Inspection and palpation of the external ear can be done with the client in any position, but is typically completed with the client sitting in an upright position. 

Steps of inspection include (see Video 1):

1. Inspect symmetry, lesions, and deformities on or around the ears.
   • Normally, the ears are symmetrical with no lesions or deformities. However, one common and normal ear lesion is Darwin’s tubercle (a thickening of or nodule on the middle to upper portion of the helix) (Figure 3). 
   • In some congenital abnormalities, one ear is significantly smaller or larger, or parts of an ear or the whole ear is not present. Another common deformity is cauliflower ear (Figure 4) caused by a physical trauma to the ear such as a sports injury: disruption to the blood supply causes inflammation and cartilage overgrowth, resulting in a deformity that has the textured appearance of a cauliflower. Ear keloids (Figure 5 and 6) are also a common deformity: these are nodules that can range in size and are firm and rubbery, often caused by minor trauma and scar tissue formation such as with ear-piercing. Ear keloids usually have the same colour as the client’s skin, but can also appear as shades of pink, red, and purple.

Figure 3: Darwin’s tubercle.

Figure 4: Cauliflower ear. (From: https://jetem.org/cauliflower_ear/cauliflower-ear-photograph-1-jetem-2018/ Cauliflower Ear. Photograph 1. JETem 2018 6. This work is licensed under a Creative Commons Attribution 4.0 International License).

Figure 5: Ear keloid. (By Htirgan, This file is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license, https://commons.wikimedia.org/wiki/File:Earlobe_Keloid,_Bulky.JPG)

Figure 6: Ear keloid (right image). By Htirgan – Own work, Creative Commons Attribution-Share Alike 3.0 Unported license, https://commons.wikimedia.org/w/index.php?curid=32782666

2. Inspect for skin integrity, colour, and swelling on and around the ears.
   • Normally, the skin is intact with no signs of discolouration or swelling. If piercings are present, assess for and describe any signs of infection such as erythema and swelling.
   • Abnormal findings may include skin that is not intact such as an open ulcer (Figure 7) or the presence of scars. Discolouration of the ear from the client’s baseline is important to evaluate such as erythema (Figure 8) and swollen or darker than the client’s baseline skin colour including shades of purple and blue and turning very black. If present, describe the location and appearance. 
3. Inspect for bugs and insect bites. Ensure you inspect the crevices of the external ear and behind the ears.
   • Normally, no bugs or bites are present.
   • If bugs or bites are present, note the location and appearance. For example, lice are bugs that are commonly found among school-age children and are often observed behind the ears.
4. Inspect the external auditory meatus and canal for discharge, swelling, discolouration (erythema), and foreign objects.
   • Normally, no discharge, swelling, discolouration, or foreign object are present.
   • If you observe discharge, swelling, or discolouration, note the appearance (colour), quantity, and location, including which ear. If a foreign object is present, describe the appearance and location, including which ear. 
5. Inspect for the presence of earwax.
   • Normally, some or no earwax is present. 
   • If earwax is present, note the colour, texture, and quantity.
6. Note the findings:
   • Normal findings might be documented as: “Ears symmetrical and intact with no lesions, deformities, discolouration, swelling, bugs, discharge, foreign objects, or earwax.”
   • Abnormal findings might be documented as: “Left auditory meatus is red and swollen with a yellow sticky discharge” or “Scaly skin rash posterior to right ear” (see example of postauricular eczema). See Figures 9, 10, and 11 for images of an ear infection with discharge.

Figure 7: Ulcer. (By Paul D.R. Johnson, Joseph Azuolas, Caroline J. Lavender, Elwyn Wishart, Timothy P. Stinear, John A. Hayman, Lynne Brown, Grant A. Jenkin, and Janet A.M. Fyfe. – Mycobacterium ulcerans in Mosquitoes Captured during Outbreak of Buruli Ulcer, Southeastern Australia. Emerging Infectious Diseases, Volume 13, Number 11., 

This image is a work of the Centers for Disease Control and Prevention, part of the United States Department of Health and Human Services, taken or made as part of an employee’s official duties. As a work of the U.S. federal government, the image is in the public domain,

https://commons.wikimedia.org/w/index.php?curid=34972908)

Figure 8: Erythema. (Left image by Tayiba Rahman, CC BY NC. Right image by Giorgio Lambru, Sarah Miller and Manjit S Matharu – “The red ear syndrome”, The Journal of Headache and Pain 2013, 14:83. doi: 10.1186/1129-2377-14-83, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=40946332)

Figures 9, 10, and 11: Ear infection (external otitis [swimmer’s ear]).

Figure 9: (By Grook Da Oger – Own work, Creative Commons Attribution-Share Alike 3.0 Unported license, https://commons.wikimedia.org/w/index.php?curid=16079610)

Figure 10: External otitis. (By Klaus D. Peter, Wiehl, Germany – Own work, Creative Commons Attribution 3.0 Germany license, https://commons.wikimedia.org/w/index.php?curid=9655043)

Figure 11: External otitis – severe case (By James Heilman, MD – Own work, Creative Commons Attribution 3.0 Unported license, https://commons.wikimedia.org/w/index.php?curid=10313999)

Video 1: Ear inspection. [0.59 seconds].

Steps for palpation include (see Video 2):

1. Assess one ear at a time. Ask the client if they have any pain as you gently pull the helix upwards and the lobe downwards, and then push on the tragus and the mastoid process. 
   • Normal findings are no pain.
   • Pain is an abnormal finding. If pain is present, assess with the PQRSTU mnemonic.
2. Gently palpate and describe any lumps or deformities that you observed. 
   • Normally, no lumps or deformities are present.
   • If a lump or deformity is present, ask the client if it is painful and measure its size, and note any signs of infection such as erythema and swelling. Describe the following characteristics: location on ear(s), colour, texture (smooth, rough, dotted), consistency (soft, firm), and mobility (moveable, fixed). 
3. Note the findings:
   • Normal findings might be documented as: “Client reports no pain when palpating the ear, and no lumps or deformities.”
   • Abnormal findings might be documented as: “Firm, rubbery lump at back of ear lobe, 2×2 centimetres. Colour consistent with client’s face.”

Video 2: Ear palpation. [0.26 seconds].

Activity: Check Your Understanding

References

Anwar, A. (2024). The cultural significance and meaning of ear piercing tradition. https://heyrowan.com/blogs/hey-rowan/how-ear-body-piercing-relates-to-culture-and-tradition