author: sarah carlton m o dule 7 osce · 2021. 1. 15. · possibly mastoiditis o t o s c o p y...

Author: Sarah Carlton

MODULE 7 OSCE Contents

1) Examination of the Neck

2) Examination of the Ear

3) Examination of the Eyes

4) Cranial Nerve Examination

5) Peripheral Nervous System Examination

6) Audiometry

7) Tympanometry

8) US, CT and MRI Scans

9) Cytology/Histology Results

10) Hearing Aids


1) Examination of the Neck Part of

Examination What to Say Additional Notes

Introduction “Hello, I’m Sarah Carlton, a … year medical student from the University of East Anglia; could I start by confirming your name and date of birth please?”

“Today I’ve been asked to perform a neck examination on you, which will include me having a look at your neck and then feeling around it while I’ll be reporting my findings to the examiner, does

that sound okay to you?” “Are you in any pain at all?”

“Please could you pull your shirt down so I can see your collarbones and then let me know when you’re

comfortable for me to begin”

Wash hands Exposure – should be able to see

supraclavicular nodes

Inspection “On general inspection, the patient looks well, there are no obvious swellings, scars or asymmetry of the

neck” “I can see a lump on … Is it painful?”

“I’m going to examine the rest of the neck first and then concentrate more on the lump itself if that’s

okay?” (If a midline lump is present) →

“Please could you stick your tongue out for me” “And now take a sip of this water and then swallow

it”

If patient is cachexic – suggests malignancy Scars – Previous surgery eg. thyroidectomy1 If you can’t see where the lump is, ask the

patient Stick tongue out – thyroglossal cyst will rise,

thyroid masses will not

Swallowing – Both thyroglossal cyst and thyroid mass will rise

Palpation “I’m just going to feel the glands in your neck, let me know if anything’s painful at all”

“Feeling the sub-mental, sub-mandibular, pre-auricular, post-auricular, anterior cervical chain,

supraclavicular, posterior cervical chain and occipital lymph nodes”

“Okay, I’m now going to the examine the lump more closely, again, let me know if they’re painful

at all” (Comment on the things to the right)

Lymph nodes - Painless, hard lymph node = malignancy. Soft, rubbery, tender lymph node =

infection Rubbery but non-tender = lymphoma

Supraclavicular enlarged node = Virchow’s node = GI cancer

Size – width / height / depth – try to describe using e.g. apple

Site – can help narrow the differential (written below) – anterior / posterior triangle / mid-line

Shape – well defined? Skin changes – erythema / ulceration /

punctum Mobility – tethering / mobility (ask to turn

head) Consistency – smooth / rubbery / hard /

nodular / irregular Colour – Red suggests infection, as does heat Fluctuance – if fluctuant, this suggests it is a

fluid filled lesion – cyst Trans-illumination – suggests mass is fluid filled

– e.g. cystic hygroma


Differential Diagnosis of Neck Lumps Mid-line

● Lymph nodes – often multiple, may suggest

infection or malignancy

● Lipoma – painless / smooth mass

● Sebaceous cyst

● Thyroid goitre – an enlarged thyroid gland. A

large, diffuse mudline swelling that will move

on swallowing. If you do find this

● Thyroid nodule – can be single or multiple – adenomas / cysts / malignancy

● Thyroglossal cysts – remnant of the embryological thyroglossal duct.

Higher than the normal position of a goitre – present in <10y/o. painless /

smooth /cystic – rises on tongue protrusion

Anterior triangle

● Lymph nodes – Causes of enlarged lymph nodes – LIST – Lymphoma and

leukaemia, Infection, Sarcoidosis and Tumour

● Lipoma

● Sebaceous cyst

● Salivary gland swelling – there are 3 pairs of salivary glands, the parotid,

submandibular and sublingual. 80% of salivary gland swelling is from

Parotid. 80% of these Parotid swellings are benign. 80% of these benign

tumours are pleomorphic adenomas. Other causes of the swellings are

stones (intermittent pain and swelling on eating), infection and Sjogren’s (also with dry eyes

and mouth. If you do find a parotid gland swelling, must then assess the facial nerve as this

runs through it.

Pulsatility – suggests vascular origin – e.g. carotid body tumour /

aneurysm Auscultation – to assess for bruits – e.g. carotid

aneurysm Conclusion “Thank you very much, that’s my examination over

with, if you get comfortable and I’m just going to report my findings back to the examiner”

“To investigate further, I would perform a thyroid status examination, examine the whole

Lymphoreticular system, examine the oral and nasal cavity, ultrasound and possibly fine needle aspirate

the lump”

Wash hands Thyroid status examination – if related to the thyroid or midline – do blood tests – thyroid

function Lymphoreticular examination, oral and nasal cavity and ultrasound – if there’s an enlarged

lymph node


● Branchial Cleft Cyst – present from birth but

show in 20s – normally in submandibular region. Painless

swelling – lump is transilluminable. Treatment is surgical

excision.

