Assignment: Shining star
Assignment: Shining star
|November 18, 2009
“The trouble with doctors is not that they don’t know enough, but that they don’t see enough.”
Sir Dominic John Corrigan (18021880)
The structures in the lower half of the face tend to increase slightly in size with increasing age. Careful examination of the ears, nose, and oral cavity is often very rewarding: Clues of significant illness may hide here and early discovery of dermatologic, infectious, neoplastic, and neurologic lesions can substantially alter the course of illness.
Assessing the Ears Visual Inspection of the Ear
Check both ears for symmetry. Inspect the external ear and look for the following:
If the upper level of the ear rests below the level of the pupils, consider a congenital abnormality such as Down’s syndrome. Note: Congenital abnormalities of the ear, in general, may be associated with abnormalities of the kidneys, heart, and great vessels. (Kidney lesions tend to be ipsilateral to the ear abnormality).
Check for basal or squamous cells, solar keratoses, or other potentially harmful skin lesions. For example, a crusted ulcer on the pinna suggests squamous cell carcinoma.
A unilateral painful rash with vesicles on the lower ear suggests herpes zoster of the geniculate ganglion (Ramsay Hunt syndrome). Be sure to check for this in any patient who presents with facial paralysis.
A unilateral bright red swollen ear suggests external otitis.
Red, lax, or floppy ears suggest relapsing polychondritis. It typically occurs with a sudden onset of unilateral or bilateral ear pain, swelling, and redness, sparing the lobules.
In superficial skin infections, such as erysipelas, the ears can be involved, but subcutaneous infections, like cellulitis, spare the ear (Millian’s sign).
Long ear hairs suggest normal androgenic function (Hamilton’s sign).
Abnormalities to the ear caused by trauma often present as a thick, rubbery painless deformity.
A diagonal ear lobe crease suggests increased risk for coronary artery disease.
Examining the Ears, Nose, and Oral Cavity in the Older Patient Mark E. Williams, MD
Tender chalky nodules on the pinna suggest gouty tophi in a person who has lived in a cold climate, as lower temperature reduces the solubility of uric acid.
Single nontender nodule on the helix present since birth suggests a Darwinian tubercle (auricular tubercle).
Movement of the ear lobe coincident with the pulse suggests tricuspid insufficiency (Paul Dudley White’s winking ear lobe sign).
Palpation of the Ear
Stiffness of the earlobe suggests Addison’s disease, while stiffness of the pinna and auricular cartilage suggests other endocrine abnormalities, such as hyperthyroidism, acromegaly, diabetes mellitus, and hypopituitarism. Consider external otitis media if the patient’s ear is painful when you tug on it or if you find a tender tragus. Note: This is a potentially serious problem in diabetic or immunocompromised patients because of a risk for progression to osteomyelitis involving the temporal bone (called malignant external otitis). In such patients, check for mastoiditis by palpating the suprameatal triangle of MacEwen, which is the depression at 11 o’clock on the right ear and 1 o’clock on the left ear. (You can locate these little depressions on your own ears.) This area is tender when mastoiditis is present but is not with external otitis media alone.
Screening for Hearing Loss
Hearing loss is the third most common chronic health condition among older Americans after high blood pressure and arthritis; an estimated 25% to 40% of adults over age 65 and 40% to 66% of people 75 years and older have at least some hearing loss. Some evidence suggests that hearing loss may be an indicator of cognitive decline. However, in some older patients thought to be demented or psychiatric, hearing loss may actually be the basis for their odd behavior. If the patient appears to have hearing loss, then the next step would be to refer the patient for audiology testing, typically with a trained audiologist.
Simple Test to Determine Presence of Hearing Loss. One useful initial way to determine whether a patient has hearing loss is to give a simple instruction without providing a visual clue. For example, stand behind the patient during a lung or back examination, and give a simple command, such as “raise your right arm.” (The challenge is to remember to do it when you get to the pulmonary examination.)
The Finger Friction Test. Another useful screening test is the finger friction test. Put your forefinger and thumb of each hand at the external auditory canal of each ear. Rub the finger and thumb together on one side and then the other; ask the patient to tell you when the sound is heard.
The Weber Test. The Weber test relies on the observation made by Earnst Heinrich Weber in 1834 that, if the neurologic function is intact, sounds will be perceived to be louder in an occluded ear canal than in an open one. This test employs a 512 Hz tuning fork, as this frequency is in the middle of the normal conversational voice range. Place the vibrating tuning fork on the patient’s forehead at an equal distance between the ears and ask whether they hear the sound (not feel the vibration). If they cannot hear it at all, then they have bilateral sensorineural hearing loss and, in fact, probably cannot hear your voice. If they do hear the tone, then ask in which ear they hear the sound. Hearing the sound in both ears or in the midline of the head does not necessarily indicate normal hearing if both ears are equally impaired. If one ear is occluded, then the sound will localize to the ear with impaired hearing. If there is sensorineural hearing loss on one side then the Weber test localizes to the good ear. In this case, slowly move the tuning fork toward the bad ear until the sound is in the midline. Now occlude the good ear (furthest from the tuning fork) and see if the equality of sound changes. If the sound is now louder in the occluded good ear then you have localized the hearing loss to the affected side. If the patient does not appreciate any change when the canal is occluded, then they are responding to the vibration of the tuning fork, not the loudness of the sound.