Ear and Balance

Ear and Balance


  • Otoscope with disposable speculums

  • Examination couch



  • Wash hands with alcohol gel

  • Introduce yourself to the patient

  • Confirm the patient’s name and date of birth

  • Obtain consent to examine the patient and explain what this will involve

  • Ask for a chaperone if required

  • Position patient – sit in chair

  • Ask the patient if they have any pain

  • Gather equipment 


  • Hearing aids, BAHA, cochlear implant

  • External ear: 

    • Pinna – scar, swellings, deformity, piercings, signs of infection

    • Pre-auricular – pre-auricular sinus/pits, scars

    • Post auricular – scars, tenderness, erythema, swelling, pain


  • External canal – wax, swelling, inflammation, discharge

  • Tympanic membrane – intact/perforation, colour – erythema, bulging, tympanosclerosis, light reflex, presence of grommet, retraction


Facial nerve

The facial nerve has motor, sensory and parasympathetic functions. 


Motor function

  • Examine the face at rest for asymmetry

  • “Raise your eyebrows” – frontalis muscle.

  • “Close your eyes as tight as you can, don’t let me open them” – orbicularis oculi muscle

  • “Open your eyes”

  • “Puff out your cheeks” – Orbicularis oris, buccinator muscle

  • “Show me all your teeth” – platysma

Sensory function

  • Ask about any dysgeusia (altered taste) 

  • Offer formal taste testing


Parasympathetic function

  • Ask about dry eyes, mouth and nose (parasympathetic supply to lacrimal gland, submandibular gland and nasal mucosa)

  • Offer to do corneal reflex (the efferent arm of the corneal reflex is via the facial nerve, the afferent arm is via the trigeminal nerve)





Vestibular nystagmus may be spontaneous or positional. Ideally you would use Frenzel glasses to remove gaze fixation. 


Spontaneous nystagmus 

  • Ask the patient to keep their head still and follow your finger with their eyes only. 

  • Keep your finger 60 cm away in front of the patient and move it horizontally to the extremes of gaze. 

  • Up to 5 beats at the extremes of gaze can be considered physiological nystagmus. 

  1. First degree nystagmus – nystagmus present only when looking towards side of the fast component 

  2. Second degree nystagmus – nystagmus present when looking straight ahead

  3. Third degree nystagmus- nystagmus when looking in direction of slow component


Positional nystagmus


The most common pathology exhibiting positional nystagmus is BPPV. The test for this is the Dix-Hallpike test. 


Dix-Hallpike test 


  1. Ask the patient if they have any pain or cervical issues. 

  2. Ask if they drove in today and advise they rest for 1 hour post-procedure and do not drive home if they are feeling dizzy, alternatively offer to perform the test at the next appointment.

  3. Warn them that the test may make them feel dizzy.

  4. Reassure them that if the test does make them feel dizzy then we have a diagnosis and you can go ahead and treat their dizziness today with some further manoeuvres which you will explain (Epley manoeuvre)

  5. Ask the patient to sit on the examination couch with their bottom at a level such that when they lie backwards, their head will hang off the edge of the bed.

  6. Explain that they must fall back quickly in order for the test to work. Reassure them that you will protect their head and neck. 

  7. Ask them to look 45º away from the midline to one side 

  8. Lie them back quickly but carefully to avoid any neck injury, until their head is 45º below the horizontal plane

  9. Ask them to keep their eyes open and observe for nystagmus

  10. Keep them there for a minimum of 1 minute.

  11. Sit them up and repeat on the other side. 

  12. https://youtu.be/8RYB2QlO1N4 


A positive result for BPPV is when the patient reports reproduction of their vertigo and there is an observed characteristic geotropic downbeating nystagmus. 


Vestibulo-ocular reflex 


  • Saccades

    • Sit or stand 2m in front of the patient with your eyes level

    • Raise your two index fingers to eye level such that they are 30cm either side of your nose.

    • Ask the patient to look back and forth between each index finger

    • Observe for abnormalities in latency, velocity or accuracy of saccades

    • Repeat in the vertical plane

    • https://youtu.be/P6uTlnyNaTs 


  • Smooth pursuit

    • Ask the patient to keep their head still and follow your index finger with their eyes as you move it side to side 60cm in front of their face. 

    • https://youtu.be/No7lOi2wX6E 


  • Head impulse test

    • Check if patient has any cervical pain or pathology

    • Hold the patients head in your hands and ask them to look at your nose

    • Explain that they must keep fixated on your nose. Explain what you are about to do and tell them to keep their eyes open.

    • Move their head quickly side to side in short sharp movements and observe their eye movements.

    • https://www.youtube.com/watch?time_continue=6&v=uIwBrYIb4A8&feature=emb_title 

Vestibulo-spinal reflex 

  • Romberg’s test

    • Ask the patient to stand with their feet together and arms by their sides and ask them to close their eyes. Reassure them that you will catch them if they fall.

        • Positive if they sway excessively or fall when they shut their eyes


      • Unteberger’s test

        • Ask the patient to raise their arms out in front of them and march on the spot.

        • Then ask them to close their eyes and to continue marching on the spot

        • Positive when patient rotates >30º to one side indicating vestibular hypofunction on that side

        • https://youtu.be/ljGJbokAOXM 

      Cerebellar exam 



      • Assess tone – hypotonia often seen in cerebellar disease

      • Finger-nose test

      • Dysdiadochokinesis

        • Patient places on hand on top of each other

        • Then ask to quickly pronate and supinate the top hand repeatedly – Slow and clumsy movements in cerebellar disease

      • Rebound test

        • Ask patient to hold both arms out in front of them outstretched with eyes closed

        • Press arm down then release

          • Normal – arm will move a short distance when resistance released and jerks back in opposite direction

          • Cerebellar lesion – no rebound

          • Spasticity – exaggerated response


      • Heel-shin test

      • Knee reflex with tendon hammer

      In cerebellar disease may have pendular response – leg keeps swinging more than 4 times after tapping




      • Assess patients gait and arm swing e.g. ataxic, broad based, shuffling, high stepping, hemi-paresis

      • Heel-toe gait – exaggerates any unsteadiness

      To complete examination 

      • Thank patient for examination

      • Suggest further examinations

      • Full head and neck examination

      • Facial nerve and cranial nerve examination

      • Audiometry and tympanometry

      • Wash your hands

      • Present findings

      • Suggest that you would document your findings in the patient’s notes

      Possible investigations that may subsequently be requested:

      • Pure tone audiometry 

      • Tympanometry 

      • MRI internal auditory meatus

      • CT temporal bone


      Nystagmus is an involuntary, rhythmical oscillation of the eyes away from the direction of gaze, followed by a return of the eyes to their original position. It can be either physiological or pathological  and pendular or jerky in character. 

      A vertical nystagmus is always considered to be central in origin. Vestibular nystagmus may be spontaneous or positional. 


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