● Carotid aneurysm –pulsatile mass – bruit present on

auscultation

● Carotid body tumour – transmits pulsation – can be moved

side to side but not up & down (due to carotid sheath)

Posterior triangle

● Lymph nodes

● Lipoma

● Sebaceous cyst

● Subclavian artery aneurysm – pulsatile mass

● Pharyngeal pouch – may present as a reducible mass

● Cystic hygroma – most commonly on left side – fluctuant mass – transilluminates –

congenital lymphatic lesion

● Branchial cyst

2) Examination of the Ear Part of Examination What to Say Additional Notes

Introduction “Hello, I’m Sarah Carlton, a … year medical student from the University of East Anglia;

could I start by confirming your name and date of birth please?”

“Today I’ve been asked to perform an ear examination on you, which will include me

having a look at your ear and then looking in your ear with a device and then do some

hearing tests. None of it should be too painful and I’ll be reporting my findings to the

examiner, does that sound okay to you?” “Are you in any pain at all?”

“Are you comfortable for me to begin?”

Wash hands

General Inspection “To start, the patient looks well” “Looking more closely at the pinna, there is no

skin colour change/eczema/dermatitis or obvious deformity, or any visible discharge

from the ear. There is no Chondrodermatitis Nodularis Helicus”

“I’m also looking for any hearing aids and any obvious lymphadenopathy”

“I can’t see anything looking in the ear canal” “Is this painful when I feel back here?”

Look at the front and back of the pinna If patient does have a hearing aid, ask them to

remove it Chondrodermatitis Nodularis Helicus – painful

nodule at top of ear Pain on feeling around the back of the ear –

possibly mastoiditis

Otoscopy “I’m going to use this special piece of equipment called an otoscope to look inside your ear, it shouldn’t be painful but if you try

Use the largest speculum that will comfortably fit in the ear and make sure it’s a new one


and stay as still as you can that’ll make it easier, let me know if

you experience any discomfort at all” “Looking at the skin of the external auditory meatus for infection, wax or foreign bodies” “Now looking at the tympanic membrane for the light reflex and any fluid built up behind it and looking for any cholesteatoma in the attic”

Ensure the otoscope is on by shining the light onto the back of your

hand Grip the otoscope like a pen, rest your little

finger on their cheek Whichever ear of the patient you are examining,

use the same side hand to hold the otoscope For adults, gently pull the pinna upwards and

backwards to straighten the cartilaginous external auditory meatus

Don’t do this if they have pain (from OE) In children, pull ear down and out

Put the otoscope in gently and first and then slowly put it in

If the handle of malleolus is in the right, this is the right ear and vice versa

Pathology below Tuning Fork “I’m going to test your hearing with this tuning

fork now. That’ll include me placing it on your head in different places. It will feel different

but shouldn’t be uncomfortable so again, please let me know if you feel any pain”

“I’m going to first put it towards the front of your ear and then I’m going to place it on the

back of your ear, you should hear it in both but please could you tell me which one you can

hear it in better” “Now performing Rinne’s test”

“Did you hear it better when it was in front of your ear or placed on the bone?”

“Performing Weber’s test” “Okay so now I’m going to put it in the middle

of your head, it will be quieter than the last test but let me know if you can hear it in the

centre, the left ear or the right ear” “Where do you hear it more?”

Can be used to distinguish between conductive and sensorineural hearing loss (but not useful in

mixed) 512Hz or 256Hz tuning forks are used

Strike the fork on your elbow, never on the patient or on a table

Rinne’s Test - Place the vibrating prongs by patient’s ear canal; ask if they can hear it (air

conduction) Place the still-vibrating base of the fork on the

mastoid process (bone conduction) Ask whether it was louder in front (air) of or

behind the ear (bone) It should be louder in front as air conduction

should be better (Rinne positive) however conductive hearing loss would lead to a Rinne

negative POSITIVE RINNE’S IS A NORMAL TEST

Weber’s Test – Place tuning fork in the middle of the patient’s head (on their forehead)

If conductive hearing loss in one ear, bone conduction will be stronger so Weber test will

show them hearing sound better on the ear with the conductive hearing loss

If it’s a sensory loss, it will be louder in the better ear

Pathology covered in audiograms section below Closing the

Examination “Thank you very much, that’s the examination

over with so do make yourself comfortable while I report my findings back to the

examiner.” “On examination…”

“If I had more time…”

Wash hands


3) Examination of an Eye Part of Examination What to Say Additional Notes

Introduction “Hello, I’m Sarah Carlton, a … year medical student from the University of East Anglia; could I start by confirming your name and

date of birth please?” “Today I’ve been asked to perform an eye examination on you, which will include me having a look at your eyes and then looking

Wash hands


in your ear with a device and then do some hearing tests.

