Central nervous system damage – usually
some recovery but often persistent
Triggers Lying on affected ear Possible presence of upper
None Drugs (e.g. aminoglycosides)
9.4 Characteristics of nystagmus
Nystagmus type Clinical pathology Characteristics
Peripheral Semicircular canal, vestibular nerve Unidirectional
Not suppressed by optic fixation
Dix–Hallpike fatigues on repetition
Central Brainstem, cerebellum Bidirectional (changes with direction of gaze)
Patient can walk (even with nystagmus)
Dysconjugate (ataxic) Interconnections of III, IV and VI nerves
Typically affects the abducting eye To either side
Pendular Eyes, e.g. congenital blindness No fast phase Straight ahead
The physical examination • 175
• Use the largest otoscope speculum that will comfortably fit
• Explain to the patient what you are going to do.
• Hold the otoscope in your right hand for examining the right
ear (left hand to examine left ear). Rest the ulnar border of
your hand against the patient’s cheek to enable better
control and to avoid trauma if the patient moves (Fig. 9.3).
• Gently pull the pinna upwards and backwards to
straighten the cartilaginous external auditory canal. Use
the left hand to retract the right pinna (Fig. 9.3).
• Inspect the external auditory canal through the speculum,
noting wax, foreign bodies or discharge. You should
identify the tympanic membrane and the light reflex
anteroinferiorly (see Fig. 9.2).
Congenital deformities of the pinna, like microtia (Fig. 9.4A)
or low-set ears, can be associated with other conditions such
as hearing loss and Down’s syndrome. Children can also have
protruding ears that occasionally require corrective surgery
(pinnaplasty). Trauma can result in a pinna haematoma (Fig.
9.4B) and subsequent ‘cauliflower ear’ due to cartilage necrosis
if untreated. Trauma may also cause mastoid bruising (‘Battle’s
sign’), suggesting a possible skull-base fracture. Lesions on the
pinna are relatively common and can be related to sun exposure;
they include actinic keratosis, and basal cell and squamous cell
• previous ear surgery, trauma
• systemic conditions associated with hearing loss (such as
granulomatosis with polyangiitis)
• any significant previous illnesses such as meningitis, which
can result in significant sensorineural hearing loss.
The aminoglycoside antibiotics (such as gentamicin), aspirin,
furosemide and some chemotherapy agents (cisplatin) are
Some causes of sensorineural hearing loss and otosclerosis are
congenital. Otosclerosis causes a conductive hearing loss due
to fixation of the stapes footplate.
The patient’s occupation should be noted, as well as any
significant previous exposure to loud noise.
• Pinna skin, shape, size, position, scars from previous
• Gently pull on the pinna and push on the tragus to check
• Gently palpate over the mastoid bone behind the ear to
assess for pain or swelling. Fig. 9.3 Examination of the ear using an otoscope.
Fig. 9.4 The pinna. A Microtia. B Haematoma. C Squamous cancer (arrow).
176 • The ear, nose and throat
an offensive discharge and erode the bony ossicles, resulting in
a conductive hearing loss (Fig. 9.5C). Fluid behind the tympanic
membrane is called otitis media with effusion (OME or ‘glue
ear’, Fig. 9.7A), and a fluid level may be seen (Fig. 9.7B). This
commonly affects children and can be treated surgically with
insertion of a ventilation tube or grommet (see Fig. 9.6C). If
persistent OME is seen in adults, the postnasal space needs
to be examined by a specialist to exclude a lesion in that site.
Acute otitis media presents with pain; the tympanic membrane
can become inflamed (Fig. 9.7C), and may bulge and eventually
If discharge is noted on otoscopy and the tympanic membrane
is intact, otitis externa is the likely cause (Fig. 9.5A). The canal
can reveal exostoses, abnormal bone growth due to cold water
exposure, often seen in surfers (Fig. 9.5B).
Scarring on the tympanic membrane (tympanosclerosis)
can be caused by previous grommet insertion or infections.
Tympanic membrane perforations can be central or marginal,
and the position and size of the perforation should be noted as
a percentage (Fig. 9.6A). A severe retraction pocket of the pars
tensa can mimic a perforation (Fig. 9.6B). A retraction of the
pars flaccida can contain a cholesteatoma, which may cause
The physical examination • 177
• Strike the prongs of the tuning fork against a hard surface
• Place the vibrating tuning fork on the mastoid process
• Now place the still-vibrating base at the external auditory
meatus and ask, ‘Is it louder in front of your ear or
With normal hearing, the sound is heard louder when the tuning
fork is at the external auditory meatus. That is, air conduction
(AC) is better than bone conduction (BC), recorded as AC >BC.
