Physical Exam: Ear, Ear

September 11, 2007

We are working down the HEENT exam.

That is: Head, Eyes, Ears, Nose, Throat Exam in doctor speak. Sometimes you will see a doctor write:

HEENT WNL.

This may mean that the entire exam above the neck was normal (within normal limits). It probably means that they looked at the patient and they had a head. While it is a positive thing for patients to have heads, the HEENT WNL exam is not a useful bit of information. It is there only to mollify the insurance companies, giving proof that the doctor did look at the patient’s head. But if you have a fractured hip, or abdominal pain, a detailed exam of the head is not really the way you want your specialist spending their time, is it?

If they are working hard, they will single out the different parts of the exam. Yet the ears still usually get shorted:

Ears: TM’s WNL.

Yet I am a primary care physician, so I do a detailed ear exam, and have probably paid my mortgage many months with it. I have to do a good ear exam - especially in my pediatrics patients.

On these guys, even I would just say "HEENT WNL"

So here is how the detailed Ear Exam commonly looks:

Ears: EAC Clear; TM’s Gray c Nl Lt Rflx

Translation: External Auditory Canals Clear, Tympanic Membranes Gray with normal Light Reflex

Note: The letter "c" with a "-" over it is commonly used in medicine as the word "with" - from the Latin word "cum" (pronounced, "coom")

Those Weird Looking Things on the Side of your Head

You have to admit, the external ear is one of the oddest looking things on our bodies. The outer portion of the ear (the funny looking part) usually evades mention when examined, as it usually is not the cause of problems, but it has a very important function. It turns out that the shape of the ear allows directional hearing based on the small difference in the reverberation off of the squiggly part of the ear (called the Auricle or Pinna) depending on the direction of the sound. This allows you to know if a sound is in front or behind you.

The main problems we have on the outer ear are associated with the skin and cartilage.

• I have had to dig earrings out of lobes.
• The little painful bumps people get in their outer ears are called sebaceous cysts, and occasionally get infected.
• A when the outer portion of the ear is injured it can form a collection of blood (hematoma) which can eat through the cartilage and make the ear look very strange. This is called cauliflower ear, and sometimes looks kind of gross, so instead of putting a picture of it, I am instead showing a picture of cauliflower. Yummy, and oh, so healthy!

Ear piercing is a common discussion with parents and kids. Some parents will pierce ears at a very young age (even under 2 months of age). I recommend that they at least hold off until 6 months, when the child won’t be in as much trouble should they get infected at the piercing site.

Parents also seem to fret about the somewhat recent habit of piercing ears in multiple locations. This is very much of a cultural phenomenon, of which our culture is very mild in its pushing of the boundaries. When I was in Africa, I visited the area where the Maasai tribe lives. They are a very noble looking tribe of people who live in southern Kenya and northern Tanzania. It is considered beautiful for a woman to have a stretched out earlobe. I saw one woman whose earlobe hung all the way down to her waist.

Hopefully this won’t catch on with our teens.

Plunge into the Abyss

Ladies and gentlemen, please buckle your seatbelts and lean back as we enter the external auditory canal. You may note that there is some brownish sticky substance above and below us….no wait….it’s completely blocked. Oh my, we are stuck! Now passengers, please don’t panic. If only this person had taken care of their ears and cleaned them out before coming in, we would never have gotten into the predicament we are now in. But not to worry, aside from morbid embarrassment, the wax causes no harm at all.

No, I am not offended by earwax. It is a common finding in ears. I see it at least 10 times per day. I have worked for 13 years, an average of 18 days per month, or 216 days per year. This means that I have seen wax over 28,000 times. I am over it. Really. I don’t think you are a bad person for having it, and I promise not to tell your mother. But here are tips on dealing with that dreaded substance.

• Never stick anything sharper than your elbow in your ear.
• If you can stick your elbow in your ear, call me. I really would like to see someone do that. I tried a lot when I was little.
• Some people just get a lot of wax. It is not a punishment from God; it is just the way their ears work.
• It is wrong to put pudding in your ear, even if it’s butterscotch!
• Q-Tips generally push the wax into the ears.
• If you have a big problem, buy one of the OTC ear cleaning kits.
• NEVER apologize to your doctor about earwax!

