EYES

Structures / Landmarks to remember:

Conjunctiva – membrane covering most of the anterior surface
- protects the eye from foreign bodies and desiccation

Lacrimal Gland – located in temporal region of superior eyelid

- produces tears that moisten the eye

Sclera – dense, avascular structure that appears as white of the eye

Cornea – continuous with sclera, anterior part of globe

- sensory innervation primarily for pain

Iris – produces the color of the eye Pupil – central aperture of iris

- controls the amt of light

reaching the retina

DEVELOPMENTAL VARIATIONS
A. INFANTS & CHILDREN
- term babies are hyperopic (farsighted) with visual acuity of 20/200
- peripheral vision is fully developed at birth, central vision
develops later
- by 2 or 3 months, lacrimal ducts begin carrying tears and infant gains
voluntary control of eye
muscles
- by 6 months, vision has developed sufficiently enough to differentiate
colors
- by 9 months, binocular is perceived
- young children have myopic acuity (nearsighted)
- adult acuity is achieved by about 6 yrs. old

B. PREGNANT WOMEN
- mild corneal edema, especially in 3rd trimester
- corneal thickening
- increase in corneal epithelial pigmentation (Krukenberg spindles)
- ptsosis may develop for unknown reasons
- subconjunctival hemorrhages may occur/resolve spontaneously

C. OLDER ADULTS
- major physiologic change is progressive change in near point of
accommodation
- by 45 yrs, lens becomes more rigid and ciliary muscle of iris becomes
weaker
- results in presbyopia (difficulty with accommodation and
decrease in near vision)
- old fibers are compressed centrally, forming a more dense central
region that may cause loss of
clarity of lens and contribute to cataract formation
I. REVIEW OF RELATED HISTORY
A. HISTORY OF PRESENT ILLNESS
Difficulty with vision – one or both eyes, corrected by lens; cataracts, adequacy
of color vision; presence of
halos
Pain – in or around the eye; burning, itching, or nonspecific uncomfortable or
gritty sensation
Secretions – color, consistency, duration, tears that run, decreased tear
formation, conjunctival redness
Medications – use of any eyedrops or ointments, antibiotics, artificial tears,
mydriatics, myotics
B. PAST MEDICAL HISTORY
Trauma – to part or whole structure or supporting structures
Surgery
Chronic Illness – hypertension, diabetes, collagen vascular diseases,
inflammatory bowel disease, glaucoma

C. FAMILY HISTORY
Retinoblastoma or Cancer of retina
Color blindness, near- or far-sighted, strabismus (both eyes do not focus
simultaneously), amblyopia
(impairment of vision)
Chronic Illness – diabetes, glaucoma, allergies

D. PERSONAL AND SOCIAL HISTORY

Employment – exposure to chemicals, foreign bodies or high-speed machinery
Activities – sporting activities that might cause injury
Allergies – type, seasonal, associated symptoms
Corrective lens – last changed, how long worn, date of last eye exam

E. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN
- preterm (resuscitated, ventilator or oxygen used, retinopathy
diagnosis, cerebral palsy)
- failure of infant to gaze at mother’s face or other objects; failure
to blink when bright lights or
threatening movements are made
- white area in pupil on a photograph; inability of one eye to reflect
light properly
- excessive tearing over lower eyelid
- strabismus some or all of the time
- excessive rubbing of eyes in young children; inability to reach for
and pick up small objects;
necessity of bringing objects close to examine them; double
vision
- necessity of sitting near front of class to see the board in school
aged children; poor
progress in school not explained by intellectual ability
 2. PREGNANT WOMEN
- presence of disorders that can cause ocular complications such as
pregnancy induced
hypertension or diabetes
- use of topical eye meds may cross placental barrier

3. OLDER ADULTS
- visual acuity: decreases in central vision, distortion, use of dim
light to increase, complaints
of glare
- production of excess tearing or complaints of blurred vision
- dry eyes
- development of scleral brown spots
- difficulty in performing near work without lenses
- nocturnal eye pain

