Clinical Preparation: Case History, Otoscopy & Selecting and Modifying Tests
Key Takeaways
A pediatric case history adds prenatal infections, birth history (NICU stay longer than 5 days, ECMO, hyperbilirubinemia), newborn screening results, developmental milestones, and caregiver concern, which is itself a JCIH risk factor.
A daily listening check confirms clear tones, no crosstalk or static, steady output when cords are flexed, and working masking, response button, and talkback before any patient is tested.
For otoscopy, brace the hand against the head and straighten the canal by pulling the pinna up and back in adults and down and back in infants and young children.
Audiologists describe otoscopic findings and refer, but diagnosing and treating middle ear disease such as otitis media is outside their scope.
Tests are chosen by developmental rather than chronological age and adapted for cognition, physical and sensory abilities, behavior, culture, and language, using qualified interpreters rather than family members.
Clinical Preparation: Case History, Otoscopy & Selecting and Modifying Tests
Every audiologic evaluation starts before the first tone is presented. The Praxis Audiology blueprint lists clinical preparation as its own assessment topic: gathering and evaluating background information, checking equipment, examining the ear, and choosing and adapting procedures for the patient's age, development, function, behavior, culture, language, and physical, sensory, and cognitive abilities.
The Case History
A good case history shapes the test battery, flags medical red flags, and sets the patient's goals.
Adult Case History
- Chief complaint and goals: What brings the patient in, and which listening situations matter most?
- Hearing loss details: onset (sudden or gradual), duration, ear(s) affected, progression, and fluctuation.
- Tinnitus: ear(s), sound quality, constant or intermittent, pulsatile or not, and how much it bothers the patient.
- Dizziness: spinning versus lightheadedness or imbalance, episode duration, triggers (head position, pressure, loud sounds), and associated hearing changes.
- Ear symptoms: pain, drainage, fullness, itching, previous ear surgery, and history of ear infections.
- Noise exposure: occupational, military, recreational, and firearm use, and hearing protection habits.
- Medical history: diabetes, cardiovascular disease, autoimmune disease, kidney disease, head injury, cancer treatment, and current and past medications (especially ototoxic drugs).
- Family history: relatives with hearing loss, particularly early-onset loss.
- Previous hearing care: earlier audiograms, hearing aids, and their outcomes.
- Communication and function: occupation, communication partners, vision, dexterity, cognition, and preferred language.
Pediatric Case History
A pediatric history adds:
- Prenatal history: maternal infections (CMV, rubella, toxoplasmosis, syphilis, Zika), medications, and substance exposure.
- Birth history: gestational age, birth weight, NICU stay longer than 5 days, ventilation, ECMO, hyperbilirubinemia, and newborn hearing screening results.
- Medical history: meningitis, recurrent otitis media, head trauma, syndromes, and craniofacial anomalies.
- Development: motor, speech, and language milestones; caregiver concern about hearing or development; and school performance.
- Family history: permanent childhood hearing loss in relatives.
Caregiver concern is itself a JCIH risk factor and a reason for prompt evaluation.
Verifying Equipment Before Testing
Equipment must be checked before patients are tested.
- Daily listening (biologic) check: listen through each earphone and the bone oscillator at several frequencies for clear tones, no distortion or static, no crosstalk to the opposite earphone, a steady output when the cords are flexed, working masking noise, response button, and talkback system.
- Immittance: check the probe in the calibration cavities (for example, 0.5, 2.0, and 5.0 cm³) to confirm the volume readings.
- OAE and evoked potential systems: run the manufacturer's probe check and confirm electrode leads and impedance.
- Formal calibration: annual exhaustive electroacoustic calibration to ANSI/ASA standards (see the instrumentation section). Document all checks.
Otoscopy
Technique
- Choose the largest speculum that fits comfortably.
- Hold the otoscope like a pencil and brace your hand against the patient's head, so the speculum moves with the patient if they move suddenly.
- Straighten the canal: pull the pinna up and back for adults and down and back for infants and young children.
- Inspect the pinna and the concha, then the canal walls, then the tympanic membrane.
Normal Tympanic Membrane Landmarks
A normal tympanic membrane is pearly gray and translucent. Landmarks include the pars tensa and pars flaccida, the manubrium of the malleus, the umbo, the annulus, and the cone of light in the anteroinferior quadrant (about 5 o'clock in the right ear and 7 o'clock in the left ear).
