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EN2.{3,5} | Otoscopy Tuning Fork Testing and Tympanic Membrane Assessment — SDL Guide (Part 3)
Applied Practice: Integrated Scenarios
Each scenario below presents a patient with ear symptoms. Work through the tuning fork test results and TM findings together to reach the correct diagnosis. The power of these two skills combined — otoscopy + TFTs — is that they almost always give a consistent picture when correctly performed; discordant results should prompt re-examination before over-interpreting.
Scenario 1 — Safe-ear CSOM:
History: 28-year-old male, right ear discharge × 8 years, gradual right hearing loss. No vertigo.
Otoscopy: right TM — large central perforation in the pars tensa; pars flaccida intact; no attic retraction; mucopurulent discharge in canal.
TFTs: Rinne right = NEGATIVE (BC > AC). Rinne left = POSITIVE. Weber = lateralises to the RIGHT. ABC = normal bilaterally.
Interpretation: NEGATIVE Rinne right + Weber to right (affected ear) + normal ABC = RIGHT CONDUCTIVE HEARING LOSS. TM confirms central perforation = CSOM tubotympanic (safe) type. The conductive loss is due to the perforation and middle ear disease impairing the TM/ossicular mechanism.
Diagram: draw a circle, vertical handle of malleus, large central opening in the pars tensa, intact pars flaccida, label 'R ear, central perforation, CSOM tubotympanic (safe).'
Scenario 2 — Meniere's disease:
History: 42-year-old female, left ear — episodic vertigo × 2 years, fluctuating left-sided hearing loss, low-pitched left tinnitus, aural fullness.
Otoscopy: left TM — normal appearance, normal light reflex, no perforation.
TFTs: Rinne left = POSITIVE (AC > BC — but both are reduced compared to the right). Rinne right = POSITIVE. Weber = lateralises to the RIGHT (better ear). ABC = REDUCED on left.
Interpretation: POSITIVE Rinne on affected side + Weber to the OPPOSITE (better) side + REDUCED ABC = LEFT SENSORINEURAL HEARING LOSS. Combined with the classic triad of episodic vertigo + SNHL + tinnitus = Meniere's disease.
Scenario 3 — Unsafe CSOM with cholesteatoma:
History: 45-year-old male, left ear foul-smelling discharge × 12 years, left hearing loss, recent dizziness.
Otoscopy: left TM — attic perforation (in pars flaccida, upper part of TM) with visible white keratin/cholesteatoma debris. Pars tensa intact. Foul-smelling discharge.
TFTs: Rinne left = NEGATIVE (BC > AC). Weber = lateralises to LEFT. ABC = normal.
Interpretation: NEGATIVE Rinne + Weber to left (affected) + normal ABC = LEFT CONDUCTIVE HEARING LOSS. TM shows attic perforation with cholesteatoma debris = CSOM atticoantral (unsafe) type. This patient needs urgent surgical referral for mastoidectomy — the dizziness may indicate labyrinthine involvement.
Key learning: The TFT pattern here is the same as safe CSOM — both give conductive loss. But otoscopy distinguishes them: attic perforation + cholesteatoma = unsafe, needing surgery regardless of TFT result.
Self-Assessment: Tuning Fork and Otoscopy Competency Check
Test your understanding of the most commonly examined elements of this SDL. Write your answers before reading the explanations.
Q1: A patient has a Rinne POSITIVE result in the right ear. Does this mean: (a) normal hearing in the right ear, (b) sensorineural loss in the right ear, or (c) either normal or SNHL in the right ear?
Answer: (c). Rinne POSITIVE = AC > BC. This occurs in both normal hearing (both routes intact, AC has ossicular advantage) AND in SNHL (both routes impaired, but ossicular advantage is preserved so AC still > BC). It does NOT indicate conductive loss. Rinne POSITIVE alone cannot distinguish normal hearing from SNHL — you need Weber and ABC for that.
Q2: Weber test: sound heard in the RIGHT ear. List all possible interpretations.
Answer: (1) RIGHT CONDUCTIVE hearing loss (Weber goes to the affected ear in conductive loss — the occlusion effect); (2) LEFT SENSORINEURAL hearing loss (Weber goes to the BETTER ear in SNHL — the left cochlea is damaged, right cochlea is better and receives the signal more strongly). You cannot know which without the Rinne and ABC results.
Q3: A 70-year-old male with right ear wax impaction undergoes Rinne testing after wax removal. Before wax removal, what result would you have expected for Rinne right, and for the Weber?
Answer: Wax impaction causes conductive hearing loss. Before removal: Rinne right = NEGATIVE (BC > AC due to canal obstruction); Weber would lateralise to the RIGHT (affected ear). After wax removal, both should normalise.
| Test | Finding | Interpretation |
|---|---|---|
| Rinne right NEGATIVE (BC > AC) | Right ear only | Right conductive hearing loss |
| Rinne right POSITIVE (AC > BC) | Right ear only | Normal OR right SNHL |
| Weber to right | — | Right CHL, OR left SNHL |
| Weber to left | — | Left CHL, OR right SNHL |
| ABC reduced right side | — | Right cochlear/nerve pathology (SNHL right) |
| ABC normal bilaterally | — | Cochlea intact bilaterally — any loss is conductive |
| Rinne NEGATIVE + normal TM + no structural cause | Suspect | False-negative Rinne (dead ear) — test with masking |
SELF-CHECK
A 55-year-old with sudden right hearing loss has: Rinne right = POSITIVE (AC > BC, but both sound quiet); Weber = lateralises to the LEFT; ABC = REDUCED on the right. These findings are consistent with:
A. Right conductive hearing loss due to wax impaction
B. Right sensorineural hearing loss
C. Left conductive hearing loss
D. Bilateral mixed hearing loss
Reveal Answer
Answer: B. Right sensorineural hearing loss
The pattern — Rinne POSITIVE right (AC > BC, ossicular mechanism intact but both routes reduced) + Weber lateralising to LEFT (the BETTER ear — in SNHL, Weber goes to the good ear) + ABC REDUCED right (cochlear damage right) — is the classic pattern of RIGHT SENSORINEURAL HEARING LOSS. This is consistent with sudden SNHL (a medical emergency). Right conductive loss would give Rinne NEGATIVE right and Weber to the RIGHT. Normal ABC would indicate intact cochlear function, ruling out SNHL.