II. EXAMINATION AND FINDINGS

A. VISUAL TESTING
- color vision is rarely tests in routine physical exam
- always talk to pt and explain procedure, especially in regards to pain

Snellen Chart – measurement of visual acuity – discrimination of small details

– tests cranial nerve II (optic
nerve) and is essentially a measurement of central vision
- position patient 20 ft. from chart, making sure it is well lit
- test ea. eye individually by covering the opposite eye, being careful to
apply pressure
- ask patient to identify letters beginning at any line
- reference to a colored line tests for color blindness
- determine smallest line patient can identify all letters (can miss 2, on 3
use the line before)
- when testing 2nd line, ask patient to read line from right to left to keep
him from memorizing letters
- test patient with and without corrective lenses, recording the readings
separately
- visual acuity is recorded as a fraction in which the numerator indicates
the distance of the patient
from the chart
- denominator indicates distance at which the average eye can
read the line
- 20/200 means that the pt can read at 20 ft what the average
person can read at 200 ft
- smaller fraction, worse myopia (nearsightedness)
- vision not correctable to better than 20/200 is considered legal
blindness
- document fraction found on chart next to line that was completely and
correctly read

Confrontation Test – accurately measures peripheral vision

 - sit or stand opposite patient at eye level at a distance of about 2 ft.
- ask patient to cover left eye while you cover right (should be looking at
each other’s eye)
- extend arm midway between you and patient and move it centrally with
fingers moving
- have patient tell you when moving fingers are 1st seen
- compare pt’s response to the time you 1st note the moving fingers
- imprecise and can be considered significant only when it is abnormal
- ex. documentation “peripheral within that of tester’s”

B. EVALUATE MUSCLE BALANCE AND MOVEMENT OF EYES

- full movement of eyes is controlled by integrated function of cranial
nerves III (oculomotor), IV
(trochlear), and VI (abducens) and six extraocular muscles

Cover / Uncover Test – used when there is an imbalance found with the
corneal light reflex test
- measurement for nerve damage and muscle weakness
- ask pt to stare straight ahead at a near fixed point
- cover one eye and observe uncovered eye for movement
- remove cover and watch for movement of newly uncovered eye as it
fixes on the object
- movement of the covered or uncovered eye may indicate either
esotropia (form of strabismus where
one or both eyes deviate inward) or exotropia (form of strabismus
where one or both eyes
deviate outward)
- document movement or as “none detected in cover/uncover test”

Six Cardinal Fields of Gaze – left & right superior/inferior rectus, left & right
inferior/superior oblique, medial
rectus, left & right lateral rectus

nystagmus – involuntary rhythmic movements of eyes that can occur in

horizontal, vertical, rotary, or
mixed patterns
- jerking nystagmus is characterized by faster movements in one
direction and is defined by its
rapid phase
- if eye moves rapidly to right and then slowly drifts leftward,
patient is said to have nystagmus
to the right

C. INSPECTION
Abbreviations that must be spelt out but doctors continue: OD = right eye
OS = left eye OU = both eyes
Quick documentation note that can be used ONLY if all tests are positive:
 P – pupils E – equal R – round R. L. – reacts to light (direct/consensual
A – accommodation or
indirect/consensual)

1. Eyebrows – inspect for symmetry, size, extension, and texture of hair

- if eyebrows are coarse or do not extend beyond temporal canthus,
patient may have
hypothyroidism

