Clinical Skills · Assessment of the Head and Neck

Ears

8 min read

On this page 9 sections

In 30 seconds
Why this matters
The college version
Eli explains
Worked example
Key takeaway
Check yourself
Study tools
Sources & references

In 30 seconds

The ear has two very different jobs: hearing (the cochlear system) and balance (the vestibular system), and it is divided into three sections — the external ear, the middle ear, and the inner ear. Nurses examine the ear to screen hearing, inspect the canal and eardrum, ask about balance and ear pain, and teach people how to protect their hearing and use hearing aids safely. Ear problems are common across the lifespan, from ear infections in young children to age-related hearing loss in older adults, and hearing loss is often under-recognized because it develops slowly. A careful ear assessment can catch problems early, keep hearing aids working, and reduce the isolation and safety risks that come with unaddressed hearing loss.

The ear exam is a screening and data-gathering skill: nurses inspect and test, then report findings. Otoscopy technique, equipment (including disposable specula), and how far you advance into the canal are all governed by facility policy and your program's skills list.

Why this matters

Hearing connects people: untreated hearing loss contributes to social isolation, confusion in the hospital, and missed instructions about medications and discharge care.
Balance and falls: the inner ear is central to balance; a balance complaint is a fall risk that needs a safety response, not just documentation.
Common, treatable problems: ear infections, (earwax) buildup, and age-related hearing loss are frequent; early detection and referral make a real difference.
Children: middle ear infections are common in early childhood — recognizing the clues helps families get care sooner.
Communication safety: a person who does not respond may not have heard you; verifying hearing prevents a person from being mistaken for confused or uncooperative.

The college version

Core Concepts

External ear inspection

Look at the auricle (the visible outer ear), the tragus (the small bump in front of the ear canal opening), and the skin around the ear for redness, swelling, lesions, discharge, or pain on gentle touch. Gently move the auricle and press on the tragus; pain with movement can suggest inflammation of the external ear — a finding to report. Ask about hearing, ringing in the ears (), ear pain, discharge, or a feeling of fullness.

Otoscopy: looking at the canal and eardrum

The has a light, a magnifying lens, and a speculum tip — always use a clean, disposable speculum. Hold the otoscope like a pen, brace your hand against the person's head so the scope moves with them, and gently straighten the ear canal by pulling the auricle up and back in adults; in infants and young children the canal curves differently, and the auricle is typically pulled down and back. Advance only as far as needed to see the (eardrum) and never force the speculum. The normal eardrum looks pearly gray and translucent, and you may see the — a triangular reflection of the otoscope light. Redness, bulging, fluid behind the drum, perforation, or visible drainage are abnormal findings to report and document. Excessive cerumen can block the view; do not dig at it — note it and follow facility policy for removal.

Hearing screening

Two classic bedside hearing screens:

Whisper test: stand at a set distance behind the person's line of sight (so they cannot lip-read), occlude one ear by pressing the tragus closed, and whisper a short phrase; the person repeats it back. Test one ear at a time. Follow facility protocol for exact distance and phrasing.
Tuning fork tests — Weber and Rinne: these help distinguish (a problem in the outer or middle ear conducting sound) from (a problem in the inner ear or auditory nerve).
- Weber: strike the fork and place it at the midline of the forehead/vertex. Sound should be heard equally in both ears; with conductive loss, sound lateralizes (is louder) toward the affected ear, while with sensorineural loss it lateralizes to the unaffected ear.
- Rinne: place the fork on the mastoid bone (bone conduction), then move it in front of the ear canal (air conduction). Normally, air conduction is heard longer than bone conduction; in conductive loss, bone conduction may be equal to or longer than air conduction.

These are screening tests; interpretation happens in context by the provider, and screening protocols vary by setting.

Balance and the inner ear

The inner ear's vestibular system (the semicircular canals and related structures) senses head position and movement. Ask about dizziness, lightheadedness, or — a false sensation that the person or the room is spinning. Vertigo is different from general dizziness, and the timing, triggers, and associated symptoms (hearing loss, ringing, nausea) matter. Because balance problems are a major fall risk, always connect a hearing or balance complaint to safety: call light within reach, ambulation assistance, and fall precautions per facility policy.

Special populations

Children: the eustachian tube is shorter and more horizontal than in adults, which helps explain why middle ear infections are common in early childhood — watch for pulling at the ears, fever, irritability, and trouble hearing, and report rather than assume. Older adults commonly develop , age-related hearing loss that usually affects high-pitched sounds first and can make speech hard to follow in noisy rooms. Hearing aid users: ask whether the aid is in place and working, help with cleaning and battery checks within your scope, and never assume a person who does not respond is confused — they may simply not hear you. Face people when speaking, reduce background noise, and speak clearly rather than shouting.