None of it should be too painful and I’ll be reporting my findings to the examiner, does


“Are you comfortable for me to begin?” Visual Acuity “I’m going to start by just testing your vision;

do you normally wear distance glasses?” “Okay, please could you wear them for this

exam” “I’m going to cover one of your eyes and

then please could you read from the top of the chart to the lowest line that you can

read, don’t worry about getting some letters wrong”

“That was 6/…” “Since the vision is good/bad, I will/will not

examine with the pinhole” “And now we’re going to test the other eye” (Pinhole) “Now I’m going to ask you to read the chart again but this time, I’m going to ask you to hold up these glasses in front of your eyes and read through the little holes”

“Now, please could you read this sentence?” “Fine print reading is good/bad”

Myopia = short sightedness = unable to see in the distance – this could be because the eye is too long, or the cornea or crystalline lens is too

strong – uses concave lens Hypermetropia (Hyperopia) = long sighted = can’t see things that are close – uses convex

lens Stand/sit the patient at 6 metres from the

Snellen chart. Visual acuity is recorded as chart distance

(numerator (eg. 6m)) over the number of lowest line reads (denominator – this is on top of the

line in the chart). Record the lowest line the patient was able to

read (e.g. 6/6 - equivalent to 20/20 in America). If patient reads the 6/5 line, but gets 2 letters correct on the 6/6, you would record as 6/5

(+2). With the pinhole, allow them to hold the glasses

in front of their face If vision is improved with a pinhole, it suggests

there is a refractive element to their poor vision.

Repeat with the other eye. Fine print reading to assess near vision

Colour Vision “Would the examiner like me to assess colour vision?”

“Have you noticed any changes to your vision recently?”

“Now if you could cover your left eye and look at this plate and tell me what colour

you see on it”

Tests for red-green colour deficiencies Give the patient the book

The 1st number is often a 12 and is a control – everybody should be able to see it Ensure you do one eye at a time

To record, count up: How many slides that the patient out the

correct/incorrect number Put this out of 17 (there are 17 slides with

numbers on them – the last is 73) If they are hesitant but get the numbers correct,

record - 17/17 slow – this suggests a subtle lesion

If a patient cannot read numbers eg. child – there are lines towards the back that they can

follow with their finger Colour blindness is usually found in males as its

X-linked recessive but is also one of the first things to go with an optic nerve lesion eg. optic


neuritis, tumour or anterior ischaemic optic neuropathy

Visual Fields “Okay, now I’m going to test some of your peripheral vision so please could you tell me

when you see my fingers come into your vision”

“Normal visual fields with no visual loss” “Now please could you keep looking at my nose and if you could tell me when you see

my fingers move” “No visual inattention”

Sit directly opposite the patient, at a distance of around 1 metre.

Ask patient to focus on your face & not move their head or eyes during the assessment.

When testing peripheral vision, make sure you finger comes in first rather than your hand to

detect more subtle visual field defects For inattention, hold both arms out, with your

fingers in the middle of the two of you Ask patient to point at which fingers are

moving. Test all 4 quadrants, ensure you move both

hands at once to test inattention If the patient only points to one of the hands,

when fingers are actually moving on both hands, this would be suggestive of visual

neglect. Visual neglect can suggest damage to the frontal

or parietal lobes of the brain from eg. stroke There is a table of the visual field defects under

the cranial nerve exam but most likely are homogenous hemianopias from stroke or

Bitemporal hemianopias from pituitary gland tumour pressing on optic chiasm

Pupils “I’m now going to look at your pupils so I’m going to be shining a light into your eyes” “I would preferably do this with the lights

dimmed” “Just looking grossly at the pupils, they are similar shape, an ordinary size and they are

symmetrical” “Testing the direct reflex”

“And the consensual reflex” “And the swinging light test”

“And now could you look into the distance… and then back to the light”

“Testing accommodation reflex”

Direct – Shine light into pupil and look at that same pupil – if the pupil doesn’t constrict/is

sluggish – s/o optic nerve damage, brain stem or drugs

Consensual – shine the light into the pupil and observe the other pupil – this should constrict

at the same rate as the other – if it doesn’t constrict s/o – damage to one or both of the optic nerves, damage to Edinger Westphal

nucleus Swinging light test – move the pen torch rapidly

between the two eyes - may detect a relative afferent pupillary defect (RAPD) – caused by

damage of the tract between the optic nerve & optic chiasm, (e.g. optic neuritis in multiple

sclerosis). It’s also known as a “Marcus-Gunn” pupil.