2. Orbital Area – inspect for edema, puffiness, or sagging tissue below the
orbit
- periorbital edema is always abnormal - - may represent presence
of thyroid hypoactivity,
allergies, or (especially in youth) presence of renal disease
- flat, slightly raised, irregularly shaped, yellow tinted lesions on
periorbital tissues represent
depositions of lipids and may suggest abnormality of lipid
metabolism

xanthelasma – elevated plaque of cholesterol deposited

most commonly in nasal
portion of either upper or lower lid

3. Eyelids – examine lightly closed eyes for fasciculations or tremors of lids

(sign of hyperthyroidism)
- inspect eyelids for ability to close completely and open widely
- observe for flakiness, redness or swelling on eyelid margin
- eyelashes should be present on both lids and should turn outward
- when eye is open, superior lid should cover a portion of iris but
not the pupil itself
- if more of one iris than the other is covered or extends over
the pupil, ptosis of that
lid may be present, indicating congenital or acquired
weakness of levator
muscle or a paresis of a branch of the 3rd cranial nerve
- record the difference
- note whether the lids evert or invert
- when lower lid is turned away from eye, ectropion is present
and may result in
excessive tearing
- when lower lid is turned inward toward the globe, entropion
may cause corneal and
conjunctival irritation, increasing the risk of secondary
infection

erythematous – yellow lump

- acute suppurative inflammation of follicle of eyelash
- hordeolum or sty

blepharitis – crusting along eyelashes

 4. Conjunctiva – usually inapparent, clear, and free of erythema
- easily inspected by having patient look upward while you draw the
lower lid downward
- inspect upper tarsal conjunctiva only when there is a suggestion
that a foreign body may
present
- observe for increased erythema or exudate
- erythema or cobblestone appearance may indicate allergic
or infectious conditions
- bright red blood in sharply defined area surrounded by
healthy appearing
conjunctiva indicates subconjunctival hemorrhage

pterygium – abnormal growth of conjunctiva that extends

over cornea from limbus
- more commonly on nasal side
- more common in people heavily exposed to ultraviolet
light

5. Sclera – ensure that it is white

- if liver disease is present, sclerae may become pigmented and
appear either yellow or green
- senile hyaline plaque appears as dark, rust-colored pigment just
anterior to insertion of
medial rectus muscle
- presence does not imply disease but should be noted

6. Cornea – examine for clarity by shining a light tangentially on it

- blood vessels should not be present
- sensitivity controlled by cranial nerve V (trigeminal)

corneal arcus (arcus senilis) – composed of lipids deposited in

periphery of cornea
- may form a complete circle (circus senilis)
- seen in majority of individuals over 60
- if present before age 40, may indicate lipid disorder,
most commonly type II
hyperlipidemia

7. Iris – pattern should be clearly visible

- irides are same color

8. Pupils – note any irregularity in shape - - should be round, regular, and

equal in size
- test for response to light both directly and consensually
- darken room so that pupils dilate
- shine penlight directly into eye and note whether pupil
constricts
 - note consensual response of opposite pupil constricting
simultaneously with tested
pupil
- exam center position

Constriction to Accommodation Test – testing for papillary

response to accommodation is
of diagnostic importance only if there is a defect in papillary
response to light
- failure to respond to direct light but retaining constriction
during accommodation is
sometimes seen in patients with diabetes or syphilis
- as patient to look at a distant object and then at a test
object held 10 cm from bridge
of nose
- pupils should constrict when eyes focus on near object

miotic – pupil fails to dilate in dark

mydriasis – dilation of more than 6 mm and failure of pupils to

constrict with light

anisocoria – inequality of papillary size

D. PALPATE
- palpate eyelids for nodules
- note whether they meet completely
- if closed lids do not completely cover globe (lagophthalmos),
cornea may become dried
and be at increased risk for infection
- palpate eye itself
- determine whether it feels hard or can be gently pushed into orbit
without causing discomfort
- if it feels very firm and resists palpation, may indicate glaucoma,
hyperthyroidism, or
presence of retroorbital tumor

- palpate region of lacrimal gland and lower orbital rim near inner canthus
- glands are rarely enlarged

