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Evaluation of Ear Disorders


David M. Kaylie

, MS, MD, Duke University Medical Center

Last full review/revision Mar 2021| Content last modified Mar 2021

Earache, hearing loss, otorrhea, tinnitus, and vertigo are the principal symptoms of ear problems.

In addition to the ears, nose, nasopharynx, and paranasal sinuses, the teeth, tongue, tonsils, hypopharynx, larynx, salivary glands, and temporomandibular joint are examined; pain and discomfort may be referred from them to the ears. It is important to examine cranial nerve function (see table Cranial Nerves ) and to perform tests of hearing and of the vestibular apparatus. The patient is also examined for nystagmus (a rhythmic movement of the eyes).


Nystagmus is a rhythmic movement of the eyes that can have various causes. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected. The presence of vestibular nystagmus helps identify vestibular disorders and sometimes distinguishes central from peripheral vertigo. Vestibular nystagmus has a slow component caused by the vestibular input and a quick, corrective component that causes movement in the opposite direction. The direction of the nystagmus is defined by the direction of the quick component because it is easier to see. Nystagmus may be rotary, vertical, or horizontal and may occur spontaneously, with gaze, or with head motion.

Initial inspection for nystagmus is done with the patient lying supine with unfocused gaze (+30 diopter or Frenzel lenses can be used to prevent gaze fixation). The patient is then slowly rotated to a left and then to a right lateral position. The direction and duration of nystagmus are noted. If nystagmus is not detected, the Dix-Hallpike (or Barany) maneuver is done. In this maneuver, the patient sits erect on a stretcher so that when lying back, the head extends beyond the end. With support, the patient is rapidly lowered to horizontal, and the head is extended back 45° below horizontal and rotated 45° to the left. Direction and duration of nystagmus and development of vertigo are noted. The patient is returned to an upright position, and the maneuver is repeated with rotation to the right. Any position or maneuver that causes nystagmus should be repeated to see whether it fatigues.

Nystagmus secondary to peripheral nervous system disorders has a latency period of 3 to 10 seconds and fatigues rapidly, whereas nystagmus secondary to central nervous system disorders has no latency period and does not fatigue. During induced nystagmus, the patient is instructed to focus on an object. Nystagmus caused by peripheral disorders is inhibited by visual fixation. Because Frenzel lenses prevent visual fixation, they must be removed to assess visual fixation.

Caloric stimulation of the ear canal induces nystagmus in a person with an intact vestibular system. Failure to induce nystagmus or a > 20 to 25% difference in the velocity of the slow phase of the nystagmus between sides suggests a lesion on the side of the decreased response. Quantification of caloric response is best done with formal (computerized) videonystagmography or, less often, electronystagmography.

Ability of the vestibular system to respond to peripheral stimulation can be assessed at the bedside. Care should be taken not to irrigate an ear with a known tympanic membrane perforation or chronic infection. With the patient supine and the head elevated 30°, each ear is irrigated sequentially with 3 mL of ice water. Alternatively, 240 mL of warm water (40 to 44° C) may be used, taking care not to burn the patient with overly hot water. Cold water causes nystagmus to the opposite side; warm water causes nystagmus to the same side. A mnemonic device is COWS (Cold to the Opposite and Warm to the Same).


Patients with abnormal hearing on history or physical examination or with tinnitus or vertigo undergo an audiogram. Patients with nystagmus or altered vestibular function may benefit from computerized videonystagmography (VNG) or electronystagmography (ENG), which quantifies spontaneous, gaze, or positional nystagmus that might not be visually detectable. In ENG, eye movements are recorded by electrodes placed around the eye, while in VNG they are recorded by infrared goggles. In both cases, data are analyzed by computer and interpreted by an audiologist. Computerized VNG or ENG caloric testing quantifies the strength of response of the vestibular system to cool and warm irrigations in each ear, enabling the physician to discriminate unilateral weakness. Different components of the vestibular system can be tested by varying head and body position or by presenting visual stimuli.

Posturography uses computerized test equipment to quantitatively assess the patient's control of posture and balance. The patient stands on a platform containing force and motion transducers that detect the presence and amount of body sway while the patient attempts to stand upright. The testing can be done under various conditions, including with the platform stationary or moving, flat or tilted, and with the patient's eyes open or closed, which can help isolate the contribution of the vestibular system to balance.

Primary imaging tests include CT of the temporal bone with or without radiopaque dye and gadolinium-enhanced MRI of the brain, the latter with attention paid to the internal auditory canals to rule out a vestibular schwannoma. These tests may be indicated in cases of trauma to the ear, head, or both; chronic infection; hearing loss; vertigo; facial paralysis; and otalgia of obscure origin.

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