1. Clinical Tests for Hearing and Tests of Eustachian Tube Function
Dr. Vijayalakshmi S

2. Tuning Fork (Gardiner Brown)
Parts:
Prongs or tines
Shoulder
Stem or handle
Base or footplate

4. Tuning Forks Frequencies used in E.N.T.: 256, 512, 1024 Hz
128 Hz → produces more of vibration sense
more than 1024 → short sound decay time

5. Striking Surfaces Hard: Olecranon, radial styloid process, patella
Soft: Thenar & hypothenar eminences,
thick rubber strip
Tuning fork is allowed to fall by its own weight Impact area is b/w proximal two-thirds & distal one-thirds of its prongs

6. Rinne Test

7. Rinne Test Duration comparison technique:
Vibrating tuning fork kept on pt's mastoid  Pt signals when sound ceases → Move vibrating tuning fork over opening of ear canal (2 cm away & axis parallel to it) → Patient indicates if sound is still heard

8. Rinne Test Loudness comparison technique (better):
Vibrating tuning fork kept on pt's mastoid  Pt signals if sound is heard → Move vibrating tuning fork immediately over opening of ear canal → If sound is heard → patient asked which sound is louder

9. Results of Rinne Test Better response: sound heard longer or louder
A.C. > B.C. (positive test):
Normal hearing or Sensorineural deafness
B.C. > A.C. (negative test):
Conductive deafness

10. Rinne Negative 256 Hz = 15 - 30 dB HL = mild conductive deafness
= moderate conductive deafness
1024 Hz = dB HL
= severe conductive deafness

11. Weber Test
Procedure:
Vibrating 512 Hz tuning fork placed in midline of pt’s skull at forehead / vertex / central incisor

12. Results of Weber test Sound heard equally (central):
Normal hearing or B/L equal deafness
Sound lateralizes to deafer ear:
Conductive deafness
Sound lateralizes to better hearing ear:
Sensorineural deafness

13. Why Weber lateralizes to deafer ear in Conductive HL ?
1. Lack of masking effect of surrounding noise on tuning fork sound, as air conduction is reduced in conductive deafness
2. Lack of dispersion of sound energy due to ossicular break

14. Absolute Bone Conduction Test

15. Absolute Bone Conduction Test
Pt's B.C. compared vs. examiner's normal B.C.
Vibrating tuning fork kept on pt's mastoid with pt’s E.A.C. occluded (to prevent A.C.) → pt signals when sound ceases → vibrating tuning fork kept on examiner's mastoid with examiner's E.A.C. occluded

16. Results of Absolute Bone Conduction Test
Pt stops hearing before examiner:
sensorineural deafness
Both hear for same duration:
normal hearing / conductive deafness

17. Schwabach Test

18. Schwabach Test Same as A.B.C. but E.A.C. is not occluded
Pt stops hearing before examiner:
sensorineural deafness
Both hear for same duration:
normal hearing
Pt hears longer than examiner:
conductive deafness

19. False Negative Rinne Etiology: U/L severe Sensorineural deafness
Detection: Rinne negative, Weber lateralized to
better hearing ear
Confirmation: A.B.C. reduced in deaf ear
Correction: Repeat Rinne test with masking of
better ear with Barany's noise box

20. False Negative Rinne Mechanism:
In deaf ear, air conduction & bone conduction are absent. Trans-cranial transmission of sound to
opposite cochlea is perceived as I/L bone
conduction. Reported as bone conduction > air conduction in deaf ear (Rinne Negative)

21. Gelle Test Vibrating tuning fork placed on pt's
mastoid & examiner increases pt's E.A.C.
pressure with Siegel's speculum
Softer sound:
normal hearing or sensorineural deafness
No change in sound:
conductive deafness

22. Bing Test Vibrating tuning fork placed on pt's
mastoid & examiner blocks pt's E.A.C.
Louder sound:
normal hearing or sensorineural deafness
No change in sound:
conductive deafness

23. Tests for E.T. function

24. 1. Valsalva Maneuver Forced expiration with mouth & nose closed.
Otoscopy shows
lateral bulging of
Tympanic membrane

25. 2. Frenzel Maneuver Hands free Valsalva for pilots
Compression of nasopharyngeal air by muscles of tongue
Otoscopy shows lateral bulging of tympanic membrane

26. 2. Frenzel Maneuver

27. 3. Toynbee Maneuver More physiological Swallowing with
mouth & nose closed
Otoscopy shows
retraction of tympanic
membrane

28. 4. Pneumatic otoscopy & Siegelization
Air pressure is alternately increased & decreased within external auditory canal
Mobility of tympanic membrane is observed
Normal mobility indicates good patency of Eustachian tube

29. Siegelization

30. Pneumatic Otoscope

31. Normal Tympanic Membrane

32. Eustachian Tube dysfunction

33. Early otitis media with effusion

34. Late otitis media with effusion

35. Acute suppurative otitis media

36. Ear drum perforation

38. 5. Politzerization

39. Politzer Bag

40. 5. Politzerization
Rubber tube attached to a Politzer bag put into one nostril & both nostrils pinched
Patient asked to swallow or repeat “k”
Politzer bag is squeezed simultaneously
Otoscopy shows lateral bulging of ear drum in patent Eustachian tube

41. 6. E.T. catheterization

42. Eustachian tube catheter

43. 6. E.T. catheterization
E.T. catheter passed along nasal floor till it touches posterior wall of naso-pharynx.
Catheter rotated 90° medially & pulled forward till it impinges on posterior nasal septum.
Catheter rotated 180° laterally, & its tip inserted into opening of E.T.
Politzer bag attached to outer end of catheter

44. 6. E.T. catheterization
Air pushed into E.T. catheter by squeezing Politzer bag. Examiner hears by Toynbee auscultation tube put in pt's ear.
Blowing sound = normal E.T. patency
Bubbling sound = middle ear fluid
Whistling sound = partial E.T. obstruction
No sound = complete obstruction of E.T.

45. 7. Tymapanometry

46. 7. Tymapanometry Type C = E.T. dysfunction
Type B = fluid in middle ear

47. 8. William’s pressure equalization test
200 mm H2O pressure is created in patient’s external auditory canal
Patient asked to swallow 10 times
Residual pressure in patient’s external auditory canal after 10th swallow is noted
Test repeated with -ve 200 mm H2O pressure created in patient’s external auditory canal

48. William’s Test Residual Pressure Result Up to + 50 mm H2O
normal E.T. function
+ 51 to mm H2O
mild dysfunction
+ 101 to mm H2O
moderate dysfunction
+ 200 mm H2O
severe dysfunction

49. 9. Sono-tubometry
Sound made in pt’s nasal cavity & detected with stethoscope in patient’s external auditory canal
Loud sound = patent Eustachian tube
10. Eustachian tube Salpingogram
Dye instilled through E.T. catheter & X-ray taken
11. C.T. scan & M.R.I. of skull

50. 12. Trans-nasal E.T. video-endoscopy
13. Test for E.T. patency in T.M. perforation
Saccharine crystal / antibiotic ear drop / methylene blue placed in middle ear via ear drum perforation.
Sweet taste / bitter taste / blue staining of secretions indicates patent Eustachian tube

51. Thank You