mastoid bone, there is a bright area, the surrounding has a bold edge, clear like clouds, thinking of cholesteatoma lesions.

Figure: Temporal-atrial posture

Hearing exam

Hearing apparatus

Outer ear

The earcups are responsible for receiving and directing sound.

Middle ear

The atrium, daughter bone and appendages carry the sound and change the negative energy to compensate for the loss in the posterior part.

Inner ear

The Corti organ with the sensory cells and the auditory nerve is responsible for receiving sounds and transmitting to the brain through 5 neuron stages. Each acoustic stimulus heard from one ear is transmitted to both hemispheres.

In the inner ear, the sound transmitted from the air environment, through the water environment (internal, external) has lost 99.9% of the energy, only 0.1% of the energy is transmitted, calculating the intensity. 30dB loss reduction. But since the eardrum-chronic system in the middle ear acted like a transformer, that compensated for the loss. The results were still heard true with real intensity from the outside.

The middle ear is responsible for transmitting sound, a disease in this part causes conduction hearing loss, hearing loss never exceed 60dB. Many types of hearing loss can be cured, including surgery.

The inner ear is the sensory-nerve organ, damage to disease in this part can cause severe deafness, even solid, complete deafness. Hearing loss in the inner ear is hearing loss.

In many cases there is damage to both the middle and inner ears, resulting in mixed hearing loss that is both conducive and receptive. Depending on the degree of inclination that is mixed deafness in favour of conduction or inclination to receive.

Subjective audiometry

These include speech audiometry, tuning fork, and audiometer.

Use voice

It is a simple way to immediately use the voice of a physician, with some simple words, usually done in a room or hallway with a length of at least 5 m, relatively quiet. Measure by whispering first, if there is hearing loss, then measure with a normal voice.

Principle: The patient must not look at the physician's mouth, stand perpendicular to the physician and point the examination ear towards the physician, and the unseen ear must be covered. 

Measuring method: At first, the physician stands 5 meters away from the patient, then slowly moves towards the patient, until the patient hears and repeats the physician's statement correctly, recording the distance.

Measured by whispers: whispering (speaking in a voice slightly, not out loud) usually exam about 5 m, speaking sentence by sentence, usually 3 to 5 words, can speak a familiar place such as: Ho Chi Minh city Minh, Hanoi ... and ask the patient to repeat. If the patient cannot hear, the physician continues to slowly approach the patient (about 0.5m), and records the first distance that the patient can repeat.

Normally, the earphones can be whispered at a distance of 5 m, the shorter the distance, the less hearing loss.

Normal voice measurement: only performed when the distance is less than 1 m from the audible distance with a whisper because normal ears can hear normal speech at a distance of 50 m. The measurement method is the same as above, replacing the whisper with a normal voice as in daily communication.

Identify:

Normal:

Whispering: hear 5 m away.

In general: can hear 50 meters away.

Results: Simple voice-based measurement also allows for the initial detection of the condition and level of hearing loss.

Preliminary hearing deficiency spreadsheet

Hearing distance is measured in meters

% Lack of hearing

A whisper

Common voice

≤ 0,5 m

0.5 m to 0.1 m

0.1 m to 0.05 m

Near the ear cannot hear

≤ 5 m

5 m to 1 m

1 m to 0.5 m

Way 1 glove close to the ear

≤ 35%

35% to 65%

65% to 85%

85 to 100%

Measure with simple tools

For those with severe hearing loss or with young children, often use relatively standardized pronunciation instruments such as drums, whistles, bells, beaters ... or simple machines that can play a few sounds or simple sounds. such as the sound of animals, train, car ... at some high intensity to see if you can hear or have a reaction, react like blink, frown, co chi, turn head ... with those noises? Thereby preliminary determination of hearing ability.

Measure with the tuning fork

Usually use a 128Hz or 256Hz tuning fork 

How to measure:

Measure the airline: after emitting the sound, let the 2 acoustic branches along with the outer ear, 2cm away.