This normal result is recorded as ‘Rinne-positive’.
In conductive hearing loss, bone conduction is better than
air conduction (BC>AC); thus the sound is heard louder when
the tuning fork is on the mastoid process (‘Rinne-negative’).
A false-negative Rinne’s test may occur if there is profound
hearing loss on one side. This is due to sound being conducted
through the bone of the skull to the other ‘good’ ear. Weber’s
• Start testing with your mouth about 15 cm from the ear
• Mask hearing in the patient’s other ear by rubbing the
• Ask the patient to repeat a combination of multisyllable
numbers and words. Start with a normal speaking voice to
confirm that the patient understands the test. Lower your
• Repeat the test but this time at arm’s length from the
patient’s ear. People with normal hearing can repeat
A 512-Hz tuning fork can be used to help differentiate between
conductive and sensorineural hearing loss.
• Strike the prongs of the tuning fork against a hard surface
• Place the base of the vibrating tuning fork in the middle of
the patient’s forehead (Fig. 9.8).
• Ask the patient, ‘Where do you hear the sound?’
• Record which side Weber’s test lateralises to if not
In a patient with normal hearing, the noise is heard in the
middle, or equally in both ears.
In conductive hearing loss the sound is heard louder in the
affected ear. In unilateral sensorineural hearing loss it is heard
louder in the unaffected ear. If there is symmetrical hearing loss
it will be heard in the middle. Fig. 9.8 Weber’s test.
Fig. 9.9 Rinne’s test. A Testing bone conduction. B Testing air conduction.
178 • The ear, nose and throat
nystagmus may occur. This assesses for gaze nystagmus
• If any oscillations are present, note:
• whether they are horizontal, vertical or rotatory
• which direction of gaze causes the most marked
• in which direction the fast phase of jerk nystagmus
Discriminating characteristics of nystagmus are detailed in
• Ask the patient to sit upright, close to the end of the
• Turn the patient’s head 45 degrees to one side (Fig. 9.10A).
• Rapidly lower the patient backwards so that their head is
now 30 degrees below the horizontal. Keep supporting the
head and ask the patient to keep their eyes open, even if
• Observe the eyes for nystagmus. If it is present, note
latency (time to onset), direction, duration and fatigue
(decrease on repeated manœuvres).
• Repeat the test, turning the patient’s head to the other
Normal patients have no nystagmus or symptoms of vertigo.
A positive Dix–Hallpike manœuvre is diagnostic for benign
paroxysmal positional vertigo. There is a delay of 5–20 seconds
before the patient experiences vertigo and before rotatory jerk
nystagmus towards the lower ear (geotropic) occurs; this lasts for
less than 30 seconds. The response fatigues on repeated testing
due to adaptation. Immediate nystagmus without adaptation,
and not necessarily with associated vertigo, can be caused by
Head impulse test (or head thrust test)
• Sit opposite the patient and ask them to focus on a target
test is more sensitive and therefore the tuning fork will lateralise
to the affected ear in conductive hearing loss before Rinne’s
test becomes abnormal (negative). In sensorineural hearing loss,
Rinne’s test will be positive, as air conduction is better than
Tuning fork test findings are summarised in Box 9.5.
• Patients should be tested with spectacles or contact
lenses for best corrected vision.
• With the patient seated, ask them to fixate on a stationary
target in a neutral gaze position and observe for
• Hold your finger an arm’s length away, level with the
patient’s eye, and ask the patient to focus on and follow
the tip of your finger. Slowly move your finger from side to
side and up and down and observe the eyes for any
oscillations, avoiding extremes of gaze where physiological
Bilateral normal hearing Central AC>BC, bilateral
Louder right AC>BC, bilaterala
Unilateral conductive loss LEFT Louder left BC>AC, left
Patients with a severe sensorineural loss may have BC>AC due to BC crossing
to the other better-hearing cochlea that is not being tested (false-negative
AC, air conduction; BC, bone conduction.
(fatigue) on repeat testing. See text for details.
If imbalance or vertigo with nystagmus is induced, it suggests an
abnormal communication between the middle ear and vestibular
system (such as erosion due to cholesteatoma).
Initial investigations in ear disease are summarised in Box 9.6
• Hold the patient’s head, placing a hand on each side of it.
