OSCE Ear Examination

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👂 The ear examination is a high-yield OSCE station assessing external ear, canal, tympanic membrane, and hearing. Key principle: Always perform **systematically** — inspection → palpation → otoscopy → hearing tests — and verbalise every step aloud. Time goal: 5–7 minutes. Most stations use manikins or simulated ears — treat them with full respect and explain as if real. Finish by stating how you’d complete the exam: “To complete my examination, I would perform tuning fork tests (Rinne & Weber), assess facial nerve function, check for nystagmus, examine the throat and post-nasal space, and arrange pure tone audiometry, tympanometry, and ENT referral if indicated.”

🛠️ Preparation & Introduction (30–45 s)

• 🧼 Wash hands thoroughly.
• 👋 Introduce yourself, confirm patient’s name & DOB.
• 💬 Explain clearly: “I’m going to examine your ears, check the ear canals and eardrums with a light, and test your hearing. It involves looking into your ears and some simple tests. It shouldn’t be painful, but tell me if anything hurts.”
• ✅ Gain informed consent, offer chaperone if needed (especially for children or anxious patients).
• 🪑 Position: Patient seated facing you at eye level, good lighting (headlight or pen torch if needed).
• 🧰 Equipment: Otoscope with multiple specula sizes (adult 4–5 mm, child 2–3 mm), 512 Hz tuning fork, pen torch, cotton wool, tissues, gloves if discharge expected.
• Verbalise: “I’m selecting the largest speculum that will fit comfortably and ensuring good lighting.”

👀 Step 1: General Inspection (30–45 s)

• Patient: facial asymmetry, abnormal head posture, hearing aid, scars (mastoidectomy).
• External ear & pinna:
  • Redness, swelling, erythema (otitis externa, perichondritis).
  • Skin lesions (basal/squamous cell carcinoma, psoriasis, eczema).
  • Discharge (purulent – acute otitis externa/media; bloody – trauma/cancer; clear – CSF leak 🚨).
  • Deformities: microtia, low-set ears (syndromic), cauliflower ear (wrestler’s ear).
  • Compare both sides for symmetry.
• Mastoid process: swelling, erythema, tenderness → mastoiditis (urgent ENT referral).
• Clinical pearl: Pain on pinna movement + tragal tenderness = **otitis externa** (“swimmer’s ear”).
• Verbalise: “On general inspection, there is no external swelling, discharge, or mastoid tenderness. The pinnae appear normal and symmetrical.”

✋ Step 2: Palpation (20–30 s)

• Gently pull pinna up and back (adults) or down and back (children) → pain = otitis externa.
• Press tragus → discomfort = otitis externa.
• Palpate mastoid tip → tenderness = mastoiditis (posterior auricular erythema, fever, protruding pinna).
• Palpate parotid region & pre-/post-auricular lymph nodes (parotitis, malignancy).
• Verbalise: “I’m gently palpating the tragus and mastoid. There is no tenderness elicited.”

🔦 Step 3: Otoscopic Examination (2–3 min – most marks here)

• Preparation:
  • Select largest comfortable speculum (4–5 mm adult, 2–3 mm child).
  • Hold otoscope like a pen; brace little finger on patient’s cheek for stability.
  • Explain: “I’m going to gently look into your ear with this light. It may feel a bit strange but shouldn’t hurt.”
• Technique:
  • Adults: pull pinna **up & back** (straightens canal).
  • Children: pull pinna **down & back**.
  • Insert speculum gently under direct vision, advance slowly.
  • Inspect canal then tympanic membrane (TM).
• Ear canal:
  • Wax (cerumen): normal (soft brown), impacted (hard, obstructing view).
  • Discharge: purulent (otitis externa/media), bloody (trauma, cancer), clear (CSF leak 🚨).
  • Inflammation, oedema, furuncle, foreign body.
• Tympanic membrane (TM):
  • Normal: pearly-grey, translucent, cone of light (anteroinferior quadrant), pars tensa/taut, pars flaccida relaxed.
  • Bulging, red, opaque → acute otitis media.
  • Retracted, dull, amber, air-fluid level/bubbles → otitis media with effusion (“glue ear”).
  • Perforation: central (safe), marginal/attic (unsafe – cholesteatoma risk).
  • Cholesteatoma: white pearly mass in attic, keratin debris, foul smell.
• Repeat on opposite ear; compare sides.
• Verbalise: “The right ear canal is clear with no discharge or inflammation. The tympanic membrane is pearly-grey, intact, with a visible cone of light and normal landmarks.”