E. MISCELLANEOUS
- inspection of interior of eye permits visualization of optic disc
- with patient looking at distant fixation point, direct light of
ophthalmoscope at pupil from about 12”
away
- 1st visualize red reflex, caused by light illuminating the retina
- any opacities in path of light will stand out as black densities
- absence of red reflex is often result of improperly positioned
ophthalmoscope, but may also
 indicate total opacity of pupil by cataract or hemorrhage into
vitreous humor
- Drusen bodies can appear as small, discrete spots that are slightly
pinker than retina
- with time spots enlarge and become more yellow
- may occur in many conditions that affect pigment layers of retina,
but most commonly are a
consequence of aging process and may be precursor of senile
macular degeneration
- when noted to be increasing in number or intensity of color,
individual should be given
Amsler grid
- grid is used to evaluate central vision
- pt is instructed to observe grid with ea. eye and note any
distortion of grid pattern

F. DEVELOPMENTAL VARIATIONS
1. Infants – often shut their eyes tightly when exam is attempted
- begin by inspecting external structures
- note size of eyes, paying particular attention to small or
differently sized eyes
- inspect eyelids for swelling, epicanthal folds, and position
- look for vertical fold of skin nasally that covers
lacrimal caruncle
- prominent epicanthal folds are common in Asians, but
may suggest Down
Syndrome in other ethnic groups
- inspect level of eyelid covering the eye
- look for sclera above iris
- observe distance between eyes, looking for wide spaces, or
hypertelorism associated with
mental retardation
- inspect sclera, conjunctiva, pupil, and iris of ea. eye

2. Children – perform inspection of external structures as described for

infants
- visual acuity is tested (when child is cooperative) with Snellen E
Game, usually at about 3
- if child wears glasses, vision should be tested both with and
without corrective
lenses and recorded separately

Anticipated Visual Acuity: 3 yrs 20/50 4 yrs 20/40

5 yrs 20/30 6 yrs 20/20

- exam of extraocular movements and cranial nerves is performed

as with adults
- peripheral vision can be tested in cooperative children
 3. Pregnant Women – retinal exam can differentiate between chronic
hypertension and pregnancy-
induced hypertension
- vascular tortuosity, angiosclerosis, hemorrhage, and exudates
may be seen in pts with long-
standing history of hypertension
- because of systemic absorption, cycloplegic and mydriatic agents
should be avoided unless
there is a need to evaluate for retinal disease
- use of nasolacrimal occlusion after instillation of topical eye
meds may reduce
systemic absorption

III. COMMON ABNORMALITIES

A. EXOPHTHALMOS - increase in volume of orbital content, causing protrusion of
globes forward
- may be bilateral or unilateral
- most common cause is Graves disease
- when unilateral, retroorbital tumor must be considered
- retraction of upper lid and exposure of sclera above iris may exaggerate

B. STRABISMUS (PARALYTIC AND NONPARALYTIC) - both eyes do not focus on an object

simultaneously
- may be paralytic, caused by impairment of one or more extraocular
muscles or their nerve supply
- nonparalytic has no primary muscle weakness
- pt can focus with either eye but not with both simultaneously
- sign of intraocular pathology such as infantile cataract or
retinoblastoma

C. MIOSIS - bilateral papillary constriction; usually less than 2 mm in diameter

D. MYDRIASIS - bilateral papillary dilation; usually more than 6 mm in diameter

E. ANISOCORIA – unilateral unequal size of pupils

F. CATARACTS – common abnormality of lens - - opacity occurring in lens commonly

from denaturation of lens
protein caused by aging
- almost everyone over 65 has some evidence of lens opacification
- congenital cataracts can result from maternal rubella or other fetal
insults during 1st trimester

G. DIABETIC RETINOPATHY (BACKGROUND) – marked by dot hemorrhages or

microaneurysms and presence of hard
and soft exudates
- hard exudates, thought to be result of lipid transudation through
incompetent capillaries, have
sharply defined borders and tend to be bright yellow
 - soft exudates are caused by infarction of nerve layer and appear as dull
yellow spots with poorly
defined margins

