Subjective Assessment

Symptoms

Questions

Clinical Tips

Pain or pressure are common unpleasant sensations associated with the ears.

Ear pain (otalgia) is subjectively described as tenderness, discomfort, and sharp pain on or around the ear or in the ear.

Ear pressure can be described as a fullness in the ear.

Pain and pressure can be related to a variety of conditions such as allergies, infections, and ear barotrauma.

Have you recently had any ear pain or pressure in the ears? If yes, do you currently have it?

Additional probes if the client’s responses are affirmative may include:

Region/radiation: Where is it located? Is it in one or both ears? Does it radiate anywhere?

Quality/quantity: What does it feel like? How bad is it?

Severity: Can you rate it on a scale of 0 to 10 with 0 being no ear pain (or pressure) and 10 being the most pain you have ever had?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Timing/treatment: When did it begin? Did it begin suddenly? What were you doing when it began? Is it constant or intermittent? How often do you get it? Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

With pre-verbal or non-verbal children, you may observe the client crying, grabbing their ear, being unable to settle or sleep, and not eating.

Ear pain is sometimes caused by an infection, so attend to cues that may suggest an ear infection such as being febrile.

Ear infections may be more common in areas with poor air quality (often during the fall and winter months) and can be related to group settings (such as group child care). Ear infections can also be common in children who swim regularly, especially if they don’t dry their ears afterwards or if they swim in natural environments that may be affected by bacteria, so you may see these ear infections during the warmer months.

Young children are particularly at risk for infections due to their underdeveloped immune system and the shape of their eustachian tubes (more narrow and horizontal), making it difficult for fluids to drain. Other risk factors include infants who are fed in the supine position, and those who are formula fed; breast milk contains antibodies that can provide protection for the infant.

Hearing impairment refers to difficulty hearing and can be categorized as partial hearing loss or complete loss of hearing (deafness).

Symptoms can include inability to hear, muffled sounds, difficulty hearing in noisy environments or when there is background noise, difficulty hearing over the telephone, and difficulty hearing certain words/sounds and higher tones (such as higher voices and consonants as opposed to vowels).

Common causes include ear infections, ear trauma, environmental/loud noises, cerumen impaction, and ototoxic medications.

Hearing loss and deafness are often categorized as:

• Sensorineural degeneration (the most common type of hearing loss) involves damage to cranial nerve VIII, the inner ear, or the brain. Presbycusis is a specific type of sensorineural degeneration that involves gradual hearing loss, which usually begins in people older than 50 years.
• Conductive hearing loss in which sound waves are not carried through to the inner ear due to some sort of blockage (cerumen impaction, foreign body).

Have you experienced any difficulty hearing?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: Tell me about it? How bad is it?

Region: Does it affect one or both ears?

Provocative/palliative: Is there anything that makes your hearing better? Is there anything that makes it more difficult to hear (e.g., loud environments or background noise)?

Timing/treatment: When did it begin? Did it begin suddenly? What were you doing when it began? Is it constant or intermittent? If intermittent, how often do you get it? Have you done anything to help your hearing?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

With newborns/young children, you may observe that they do not startle to loud noises or turn their head to sounds. They may begin speaking later in life and may have unclear speech.

Some clients may report difficulty hearing, but sometimes hearing loss is so gradual that the client will not necessarily notice it. Family members or others living with the client may report that the client is turning up the volume on the television or radio, or often asks people to repeat themselves, or is speaking louder than normal.

Hearing loss can also be associated with stigma, which may prevent some clients from reporting a problem. This stigma can be associated with feelings of being old, being categorized as having a disability, and being misperceived as cognitively impaired. This kind of stigma can lead to diminished sense of self and a sense of belonging, withdrawal from social gatherings, and social isolation.

Some tips when communicating with clients who have a hearing impairment:

• Ensure a well-lit and quiet environment.
• Face them directly and be at their eye level when speaking.
• Project your voice clearly, but don’t exaggerate speech volume or mouth movements.
• Use a moderate pace with pauses between sentences.

Be aware that some clients may require a sign language interpreter; you may need to advocate for the client to ensure one is available. Also, some clients may be lip readers so ensure you face them directly.

Dizziness is a sensation of feeling light-headed and even faint (the feeling that you might lose consciousness), whereas vertigo is a sensation in which the person feels like they or their surroundings are moving or spinning when there is actually no movement.

Both dizziness and syncope can be associated with nausea, vomiting, and loss of balance.

Note that components of the inner ear are used to gather information and are involved in motion, changes in space, and balance.

Have you experienced any dizziness or a sensation like you or the room is spinning? If yes, do you currently have it?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does it feel like? How bad is it?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better (e.g. lying down)?

Timing/treatment: When did it begin? Did it begin suddenly? What were you doing when it began? Is it constant or intermittent? How often do you get it? Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

Ask specific probing questions to help determine the cause of dizziness or vertigo. For example, dizziness can be caused by many conditions and factors such as anxiety, dehydration, shock, orthostatic hypotension, and medications that cause drowsiness.

Other causes of dizziness and vertigo can be more directly related to the vestibulocochlear system such as vestibular neuritis, labyrinthitis, and Ménière's disease.

Always ensure the client’s safety when they are experiencing dizziness and vertigo: help them to sit or lay down. Measure their pulse and blood pressure.

