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External Ear Examination by Using Bull's Lamp and Reflective Mirror

Traditional method of external ear examination by using light source from Bull's lamp and reflected by head mirror.  Today, this technique was superseded by using electric or battery operated headlights utilizing Xenon bulb or LED (light emitting diode).

Principles of Otoscopy

Otoscopic Examination

Preliminary external ear examination     Correct speculum size selected (largest

under good illuminations, followed by     which can fit nicely into the introitus). 

gentle palpation to elicit area of local     Otoscope being held as shown with the

tenderness.  Pinna is being pulled         ulna side of little and ring fingers resting

downward in neonates,backward in        gently onto the patient's face.  Then, the

children, and upward and posteriorly      examining eye see through the eyepiece. in adults.                                             Systematic examination of the ear canal

                                                          and eardrum performed and findings 

                                                          recorded appropriately.                   

Tympanic Membrane Mobility Testing

This test is usually done clinically by performing siegelisation or by using a    pneumatic otoscope while the patient performs valsalva manouevre.  Outward bulge is seen when the pressure in the middle ear cleft exceeded the atmospheric  pressure (above the opening threshold of the eustachian tube).  Similar effect is to be seen upon blowing nasal balloon.  The reverse movement (indrawing) is seen upon swallowing with the mouth and nostrils closed; the so called Toynbee manouevre.  Modern days technique incorporate otoendoscopy for the sharper image and detecting even the subtle mobility. This figure shows the bulging of eardrum soon after the patient performs valsalva manouevre.

 

Normal Eardrum Mobility.

 

Retraction & Selective Dysventilation Syndrome.

Otoendoscopy

 

An example of portable otoendoscope with attached camera head and wiewing panel is shown.  Research and development in optics and image processing had enable ear canal and the eardrum to be seen more clearly with the advantage of still image capture and archiving for record keeping and documentation purposes. 

ENT- Hearing Test- Rinne's and Weber's Examination

Tuning Fork Vibrations in Super Slow Motion

Nystagmus

 

 Vertigo of vestibular origin is made more noticeable with eyes closure and may be felt by palpation.  Alternatively, Frenzel glasses with +20 diopter can be used to eliminate visual fixation.

 

Frenzel glasses in-used (Rechargeable battery-operated with head-band). 

 

 Frenzel glasses (hand-held battery operated).

Spontaneous nystagmus is defined as nystagmus occurring without optic fixation: eyes under Frenzel glasses, or eyes open in total darkness or eyes closed.  It indicates active vestibular-ocular imbalance. 

 

Reference: Gordon B. Hughes. Textbook of Clinical Otology. ISBN 0-86577-183-9.

Horizontal Nystagmus

Peripheral Nystagmus: Acute Vestibular Neuronitis

 

These jerky eye movements is called nystagmus.  It is described by the direction of the fast component (towards left) and the affected side is the reverse.  This is spontaneous at rest (not induced).  This phenomena is seen in peripheral lesion affecting the labyrinth or the vestibular system.  Patient presents with vertigo (spinning/rotating sensation) which may be associated with vomiting.  Presence of hearing loss or tinnitus indicates labyrinthine disorder in contrast to acute vestibular neuronitis (vertigo without hearing loss or tinnitus).  Parenteral labyrinthine medication is required in the early phase when the the symptoms were intense.  Symptoms will usually resolved within few days. 

Peripheral Nystagmus: Caloric-Induced

Halmagyi Head Thrust Maneuver

Dix-Hallpike Test

 

 

 Rotatory nystamus in BPPV.

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