Beat the Drum

Doctors look into ears with something called the otoscope. One time I was going to look in a child’s ear in the hospital and had to get the otoscope from the nurse’s station.. I told the mother of the child, "I have to go out to get the ear-look thingy." I paused and explained, "I call it an ear-look thingy."

She smiled and replied, "That’s why you’re our doctor."

When we look into the ear with the ear-look thingy, we are looking at the eardrum, or tympanic membrane. That is ultimately what we are trying to see when we look into ears. Of course, there are many other things one can find in the way of the eardrum. I have seen roaches, toothpicks, beads, pencil erasers, paper, and food in ears. Most of these were in children too embarrassed to tell their parents, but some were in very surprised adults.

The eardrum normally looks gray and has a little line down the middle of it where one of the ossicles (or ear bones) attaches to the eardrum.

what a fairly normal eardrum looks like through the ear-look thingy

Behind the eardrum is the middle ear. Many people think that it is the inner ear behind the eardrum, but the inner ear is where the actual organs of hearing are, along with the vestibular system (what keeps your balance). The middle ear is just a space with air in it and the three ossicles. When sound hits the eardrum, it vibrates and makes the ossicles move, which in turn transmit vibration to the inner ear so that your brain can translate it into sound.

The middle ear is kept at equal pressure with the outside world through the eustachian tube. This is what makes your ears pop when you yawn - your eustachian tube opens up momentarily. Unfortunately, this tube doesn’t always work, and so fluid can collect behind the eardrum in the middle ear. This is what happens when your ears get plugged up when you get a cold. If that fluid gets infected, it is then officially what is called otitis media, or an ear infection.

Ouch! This is a bad ear infection.

Looking in ears is hard to do, especially in screaming, squirming kids. I have all sorts of tricks to get them to hold still, but sometimes resort to the brute force method: "OK, Mom, you hold the hands, and I’ll get the head."

If a person gets a bunch of ear infections, then they are at increased risk of developing resistance to antibiotics. This is when we elect to put tubes into the eardrum. The tubes allow drainage of fluid out to the external ear and keep the pressure equalized. They work very well, and rarely cause significant problems. It is certainly safer than having resistant bacteria in the body. *I will not address "watchful waiting" in this post.

Sometimes you can’t tell if an ear has fluid behind it or not, so you use a bulb to blow air into the canal and watch the eardrum moves. If it moves, things are fine. If it doesn’t, they’re not so good. This is called pneumatic otoscopy. I call it using a bulb-thingy on your ear-look thingy.

Finally, sometimes the ear infection causes the eardrum to rupture. I remember when I was a kid being terrified when I saw Tarzan on TV and he ruptured his eardrums. He had blood coming out of his ears. It really creeped me out. The fact is, however, an eardrum usually ruptures at the best spot possible and heals up without problem. Furthermore, the pain is usually from the pressure on the inside of the ear being so high. Once the eardrum ruptures, it often feels much better.

The arrows are not a natural part of the ear. They are just a trick of technology.

The Inner Ear

You really don’t see the inner ear on exam. The best way to find out about the inner ear is to say, "Hey patient! Can you hear me?" If they say, "Yes doctor I can!" Then their inner ear works.

If they say, "The serpent bit my brother!" Then they might not be able to hear you, although they may just be stoned. You have to do other testing to determine that.

Seriously, the hearing of a person goes over time. This is due to increased rigidity of the tympanic membrane and less mobility of the ossicles. My daughter can hear the high pitched sound that the TV makes and is always complaining about it. I can’t hear it at all.

So there you have it. Ears are truly odd looking things, but without them we couldn’t hear. Without hearing, we would end up a loser and just be stuck spending all of our time on the Internet blogging and have absolutely no social life whatsoever….

What? Did you say something to me?

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Posted in Physical Exam