Clients experiencing vertigo may feel distressed, especially if it is the first time. Although the cause may not be yet known, support the client and talk with them. It might be helpful to discuss management strategies such as sitting or lying down as needed, keeping the head elevated when in supine, moving slowly when standing up, focusing on a spot on the wall, and using relaxation strategies (close eyes, deep breathing).

If the client has chronic dizziness or vertigo, discuss fall safety prevention strategies with them.

Pruritus and discolouration are symptoms that can sometimes be related. Clients may describe that their ears are itchy particularly just inside the external auditory meatus. This is sometimes associated with changes in colour such as erythema. Erythema can also be associated with inflammatory processes such as infections.

Otorrhea (discharge from inside the ear) or discharge from around the ear can occur as a result of infection or injury. Discharge can be clear, serous (clear to yellow), sanguineous (blood, red), and purulent (pus).

Cerumen is a protective substance produced by the glands in the ear canal. It lubricates and cleans the ear and also prevents microorganisms and other irritants from entering and damaging the ears. Some people experience excessive cerumen production and impaction (blockage) which can lead to pain, pruritus, and hearing impairment. Cerumen combined with dead skin cells, dust, and other debris, is commonly referred to as earwax.

Have you experienced any itching in or around your ears? Colour changes? Ear discharge? Excessive earwax?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does it feel like or look like? How bad is it?

Region: Where have you noticed it? Is one or both ears affected?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Timing/treatment: When did it begin? Did it begin suddenly? What were you doing when it began? Is it constant or intermittent? How often do you get it? Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Pruritus in the ears can be distressing, and some clients may resort to scratching inside their ear with small objects such as a cotton swab (Q-tip). Putting any object inside the ear is risky as it can damage the ear canal, or even perforate the tympanic membrane. Always discuss these risks with clients.

The presence of excessive earwax can affect a client’s perception of self; it can lead to stigma (e.g., being considered dirty or unhygienic). Additionally, extensive earwax blockage can also lead to impaired hearing. In general, ears don’t require cleaning, but you can advise clients to wipe away loose earwax in the external part of the ear with a warm damp washcloth. Clients with extensive earwax or cerumen impaction should be referred to their primary care provider. Sometimes, a warm mineral oil solution (or 1 part hydrogen peroxide, 1 part warm water) will be advised to soften and loosen the earwax (American Academy of Otolaryngology-Head and Neck Surgery Foundation, 2024). This may be followed by flushing of the ear with a gentle spray of warm water in the shower or with a syringe. Although the above interventions are fairly safe, they should not be used without consulting a physician or nurse practitioner, especially if the client has had ear surgery, ear infections, or perforation of the tympanic membrane (Berg, 2023).

Tinnitus is an intermittent or constant sound in the ear that is often described as a ringing, humming, or buzzing.

Most people have experienced a temporary and mild form of tinnitus after a loud concert or an event with loud music.

Although the underlying cause is unknown, several related factors may include excessive noise exposure, damage to the inner ear hair cells, hearing loss, ear infections and blockages, head or neck trauma affecting the inner ear, and some ototoxic medications.

Have you experienced any abnormal sounds like ringing, humming, or buzzing in your ears?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does it sound like? How bad is it?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Timing/treatment: Do you have it now? When did it begin? What were you doing when it began? Is it constant or intermittent? How often do you get it? Have you taken anything to treat it? Have you taken any medications for it?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

Always ask about the client’s current or recent medications.

Advise clients that it is important to protect their ears from physical trauma and loud sounds to prevent conditions such as tinnitus.

The constant sound associated with tinnitus can affect quality of life and can lead to difficulty concentrating, sleep disruption, and overall irritability.

White noise (e.g., a fan) may be of therapeutic value by masking the sound of tinnitus. Hearing aids are another form of treatment: in addition to treating hearing impairment, they may be used to amplify external noises or generate a type of white noise that masks the sound of tinnitus.

Other vestibulocochlear symptoms can include fatigue, nausea, vomiting, and issues with balance or falling.

Always ask about personal and family history of vestibulocochlear conditions and diseases.

These can include a wide variety of conditions such as chronic ear infections, cerumen impaction, deafness, otosclerosis, Ménière’s disease, and tinnitus.

Explore these symptoms further with clients.

Use variations of the PQRSTU mnemonic to assess the symptoms.

Do you have any chronic conditions or diseases associated with your ears? Do you have a familial history of any conditions or diseases associated with your ears?

If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disease? How does it affect your daily life?

Remember to incorporate the language that the client uses into your probing questions.

If the client has a personal history, probing questions might include:

Timing: When were you diagnosed? How often do you get it?

Quality/quantity: How does it affect you? What symptoms do you have?

Treatment: How is it treated? Do you take medication?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

These symptoms can be related to the vestibulocochlear system as well as other body systems.

Risk factors may be influenced by genetics and/or culture, so you should ask about the biological and non-biological nature of family.

Some vestibulocochlear associated diseases are related to genetics, but environmental and cultural factors (such as family traditions and practices related to diet or smoking) usually play a larger role.

Note that personal conditions including hearing loss can be gendered. For example, loud environmental noises are a major risk factor associated with hearing loss and more men than women are in occupations that may pose this kind of risk (e.g., construction, carpentry, military).