H. DIABETIC RETINOPATHY (PROLIFERATIVE) – development of new vessels as result of

anoxic stimulation
- may occur in peripheral retina or on optic nerve itself
- new vessels lack supporting structure of healthy vessels and are likely
to hemorrhage
- bleeding from these vessels is major cause of blindness in
patients with diabetes
- laser therapy can often control this neovascularization and prevent
blindness

I. GLAUCOMA – abnormal condition of elevated pressure within eye caused by

obstruction of outflow of aqueous
humor
- accompanied by intense ocular pain, blurred vision, red eye and dilated
pupil
- may occur chronically in which symptoms are absent except for gradual
loss of peripheral vision over
a period of years

J. RETINOBLASTOMA – embryonal malignant tumor arising from retina, often during 1st
2 yrs of life
- may be transmitted either by autosomal dominant trait or chromosomal
mutation
- initial signs are white reflex (cat’s eye reflex) rather than usual red
reflex
- exam reveals ill-defined mass arising from retina - - often chalky white
area of calcification
EARS

Structures to remember during inspection: umbo light reflex

DEVELOPMENTAL VARIATIONS
A. INFANTS AND CHILDREN – because development of inner ear occurs during 1st
trimester, an insult to fetus may
impair hearing
- external auditory canal is shorter than adult’s and has upward curve
- eustachian tube is relatively wider, shorter, and more horizontal than
adult’s
- with growth of lymphatic tissue, specifically adenoids, eustachian tube
may become occluded,
interfering with aeration of middle ear

B. PREGNANT WOMEN – capillaries of nose, pharynx, and eustachian tubes become

engorged, leading to
symptoms of nasal stuffiness, decreased sense of smell, a sense of
fullness in ears and impaired
hearing

C. OLDER ADULTS – hearing tends to deteriorate with degeneration of hair cells in

organ of Corti, usually after 50
- sensorineural hearing loss 1st occurs with high-frequency sounds and
then progresses to tones of
lower frequency
- hearing deterioration may also result from excess deposition of bone
cells along ossicle chain,
causing fixation of stapes in oval window
- cerumen may become very dry and may totally obstruct external
auditory canal, interfering with
sound transmission
- tympanic membrane becomes more translucent and sclerotic

I. REVIEW OF RELATED HISTORY

A. HISTORY OF PRESENT ILLNESS
Vertigo or dizziness – onset, description of sensation, associated symptoms
(presence or absence of tinnitus,
hearing loss, double vision), unsteadiness, meds
Earache – onset, concurrent upper respiratory infection, associated symptoms
(vertigo, tinnitus), method of
cleaning ear canal, meds
Hearing Loss (one or both ears) – onset, repeated history of cerumen
impaction, hears best when?, speech
(soft or loud, articulation), management (aids), ototoxic meds (ex. Lasix,
diuretics)

B. PAST MEDICAL HISTORY

Systemic Disease – hypertension, cardiovascular, diabetes, bleeding disorder
 Ear – frequent ear problems during childhood; surgery, labyrinthitis, antibiotic
use, dosage, and duration

C. FAMILY HISTORY
Hearing problems or loss, allergies

D. PERSONAL AND SOCIAL HISTORY

Environmental Hazards – exposure to loud, continuous noises; types of
protective devices used
Ototoxic Drugs – lasix, diuretics

E. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN – ototoxic antibiotic use, chronic otitis media, playing
with small objects (could
place in ears), behaviors indicating hearing loss (no reaction to loud
or strange noises, no
babbling after 6 mos, no communicative speech, inattention)

2. PREGNANT WOMEN – presence of symptoms before pregnancy, exposure to

infection

3. OLDER ADULTS – hearing loss causing any interference with daily life,
ototoxic drugs

II. EXAM AND FINDINGS

A. HEARING
- cranial nerve VIII is tested by evaluating hearing
- screening begins when patient responds to questions and directions

