Hearing loss is a very common presenting symptom of ear disease. It is estimated that ten million people in the UK suffer with this complaint. Hearing loss can occur in the external, middle or inner ear and can be conductive, sensorineural in nature or both. The clinician should ask the patient how long they have been experiencing the symptoms, was it a sudden loss or gradual and whether it is unilateral or bilateral. Unilateral loss could indicate important pathology. Family history of hearing loss can be relevant, and gaining an understanding of any professional or recreational noise the patient has been exposed to could be significant. In a child, it is important to enquire about previous infections, trauma at birth or anoxia, and other medical conditions. Ear problems can very often result in otalgia (ear pain).

Due to the distribution of cranial nerves and shared innervations such as of temporomandibular joint, mouth, teeth, salivary glands and throat; otalgia can quite often be because of referred pain. Therefore, the clinician needs to determine if the pain is from a direct or a referred cause. The clinician should explore whether the pain is acute or chronic and whether it has been a recurrent problem. The patient may describe the pain as sharp, dull, a discomfort, a deep penetrating pain or diffuse anterior pain. The clinician should ascertain what the exacerbating and alleviating factors are and whether there are any associated symptoms such as fever, congestion, nasal or ear discharge, sinus pain or headaches. As mentioned, otalgia can be because of referred pain for example tonsillitis. Fifty percent of ear pain is from a dental or TMJ causes, therefore a comprehensive history should assess ear, dental, sinus, jaw, neck, tongue, mouth and neurological disorders that can affect the head and neck.

Patients complaining of ear noise (tinnitus) often indulge in a very detailed description of what they hear. Most of this is useless in making the diagnosis. Tinnitus has many causes, including hearing loss, loud noise exposure, head injury or surgery and side effects of medications. Aspirin, NSAIDs, furosemide and quinine have all been associated with tinnitus. The clinician should ascertain the patient’s symptoms, whether they are experiencing a ringing, any aural fullness, fluctuating hearing loss, vertigo, otalgia or vestibular symptoms. However, it is important to recognize if the tinnitus is non-pulsating or pulsating since the latter may occur with severe vascular tumours or malformations. Ear popping and cracking are suggestive of Eustachian tube dysfunction, as it is a feeling of pressure inside the ear. Subjects suffering from Ménière’s syndrome may report a similar experience. Dizziness accounts for 2.5% of primary care presentations and of which 50% of dizziness presentations have an ontological cause. When obtaining the clinical history, the clinician should ascertain onset, duration and associated symptoms. Hain (1997) suggests duration can help to diagnose the complaint: BPPV (usually lasts seconds), TIA (minutes), Ménière’s (hours), vestibular neuronitis (days) and ototoxins (years). Associated head movement or change in head position, hearing disturbance, headache, cognitive symptoms and stress are helpful to explore. If after picking up the history you do not have a suspect, it is unlikely that diagnostic clinical examination and further investigations may bring to fruitful results. The facial nerve is in close anatomic relationship with the ear and it can be involved in its pathology. Therefore, the patient may experience change in sense of taste or facial weakness. The clinician should explore this, as the patient may fail to recognise the link and its relevance (Fig. 2.1).

It is a fundamental tool that can be fitted with or without sliding lens (this allowing the use of instruments such as the Jobson Horne for removal of earwax), and pneumatic pump for assessment of tympanic membrane mobility. Best visualisation of the external auditory canal (EAC) is achieved positioning your head at the same level as the patient’s head. With the free hand, the clinician should straighten the external auditory meatus (ear canal) by gently pulling the auricle upward and backward in the adult and downwards and backwards in the child. The clinician should choose the widest speculum that will comfortably fit into the patient’s ear, as this would provide the best view of the ear structures. The clinician should choose the largest speculum that will comfortably fit into the patient’s ear, as this would provide the best view of the ear structures (Fig. 2.2).

In ENT, tuning forks are used to assess hearing loss and ascertain whether the hearing loss is conductive or sensorineural in nature. Each tuning fork carries a number (128, 256, 512 and 1024 Hz.) This is the frequency at which the fork vibrates.

The Frenzel goggles are helpful to assess nystagmus, a condition of involuntary movement of the eyes, the assessment of which is often extremely helpful to diagnose pathologies affecting the vestibular system (Fig. 2.4).

Ear syringing is the most common ENT procedure carried out in primary care. Its purpose is the removal of cerumen. There are many types of ear syringe, including metallic, glass or made of plastic and electric with automatic pressurization (Propulse II.) The Medical Device Agency advocates the use of the Propulse II as the safest device (Fig. 2.5).

The main local causes of otalgia are trauma, or pathology of the pinna, otitis externa, and otitis media.