• Rapidly turn the patient’s head to one side in the
horizontal plane (roughly 15 degrees) and watch for any
corrective movement of the eyes. Repeat, turning the head
towards the other side. The eyes remain fixed on the
examiner’s nose in a normal test. When the head is turned
towards the affected side the eyes move with the head
and there is then a corrective saccade.
This is a test of the vestibulo-ocular reflex. The presence of a
corrective saccade is a positive test and indicates a deficiency
in the vestibulo-ocular reflex. It is useful to identify unilateral
peripheral vestibular hypofunction. You must be careful when
performing this test in patients with neck problems because of
the rapid movements of the head.
• Ask the patient to march on the spot with their eyes
closed. The patient will rotate to the side of the damaged
• Compress the tragus repeatedly against the external
auditory meatus to occlude it.
9.6 Investigations in ear disease
Investigation Indication/comment
culture can help guide treatment
Magnetic resonance imaging Acoustic neuroma (Fig. 9.11)
Asymmetrical sensorineural hearing loss or unilateral tinnitus
The compliance of the tympanic membrane is measured during changes in pressure in the ear canal;
compliance should be maximal at atmospheric pressure
Vestibular testing: Unilateral vestibular hypofunction
nystagmus. The response is reduced in vestibular hypofunction
Posturography Reveals whether patients rely on vision or proprioception more than usual
Usually reserved for specialist balance clinics
Fig. 9.11 Magnetic resonance image showing a right acoustic
The external nose consists of two nasal bones that provide support
and stability to the nose. The nasal bones articulate with each
other and with bones of the face: the frontal bone, the ethmoid
bone and the maxilla. The nasal bones also attach to the nasal
septum and the paired upper lateral cartilages of the nose. There
are two further paired cartilages, the lower lateral cartilages, which
form the nasal tip. Internally the nasal septum, which is bone
posteriorly and cartilage anteriorly, separates the nose into two
nasal cavities that join posteriorly in the postnasal space. There
are three turbinates on each side of the nose, superior, middle and
inferior, which warm and moisten nasal airflow (Figs 9.13 and 9.14A).
One important function of the nose is olfaction. The olfactory
receptors are situated high in the nose in the olfactory cleft.
Olfactory fibres from the nasal mucosa pass through the cribriform
plate to the olfactory bulb in the anterior cranial fossa.
180 • The ear, nose and throat
trauma. Bilateral obstruction can be due to rhinitis (allergic or
non-allergic), or chronic rhinosinusitis with or without polyps.
• unilateral or bilateral discharge (rhinorrhoea)
• anterior discharge or postnasal drip.
Clear, bilateral watery discharge suggests allergic or non-allergic
rhinitis. Purulent discharge can point to acute bacterial rhinosinusitis
or chronic rhinosinusitis. A unilateral, purulent discharge in a child
raises the possibility of a foreign body in the nose. Following a
head injury, unilateral clear rhinorrhoea suggests a possible CSF
leak secondary to an anterior skull-base fracture.
Epistaxis (bleeding from inside the nose)
• unilateral or bilateral bleeding
• frequency and duration of episodes
The paranasal sinuses are air-filled spaces in the skull. There
are paired frontal, sphenoid, maxillary and anterior and posterior
ethmoid sinuses. The anterior nasal sinuses (frontal, maxillary
and anterior ethmoid) drain into the middle meatus (between
the middle turbinate and lateral wall of the nose). The posterior
ethmoid and sphenoid sinuses drain into the sphenoethmoidal
recess (between the superior turbinate and nasal septum).
• unilateral or bilateral obstruction
• associated symptoms (bleeding, swelling, pain).
Unilateral nasal obstruction may be caused by anatomical
blockage, such as a deviated septum possibly secondary to
A Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
B Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
C Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
conduction, Left air conduction, Bone conduction)
If bleeding is unilateral and associated with nasal obstruction
and pain, the possibility of sinonasal malignancy should be
considered. In adolescent males with unilateral nasal obstruction
and epistaxis, the rare diagnosis of juvenile angiofibroma should
be excluded on nasendoscopy by an ear, nose and throat
• whether symptoms occur all year round, only during
certain seasons, or during contact with allergens.
Sneezing is a protective sudden expulsive effort triggered by
local irritants in the nose and is most commonly due to allergy
• complete loss of smell (anosmia)
• reduced sense of smell (hyposmia)
• unpleasant smells (cacosmia)
• associated nasal symptoms such as obstruction
and rhinorrhoea, which may suggest rhinitis or nasal
A sudden onset of anosmia can occur following a significant
head injury or viral URTI due to damage to the olfactory
epithelium. Inflammation and swelling in the nasal mucosa as
a result of rhinitis, chronic rhinosinusitis or nasal polyps usually
cause hyposmia. Cacosmia is usually caused by infection in the
nose or sinuses, or occasionally by a foreign body in the nose.