1. WHISPERED VOICE TEST – check patient’s response to whispered voice, one

ear at a time
- have patient place a finger in the ear canal and gently move it
rapidly up and down
- stand to the side of pt. at a consistent distance best for you
(approx. 1 – 2 ft.) away from ear
being tested
- whisper 1 and 2 syllable words very softly and ask pt. to repeat
the words heard
- pt. should hear softly whispered words in ea. ear, responding
correctly at least 50% of the
time

2. WEBER AND RINNE TESTS – tuning fork is used to compare hearing by bone
conduction with that by air
conduction
- hold base of tuning fork with one hand without touching the tines,
and stroke or tap the tines
gently with your other hand, setting the tuning fork in
vibration
 a. Weber Test – place base of vibrating tuning fork on the
midline vertex of pt.’s head
- ask pt. if sound is heard equally in both ears or is
better in one ear
(lateralization)
- pt. should hear sound equally
- if sound is lateralized, have pt. identify which ear
hears the best
- to test reliability of response, repeat procedure while
occluding one ear,
asking pt. in which ear the sound is best heard
- sound should be heard better in occluded ear

b. Rinne Test – place base of vibrating tuning fork against pt’s

mastoid bone
- begin counting or timing interval with watch
- ask pt to tell when sound is no longer heard, noting
number of seconds
- quickly position still vibrating tines ½ - 1” from
auditory canal and again ask
pt to tell when sound is no longer heard
- continue counting or timing interval to determine
length of time sound is
heard by air conduction
- compare number of seconds heard by bone vs. air
conduction
- air-conducted sound should be heard twice as
long as bone
- conductive hearing loss results when sound
transmission is impaired
through external or middle ear
- sensorineural hearing loss results from a defect in
inner ear that leads to
distortion of sound and misinterpretation of
speech

B. INSPECTION
1. EXTERNAL EAR- inspect auricles for size, shape, symmetry, landmarks,
color, and position on head
- shape of landmarks is not significant unless deformities are noted
- should have same color as facial skin, without moles, cysts, or
other lesions, deformities or
nodules
- blueness may indicate some degree of cyanosis
- pallor or excessive redness may be result of vasomotor instability
- unusual size or shape may be familial trait or indicate abnormality
- cauliflower ear is the result of blunt trauma and necrosis of
underlying cartilage
 tophi – small, whitish uric acid crystals along peripheral
margins of auricles may
indicate gout

sebaceous cysts – elevations in skin with punctum

indicating blocked sebaceous
gland
- common

- position should be almost vertical, with no more than 10° lateral

posterior angle
- low-set or unusual angle may indicate chromosomal
aberrations or renal disorder

- examine lateral and medial surfaces and surrounding tissue,

noting color, presence of
deformities, lesions and nodules

Darwin tubercle – thickening along upper ridge of helix

- expected variation as are preauricular pits - - found in
front of ear where
upper auricle originates

2. AUDITORY CANAL – inspect for discharge, cerumen, color, lesions, foreign

bodies and note any odor
- purulent, foul-smelling discharge is associated with otitis or
foreign body
- bloody or serous discharge is suggestive of skull fracture in case
of trauma
- note discharge, scaling, excessive redness, lesions, foreign bodies,
and cerumen
- expect to see minimal cerumen, uniformly pink color, and
hairs in outer third of canal
- cerumen may vary in color and texture and should have no
odor
- no lesions, discharge, or foreign body should be present