Bone measurement: gently press the catheter handle to apply to the mastoid bone. Calculate the time between tapping the treble tone until inaudible, in seconds.

The solutions: use the treble 128Hz (oscillating 128 cycles/second) tap on the palm of the hand and do the following 3 methods:

Weber test: knocking and then rolling the sound over the top of the head or the middle of the forehead, asking the patient which ear can hear better, if which ear is better, weber deviates to that ear (normally the two headphones are the same).

Schwalbach manoeuvre: calculate time to hear by bone (normal 20 seconds).

Rinne test: compare the time of listening with the air line and the time listening by the bone. Normally, the listening time using the airway is longer than the time listening with the Rinne (+) test. If the airline listening time is shorter than the bone line listening time, the Rinne (-) method.

Assessment: Simple hearing sheet

Right ear 

Method

Left ear

50 m

Speak normally

5 m

5 m

Whisper

Close to the ear

(+)

Rinne

(-)

20 seconds

Schwalbach

20 seconds

 

Weber

To the left

Conclude:

The ear should listen normally.

The left ear can hardly conduct the transmission.

In the case of mixed deafness: the use of 128, 256, 512, 1024, 2048, and 4096Hz trebles will find that for these trebles (e.g., bass) there is conduction, for other types (e.g., high) is receptive.

Using a hearing meter (Audiometer - Audiometer)

How to measure:

Audiometry means finding the patient's hearing threshold (the minimum level of intensity to be able to hear monophonic tones at each frequency). 

Sound is played either airway (through the ear speaker) or through the bone line (through the vibrator) to each ear.

Measurements shall be performed in an acoustic chamber. Connect the thresholds of hearing at the frequencies to form a chart called an audiogram.

Symbol

Right ear

Left ear

Air line

0 ¾ 0 (blue)

x ¾ x (red)

Bone line

[¾ [

] ¾]

  
Measure each ear in turn, the results recorded on the hearing chart with the symbol:

 Identify:              

The vertical axis is the intensity axis in dB. The horizontal axis is the frequency axis unit in Hz.

The machine typically emits tones of 125, 250, 500, 1000, 2000, 4000, 8000 Hz and can be intermediate frequencies of 3000, 6000 Hz, at intensity levels 0-100 dB. Hearing loss meter compared to the average person, 0 dB is the minimum intensity for the average person to begin hearing. Meter level 5 dB, on board with intensity recording - 20 dB, - 10 dB measured for listeners better than normal. The more hearing loss, the larger the measurement.

Measuring bone line by vibrating mass, the results reflect cochlear reserve, hearing potential.

Classification of deafness:

Normal hearing.

Pure conductive deafness.

Pure hearing deafness.

Mixed deafness.

Deafness:

Mild hearing loss 20-40 dB.

Moderate deafness 40-60 dB.

Deafness weighs 60-80 dB.

Deafness> 80 dB.

Objective audiometry

Impedance measurement

There are two clinical applications.

Tympanometry: normally manifests as a disproportionate cone, flared base, peak with pressure equal to zero. When there is secretion or mucus in the ear canal, the ear is partially or completely blocked. Atrium has a special pathological image.

Impedancemetrie: Under normal and pure conduction deafness, the threshold of reflection is approximately 85 dB from the hearing threshold. When there is a hearing, this threshold narrows. Reflectometer can detect many cases of fake deafness.

Measurement of cochlear implant and brain stem auditory power

Principle: When listening to a sound is like receiving a stimulus, a different sensation, the electroencephalograph changes, but the change is too small to be mixed in the EEG chart synthesizing many processes of activity. of the brain. If we make continuous sounds (click or burst) and record the currents of the brain (by specifically analysing the current into multiple points, using an electronic computer to record the sum at each point after each pronunciation) will show the brain's response to sound if the ear can be heard, depending on the polar position.

How to measure:

Electrocochleography: The electrode is placed at the base of the ear canal or ear canal.

Electro responded audiometry (ERA) (Electro responded audiometry) and BERA (Brain electro responded audiometry) electrodes placed in the forehead, crown, and mastoid regions.