Phantosmia describes olfactory hallucinations, which may occur
Nasal pain is rare, except following trauma. Facial pain can
be caused by a number of problems but is often incorrectly
attributed to sinusitis. The key to identifying the cause of facial
• provoking factors such as trauma, sneezing, or blowing or
• bleeding from the front or back of the nose.
The nasal septum has a very rich blood supply, particularly in
Little’s area (anterior septum), which is a common site for bleeding.
Fig. 9.13 The nose and paranasal sinuses.
182 • The ear, nose and throat
• use of anticoagulants, including warfarin, apixaban or
• use of antiplatelet drugs (aspirin, clopidogrel).
Intranasal cocaine use can cause septal perforation, epistaxis,
A family history of atopy is relevant in rhinitis. In patients with
epistaxis it is important to establish a family history of hereditary
haemorrhagic telangiectasia or inherited bleeding disorders.
Occupation is relevant because exposure to inhaled allergens,
occupational dusts and chemicals may exacerbate rhinitis.
Exposure to hardwood dust is associated with an increased
risk of sinonasal cancers. Atopic patients should be asked
Heavy alcohol intake, leading to liver disease, can affect
coagulation and is relevant for epistaxis. Smoking impedes
mucociliary clearance and can contribute to nasal problems.
• Assess the external appearance of the nose, noting
swelling, bruising, skin changes and deformity.
• Stand above the seated patient to assess any external
• Ask the patient to look straight ahead. Elevate the tip of
their nose using your non-dominant thumb to align the
nostrils with the rest of the nasal cavity.
• Look into each nostril and assess the anterior nasal
septum (Fig. 9.16); note the mucosal covering, visible
vessels in Little’s area, crusting, ulceration and septal
perforation. In trauma, a septal haematoma should be
• Using an otoscope with a large speculum in an adult,
assess the inferior turbinates. Note any hypertrophy and
swelling of the turbinate mucosa.
• You may see large polyps on anterior rhinoscopy. To
distinguish between hypertrophied inferior turbinates and
nasal polyps, you can lightly touch the swelling with a
cotton bud (polyps lack sensation).
• Palpate the nasal bones to assess for bony or
• In trauma, palpate the infraorbital ridges to exclude a step
deformity and also to check infraorbital sensation. Eye
movements should be assessed to rule out restriction of
movement related to ‘orbital blowout’.
• Place a metal spatula under the nostrils and look for
condensation marks to assess airway patency.
• Palpate for cervical lymphadenopathy (p. 32).
• Note that rigid nasendoscopy and tests of olfaction are
confined to specialist clinics.
• quality of pain: for example, throbbing, aching, sharp,
• location of pain: unilateral or bilateral
• duration and frequency of pain
• associated nausea, photophobia or aura (migraine)
• relieving and exacerbating factors.
rhinosinusitis, trigeminal neuralgia (severe, sharp pain in a
trigeminal distribution), tension headache (band-like, tight pain)
and cluster headaches (unilateral nasal discharge, eye watering).
The most common cause of nasal deformity is trauma, resulting
in swelling, bruising and deviation of the nose. The swelling
following trauma will settle over a couple of weeks but residual
deviation may remain if the nasal bones were fractured and
displaced. It is important to establish the impact of the nasal
injury on function (nasal breathing, sense of smell) and cosmetic
Nasal septal destruction or perforation can result in ‘saddle
deformity’ of the nasal bridge. Causes include granulomatosis
with polyangiitis, trauma, cocaine abuse, congenital syphilis and
iatrogenic factors (septal surgery, Fig. 9.14B).
The nose can appear widened in acromegaly or with advanced
nasal polyposis (Fig. 9.14C). Rhinophyma can also result from
chronic acne rosacea of the nasal skin (Fig. 9.15).
• asthma (around one-third of patients with allergic rhinitis
• prior nasal trauma or surgery
• history of bronchial infection (cystic fibrosis or ciliary
disorders may affect the nose and lower airways).
For patients with epistaxis it is important to identify any history
of bleeding diathesis or hypertension.
Fig. 9.15 Rhinophyma as a complication of rosacea.
9.7 Investigations in nasal disease
Investigation Indication/comment
Plain X-ray Not indicated for nasal bone fracture
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