3. TYMPANIC MEMBRANE – otoscope is used to inspect, using the largest

speculum that will fit comfortably
in pt’s ear
- hold handle between thumb and index finger, supported by
middle finger (using right
hand for right ear and left hand for left ear), which
leaves ulnar side of hand
to rest against pt’s head, stabilizing otoscope as it is
inserted
- tilt pt’s head toward opposite shoulder and simultaneously
pull pt’s auricle upward
and backward in order to straighten auditory canal,
giving the best view
 - inspect for landmarks (umbo, handle of malleus, light reflex),
color, contour, and perforations
- should have no perforations with a slightly conical contour
and a concavity at the
umbo
- bulging tympanic membrane is more conical, usually with a
loss of bony landmarks
and a distorted light reflex
- retracted tympanic membrane is more concave, usually
with accentuated bony
landmarks and distorted light reflex
- should be translucent, pearly gray color
- light reflex in right ear should be located at 5:00 position, in
left ear at 7:00 position

C. PALPATE
- palpate auricles and mastoid area for tenderness, swelling, or nodules
- consistency should be firm, mobile, and without nodules
- if folded forward, it should readily recoil to usual position
- pulling gently on lobule should cause no pain

D. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN – auricle should be well formed, with all landmarks
present on inspection
- auricles either poorly shaped or positioned below imaginary line
are associated with renal
disorders and congenital anomalies
- newborn’s auricle is very flexible but should have instant recoil
after bending
- no skin tags should be present
- tympanic membrane is usually in an extremely oblique position
until infant is 1 month old
- because tympanic membrane does not become conical for
several months, light
reflex may appear diffuse
- limited mobility, dullness, and opacity of pink or red
tympanic membrane may be
noted in neonates
- hearing should be evaluated at regular intervals

2. CHILDREN – while using otoscope, pull auricle either downward and back or
upward and back to gain
best view of tympanic membrane
- as child grows, shape of auditory canal changes to S-shaped curve
of adult
- if child is crying, tympanic membrane can appear red - - cannot
assume redness is hallmark
of middle ear infection
- pneumatic otoscope is especially important to differentiate red
tympanic membrane caused
 by crying (membrane is mobile) from that resulting from
disease (no mobility)
- evaluate hearing by observing response to whispered voice and
various noisemakers (avoid
giving visual cues)
- Weber and Rinne tests are used when child understands directions
and can cooperate
(between 3 – 4 yrs.)

3. PREGNANT WOMEN – tympanic membranes may have increased vascularity

and be retracted or bulging
with serous fluid

4. OLDER ADULTS – inspect auditory canal of pt who wears a hearing aid for
areas of irritation from ear
mold
- tympanic membrane landmarks may appear slightly more
pronounced from sclerotic
changes
- some degree of sensorineural hearing deterioration, marked by
greater difficulty
understanding speech rather than a reduction in all sounds
heard
- conductive hearing loss from otosclerosis and cerumen
impaction may occur

III. COMMON ABNORMALITIES

A. OTITIS EXTERNA – infection of auditory canal resulting when trauma or moist
environment favors bacterial or
fungal growth

B. MIDDLE EAR EFFUSION – inflammation of middle ear resulting in collection of

serous, mucoid, or purulent fluid
(effusion) in middle ear when tympanic membrane is intact
- conductive hearing loss results
- causes include obstructed or dysfunctional Eustachian tube, allergies,
and enlarged lumphoid tissue
in nasopharynx
- once obstruction occurs, middle ears absorbs air, creating vaccum, and
mucosa secretes transudate
into middle ear

C. ACUTE OTITIS MEDIA – presence of middle ear effusion in conjunction with rapid
onset of one or more of the
following: ear pain, fever, marked redness or distinct fullness or bulging
of tympanic membrane, and
hearing loss
- most common infection of childhood
D. LABYRITHITIS – inflammation of labyrinthine canal of inner ear occurs as
complication of acute upper respiratory
infection
- symptoms of severe vertigo, associated with nystagmus, increase in
severity with head movement
- total sensorineural hearing loss occurs on affected side

E. PRESBYCUSIS – common auditory disorder in which there is bilateral sensorineural

hearing loss associated with
aging
- loss in perception of auditory stimuli – initially of high-frequency sounds
– and tinnitus
- speech may be poorly understood when spoken quickly or when
background noise is present