🎼 Step 4: Hearing Assessment (1–2 min)

• Whisper test:
  • Occlude one ear (gently, not press), stand 60 cm behind patient.
  • Whisper numbers/words (e.g., “99”, “apple”, “table”), ask patient to repeat.
  • Normal: hears at 60 cm; reduced → sensorineural or conductive loss.
• Rinne test (512 Hz fork preferred):
  • Strike fork, place on mastoid process (bone conduction).
  • When sound stops, move fork to external auditory meatus (air conduction).
  • Normal/positive Rinne: air > bone conduction.
  • Abnormal/negative Rinne: bone > air → conductive hearing loss (e.g. otitis media, wax, otosclerosis).
• Weber test:
  • Strike fork, place on vertex or forehead midline.
  • Normal: heard equally both ears or midline.
  • Lateralises to affected ear → conductive loss.
  • Lateralises to unaffected ear → sensorineural loss.
• Voice test (if whisper not possible): shout or speak normally at 60 cm.
• Pearl: Rinne + Weber together localise lesion type — conductive vs sensorineural.

✅ Step 5: Closure & Completion (30–45 s)

• Thank patient, ensure comfort, help reposition if needed.
• Wash hands 🧼.
• Present findings clearly & succinctly: “On examination, both ear canals are clear with no discharge or inflammation. The tympanic membranes are intact, pearly-grey, with visible cone of light and normal landmarks. Whisper test is normal bilaterally.”
• State: “To complete my examination, I would perform tuning fork tests (Rinne & Weber), assess facial nerve function, check for nystagmus, examine the throat and post-nasal space, and arrange pure tone audiometry, tympanometry, and ENT referral if indicated.”

📊 High-Yield Ear Examination Findings Table (OSCE Master Reference)

🚩 Red Flags & Do-Not-Miss OSCE Points

• Mastoid tenderness + swelling + fever → **mastoiditis** (urgent ENT referral – risk of intracranial abscess).
• Attic perforation + white pearly mass + foul discharge → **cholesteatoma** (urgent ENT – risk of intracranial complications).
• Sudden unilateral sensorineural loss + tinnitus → **sudden sensorineural hearing loss** (urgent ENT – steroids within 2 weeks).
• Facial nerve palsy + ear discharge → **malignant otitis externa** (elderly diabetic, Pseudomonas) or Ramsay Hunt syndrome (herpes zoster).
• Clear fluid discharge + head trauma → **CSF otorrhoea** (urgent neurosurgery/ENT).

💡 OSCE Examiner & Candidate Pearls

• Always offer a chaperone — even on manikin; document it.
• Verbalise reassurance throughout: “I’m going to gently look into your ear with this light. It may feel a bit strange but shouldn’t hurt.”
• Brace otoscope with little finger on cheek → prevents trauma if patient moves.
• Compare both ears systematically — asymmetry is key.
• Common fail points: skipping external inspection/palpation, wrong pinna pull direction, poor otoscope technique, forgetting hearing tests, no verbalisation.
• Finish strong: “To complete my examination, I would perform tuning fork tests (Rinne & Weber), assess facial nerve function, check for nystagmus, examine the throat and post-nasal space, and arrange pure tone audiometry, tympanometry, and ENT referral if indicated.”

📚 References & Resources (Feb 2026)

• Logan Turner’s Diseases of the Nose, Throat and Ear (15th ed., 2025 update).
• Geeky Medics Ear Examination OSCE Guide (2026 revision).
• OSCEstop & PassMedicine ENT sections.
• ENT UK / NICE Guidelines: Otitis Externa & Media (2025).