|Inspect auricles and mastoid area|
|Examine lateral and medial surfaces and surrounding tissue.|
|EXPECTED:Familial variations. Auricles of equal size and similar appearance. Darwin tubercle.|
|UNEXPECTED:Unequal size or configuration. Cauliflower ear and other deformities.|
|UNEXPECTED:Moles, cysts or other lesions, nodules, or tophi.|
|EXPECTED:Same color as facial skin.|
|UNEXPECTED:Blueness, pallor, or excessive redness.|
Draw imaginary line between inner canthus and most prominent protuberance of occiput. Draw imaginary line perpendicular to first line and anterior to auricle.
|EXPECTED:Top of auricle touching or above horizontal line. Vertical position.|
|UNEXPECTED:Auricle positioned below line (low-set); unequal alignment. Lateral posterior angle greater than 10 degrees.|
|EXPECTED:Preauricular pits, skin tags, or smooth skin.|
|UNEXPECTED:Openings in preauricular area, discharge.|
|External auditory canal|
|EXPECTED:No discharge, no odor; canal walls pink.|
|UNEXPECTED:Serous, bloody, or purulent discharge; foul smell.|
|Palpate auricles and mastoid area|
|EXPECTED:Firm and mobile, readily recoils from folded position; no tenderness in postauricular or mastoid area.|
|UNEXPECTED:Tenderness, swelling, nodules. Pain when pulling on lobule.|
|Inspect auditory canal with otoscope|
|EXPECTED:Minimal cerumen in varying color and texture. Uniformly pink canal. Hairs in outer third of canal.|
|UNEXPECTED:Cerumen obscures tympanic membrane, odor, lesions, discharge, scaling, excessive redness, foreign body.|
|Inspect tympanic membrane|
Vary light direction to observe entire membrane and annulus.
|EXPECTED:Visible landmarks (umbo, handle of malleus, light reflex).|
|UNEXPECTED:Perforations, landmarks not visible.|
|EXPECTED:Translucent, pearly gray.|
|UNEXPECTED:Amber, yellow, blue, deep red, chalky white, dull, white flecks, or dense white plaques; air bubbles or fluid level.|
Tympanic membrane. From Barkauskas et al, 2001.
|EXPECTED:Slightly conical with concavity at umbo.|
|UNEXPECTED:Bulging (more conical, usually with loss of bony landmarks and distorted light reflex) or retracted (more concave, usually with|
|accentuated bony landmarks and distorted light reflex).|
Seal canal with speculum, and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment.
|EXPECTED:Movement in and out.|
|Questions during history|
|EXPECTED:Responds to questions appropriately.|
|UNEXPECTED:Excessive requests for repetition. Speech with monotonous tone and erratic volume.|
Have patient mask hearing in one ear by inserting a finger in ear canal. Stand 1 to 2 feet from other ear and softly whisper three letter and number combinations (e.g., 3, T, 9 or 5, M, 2). Use a different letter number combination in other ear.
|EXPECTED:Patient repeats numbers and letters correctly more than 50% of time.|
|UNEXPECTED:Patient unable to repeat whispered words.|
Place base of vibrating tuning fork on midline vertex of head. Repeat with one ear occluded.
|EXPECTED:Sound heard equally in both ears (unoccluded). Sound heard better in occluded ear.|
|UNEXPECTED:See table on p. 84.|