Common Otoscopic Findings
| Finding | What You See |
|---|---|
| Cerumen impaction | Canal blocked by wax; no view of the tympanic membrane |
| Foreign body | Object, insect, or hearing aid dome in the canal |
| Exostoses | Multiple broad-based, smooth bony swellings, often bilateral (linked to cold-water exposure) |
| Osteoma | Single, rounded bony growth |
| Otitis externa | Red, swollen canal with debris; pain when the pinna is moved |
| Perforation | Hole in the tympanic membrane |
| Retraction pocket or cholesteatoma | Retracted membrane, often in the pars flaccida, or white keratin debris |
| Tympanosclerosis | White, chalky plaques on the membrane |
| Pressure-equalization tube | Small tube visible in the membrane |
| Middle ear effusion | Dull or amber membrane, possibly with an air-fluid level or bubbles |
| Acute otitis media | Red, bulging membrane |
| Vascular mass | Red or blue mass behind the membrane, possibly pulsating |
Scope reminder: Audiologists perform otoscopy to describe what they see, guide testing, and decide on referral. Diagnosing and treating middle ear disease such as otitis media is a physician's role. An audiologist can report "the tympanic membrane appears red and bulging" and refer, but should not tell the family the child has an ear infection that needs antibiotics.
Before and after procedures: inspect the ear before inserting earphones or probes and before and after cerumen removal or ear impressions.
Selecting and Modifying Tests
Choosing by Developmental Age
Choose procedures based on developmental age, not chronological age.
| Developmental Age | Primary Behavioral Method | Physiologic Measures |
|---|---|---|
| Birth to about 6 months | Behavioral observation only (not for threshold estimation) | ABR (click and tone burst), OAEs, 1000-Hz tympanometry |
| About 6 months to 2 to 3 years | Visual reinforcement audiometry | OAEs, tympanometry, and ABR as needed |
| About 2.5 to 5 years | Conditioned play audiometry | OAEs and tympanometry to cross-check |
| About 5 years and older | Conventional audiometry | As indicated |
Speech testing also follows development: picture-pointing word tests for young children, children's word lists for school-age children, and adult lists for adults.
Modifying for Function, Behavior, and Ability
- Cognitive impairment or dementia: short, simple instructions, demonstrations, extra practice, shorter sessions, and physiologic measures to cross-check; involve caregivers.
- Physical limitations: change the response mode (raising a finger, saying "yes," eye gaze); position the patient comfortably; test from a wheelchair if needed.
- Visual impairment: use touch or sound cues for conditioning instead of visual reinforcement.
- Autism or sensory sensitivities: visual schedules, a familiar caregiver, a quiet waiting area, short tasks, and sedated ABR when behavioral testing is not possible.
- Craniofacial anomalies or atresia: adjust transducer placement (for example, the bone oscillator position) and rely more on bone conduction and physiologic tests.
Modifying for Culture and Language
- Use recorded speech materials in the patient's language when available. If none exist, use tests that do not depend on language, such as digits, picture pointing, or physiologic measures, and note the limitation in the report.
- Use a qualified interpreter for instructions and case history. Family members, and especially children, should not interpret except in emergencies. Federal civil rights rules (Title VI and Section 1557 of the Affordable Care Act) require meaningful access for people with limited English proficiency, and the ADA requires effective communication, including qualified sign language interpreters for Deaf patients.
- An interpreter should not present speech test words by live voice, because that changes the test.
- Respect cultural views of hearing loss, including Deaf culture, and ask about communication preferences rather than assuming them.
During otoscopy on a 3-year-old, the audiologist sees a red, bulging tympanic membrane. The parent asks whether the child has an ear infection and needs antibiotics. Which response best reflects the audiologist's scope of practice?
Confirm that the child has acute otitis media and advise the parent to request antibiotics from the pharmacy.
Say that the eardrum looks normal for a 3-year-old, because otoscopic findings in young children are unreliable.
Describe how the eardrum looks, explain that a physician must diagnose and treat it, and refer promptly.
Tell the parent that the problem will resolve on its own and that hearing testing should be repeated in six months.
A 4-year-old with a significant developmental delay functions at about a 12-month developmental level. Which behavioral test method is most appropriate to try first?
Conventional audiometry with hand raising, because the child is four years old chronologically
Conditioned play audiometry, because play methods are designed for children aged 2.5 to 5 years
Behavioral observation audiometry to establish ear-specific thresholds before any other testing
Visual reinforcement audiometry, because methods are chosen by developmental age
A Spanish-speaking adult with limited English proficiency arrives for a hearing evaluation with her 12-year-old grandson, who offers to interpret. No recorded Spanish word lists are available at the clinic. What is the best approach?
Have the grandson interpret instructions and repeat each word of the English list in Spanish by live voice
Use a qualified medical interpreter for history and instructions, plus recorded or language-independent speech tests
Test in English only, because word recognition scores are equivalent in any language the patient has heard before
Skip speech audiometry entirely and report pure-tone results, since speech tests are invalid for anyone not fluent in English
Sections you finish are checked off in the contents.