Ear Examination
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Direct answer
Two tuning fork tests, not an X-ray, settle most ear questions: a 512 Hz fork moved from mastoid to meatus (Rinne) and placed on the vertex (Weber) tells you at the bedside whether a hearing loss is conductive or sensorineural. Otoscopy comes first — pinna, canal and tympanic membrane — and Siegle's pneumatic speculum tests drum mobility, restricted when fluid sits behind an intact drum. Add absolute bone conduction and the fistula test, and the ear examination expected in FMGE ENT is complete.
What you must remember
- Always use a 512 Hz tuning fork: lower frequencies are felt as vibration rather than heard, and higher ones decay too quickly — a standard viva opener.
- Rinne positive (air conduction better than bone) means normal hearing or sensorineural loss; Rinne negative means conductive loss on that side.
- Weber lateralises towards the ear with conductive disease and away from the ear with sensorineural loss.
- Absolute bone conduction is reduced only in sensorineural loss, because the cochlea itself is damaged; mask the opposite ear or you will test the wrong cochlea.
- Otoscopy follows a fixed order: pinna and postauricular sulcus, external canal (wax, discharge, attic crater), then the tympanic membrane — handle, malleus, light reflex, pars tensa, pars flaccida.
- Siegle's pneumatic speculum or pneumatic otoscopy assesses tympanic membrane mobility; a drum that does not move suggests middle-ear effusion or perforation.
- The fistula test (pressure on the tragus provoking vertigo with nystagmus) is positive when a labyrinthine fistula has formed, classically erosion of the lateral semicircular canal by cholesteatoma.
How to work through tuning forks in the exam
Take the common scenario: a patient with right ear discharge complains of poor hearing in that ear. Strike the 512 Hz fork on your knuckle or elbow — never on a table, which produces overtones. For Rinne, place the base on the right mastoid; when the patient stops hearing it, bring the still-vibrating prongs beside the meatus. If the patient hears it again, Rinne is positive. Suppose it is negative on the right: bone conduction outlasting air conduction means the canal or middle ear is blocking sound — a conductive loss. Now place the fork on the vertex or forehead. The patient says the sound is louder in the right ear: lateralisation to the side of the conductive loss confirms it. Absolute bone conduction, compared with the examiner's own ear as control, is normal — the cochlea is intact, only sound delivery is impaired. The pattern fits chronic suppurative otitis media, and the next step is an audiogram and examination for cholesteatoma.
Now reverse the exercise. The same battery on a patient with noise-induced loss gives Rinne positive on both sides and a Weber that lateralises to the better ear, with reduced absolute bone conduction on the damaged side. Working each case through this three-step grid — Rinne, Weber, absolute bone conduction — until it is automatic is worth more marks than memorising long lists of causes.
Where students slip
The trap examiners love most is the false negative Rinne. In a profoundly deaf (dead) right ear, the fork on the right mastoid is actually heard by the left cochlea through the skull, so the patient appears to hear bone but not air conduction — an apparently negative Rinne. One question saves you: ask where Weber lateralises. In a true conductive loss it goes to the bad ear; in a dead sensorineural ear it goes to the good ear. A second recurring error is striking the fork too hard, producing harmonics, or resting it on hair instead of skin. Both distort an otherwise clean answer, and both are corrected in seconds during a viva.
Frequently asked questions
Which tuning fork frequency is used for clinical hearing tests?
512 Hz. A 256 Hz fork is felt as vibration before it is heard, which falsely prolongs bone conduction, while 1024 Hz fades too quickly to time.
Rinne is negative on the left and Weber lateralises to the left. What is the diagnosis?
Left conductive hearing loss — the pattern of otitis media, perforation, wax or otosclerosis; absolute bone conduction will be normal.
What does reduced absolute bone conduction signify?
Sensorineural loss involving the cochlea or nerve, since even direct bone-delivered sound is poorly perceived; the examiner's ear serves as the control.
What is a false negative Rinne and when does it occur?
In profound unilateral sensorineural loss, cross-hearing by the opposite cochlea makes bone conduction seem better than air conduction; Weber lateralising to the good ear exposes it.
What does Siegle's pneumatic speculum assess?
Tympanic membrane mobility, by applying positive and negative pressure; reduced mobility indicates middle-ear fluid, thickening or perforation.