Common Confusions

Do Not Confuse	With	Difference
Weber lateralization (conductive)	Weber lateralization (sensorineural)	Conductive loss: sound is louder in the affected ear. Sensorineural loss: sound is louder in the unaffected ear.
Rinne "bone ≥ air"	Normal Rinne	Normal is air conduction heard longer than bone conduction; bone equal to or longer than air suggests conductive loss (context matters).
Vertigo	Dizziness or lightheadedness	Vertigo is a false spinning sensation; dizziness is broader — document exactly what the person feels.
Pulling the auricle in adults	Pulling the auricle in young children	Adults: up and back. Infants/young children: down and back (the canal curves differently).
Ear pain with tragus or auricle movement	Middle ear infection	Pain on moving the outer ear points to the external canal; middle ear problems often present differently (fever, hearing loss, irritability).
Hearing loss	Confusion or disinterest	A person who does not respond may not have heard; verify hearing before assuming cognitive change.

Eli explains

The same idea, in plain words

Explain it like I’m 10

Your ear has three parts: the outside part you can see, a little tunnel with a drum at the end, and a deep part that helps you hear and keep your balance. The nurse shines a light into the tunnel to check the drum, whispers words to see how well you hear, and taps a tuning fork to check which part of your ear is doing the hearing work.

Worked example

Mrs. Chen, 74, tells you at her clinic visit that she has been turning the television up "because everyone mumbles." You face her, speak clearly, and confirm her hearing aid is in and working. You perform the whisper test one ear at a time and note that she misses the phrase in her left ear, then do the Weber and Rinne tests and record the results. You document her own words ("everyone mumbles"), the screening results, and that she has no pain, discharge, or dizziness. You teach her that hearing loss is common and often addressable, confirm she knows how to clean and charge her hearing aid, and report the findings to the provider, who can arrange formal hearing testing. You never assume her hearing problem is "just age" or something to live with — you screened, documented, taught, and referred.

Key takeaways

Three divisions of the ear: external (auricle, canal), middle (eardrum, ossicles, eustachian tube), inner (cochlea for hearing, vestibular system for balance).
Pull the auricle up and back for adults; down and back for infants and young children; never force the speculum.
Normal tympanic membrane: pearly gray, translucent, with a visible cone of light.
Hearing screening: test one ear at a time; keep the whisper out of the person's line of sight.
Weber lateralizes toward the affected ear in conductive loss and away from it in sensorineural loss; Rinne normally shows air conduction heard longer than bone conduction.
Vertigo (false spinning sensation) is not the same as general dizziness — document exactly what the person feels, in their words.
Hearing loss is common, gradual, and isolating; screen, refer, and adapt communication.
Scope: nurses screen and educate; diagnosis and treatment are provider responsibilities; technique and protocols vary by facility.

Check yourself

6 review questions from the chapter. Try each one, then open the answer.

Name the three divisions of the ear and one function of each.
Show answer
External (auricle and canal — collects and channels sound), middle (eardrum and ossicles — conducts vibrations; eustachian tube equalizes pressure), inner (cochlea for hearing, vestibular system for balance).
In what direction do you pull the auricle for an adult versus a young child, and why?
Show answer
Up and back for adults; down and back for infants and young children, because the child's canal curves differently — this aligns the canal for viewing.
List three normal landmarks or features of a healthy tympanic membrane.
Show answer
Pearly gray color, translucency, and a visible cone of light.
In the Weber test, where do you place the tuning fork, and where does sound lateralize in conductive versus sensorineural loss?
Show answer
Midline of the forehead/vertex; sound lateralizes toward the affected ear in conductive loss and toward the unaffected ear in sensorineural loss.
What is the difference between vertigo and dizziness, and why does the difference matter?
Show answer
Vertigo is a false spinning sensation (inner-ear/vestibular); dizziness is a broader lightheadedness. The distinction guides what the provider investigates.
Why is the eustachian tube difference in young children relevant to ear infections?
Show answer
A shorter, more horizontal eustachian tube makes it easier for infection to reach the middle ear — a key reason ear infections are common in early childhood.

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Study tools & related lessonsKey vocabulary · Related

Key vocabulary

Otoscope: Handheld lighted instrument used to view the ear canal and eardrum
Tympanic membrane: The eardrum — the thin membrane separating the outer and middle ear
Cone of light: Triangular light reflection seen on a normal eardrum
Cerumen: Earwax
Conductive hearing loss: Hearing loss from problems in the outer or middle ear (sound cannot reach the inner ear)
Sensorineural hearing loss: Hearing loss from problems in the inner ear or auditory nerve
Presbycusis: Age-related hearing loss, often starting with high-pitched sounds
Vertigo: False sensation of spinning or movement
Tinnitus: Ringing or noise in the ears with no external source

Sources & references

openstax.org — Clinical Nursing Skills

This lesson was adapted from the open educational references above; their licenses and attributions are preserved. See Copyright & Licensing.

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