A RAPD can be detected by paradoxical dilatation of the affected pupil when light is

shining into it (it should normally constrict). - https://www.youtube.com/watch?v=HSYo7LhfV

3A Accommodation reflex – pupils should normally

constrict when looking at the object which is closer

https://www.youtube.com/watch?v=HSYo7LhfV3A

https://www.youtube.com/watch?v=HSYo7LhfV3A


Cover/Uncover Test and Alternating Cover

Test

“I’m just going to look more closely at your eyes now, please

could you look into the light please? If it gets too uncomfortable let me know”

“The corneal light reflex is/isn’t normal, suggesting there isn’t/is any strabismus”

“I’m now going to cover and then uncover your eye”

“No sign of any tropia” “I’m going to cover your eyes on after the

other” “Alternating cover test showed no phorias”

Have the patient focus on the light

Should be able to see the light reflex straight in the middle of the pupil

Cover/Uncover Test – tests for tropias (misalignment of the eye that’s there all the

time) Cover the fixating eye (the one that’s looking straight) and observe the movement of the

other eye. If the eye was exotropic, covering the fixating

eye will cause an inwards movement; and esotropic if covering the fixating eye will cause

an outwards movement. Alternating Cover Test – tests for phorias –

misalignment that only presents when the eyes are disassociated - switch from covering one

eye quickly to covering the other eye – this will cause the eyes to go in/out as above

Myopic people – tend to have an exophoria Hypermetropic people – tend to have an

endophoria https://www.youtube.com/watch?v=Wf8DGL7

WE8U Eye Movements “Now could you follow the light with your

eyes while keeping your head still please?” “Let me know if you get any pain or double

vision at any time” “Eye movements are normal”

“Now can you look at the pen and then at my thumb”

“Testing saccades which is normal”

Move the light through the various axis of eye movement (“H“ shape).

Observe any restriction in eye movements and any nystagmus

3rd nerve palsy – the eye will be down and out (as the only muscles acting are superior oblique and lateral rectus) – also with ptosis and dilated pupil (if it’s just the pupil, worry about SOL so

CT immediately) 4th nerve palsy – superior oblique - unable to

move the eye down when it’s adducted so struggle to read a book

6th nerve palsy – lateral rectus – unable to look temporally

Saccades – tests vision going from close to closer – if this isn’t right – suggests intranuclear

ophthalmoplegia Fundoscopy “I’m now going to use this device to have a

look at the back of your eye which’ll mean shining this light into your eye, does that

sound okay?” “I would preferably do this with the lights

dimmed” “I’m also going to have to get quite

uncomfortably close if that’s okay, let me know if you feel uncomfortable at any point”

If they have glasses, need to know whether they are myopic or hypermetropic – if you can’t

remember, look at them straight on and if their face is refracted inwards where their glasses

start, they are myopic Ideally the patient should have their pupils

dilated with Tropicamide drops (not if driving home or has history of closed angle glaucoma) Red reflex - Ideally this should be assessed at a

distance of around 30cm


“I’m going to ask you to take your glasses off for this please?” “And can you just focus on a point above my

shoulder please?” “Looking at the red reflex which is normal”

“Looking for the optic disc, the retinal vessels and the macula”

The red reflex is caused by light reflecting back from the

vascularised retina. Absence of the red reflex in adults often is due to cataracts in the patient’s lens blocking the

light, but it can also be associated with retinoblastoma, and vitreous haemorrhage. Cataracts – Nuclear – forms in centre and is

often hardest to see on red reflex – comes with ageing

Cortical – forms like bike spokes around edge of lens

Posterior subcapsular – occur at the back of the lens and are seen as gritty bits at the back –

caused by diabetes/high dose steroids Examine the patient’s right eye with your right eye – rest your hand on their forehead so you

don’t hit into them If they have glasses, you’ll need to change the focus – if they’re myopic, it needs to be more

positive – can test this by looking at the hairs on the back of your arm – should be more zoomed

in the more positive you go If they’re wearing contact lenses, you don’t

have to do this as the refractive error has been accounted for

Begin medially & assess the optic disc – come in

at 10-15 degrees – colour / contour / cupping (glaucoma is cup:disc ratio >1/3)

Assess the retinal vessels – cotton wool spots / AV nipping / neovascularisation

Finally assess the macula – ask to look directly into the light – drusen seen in macular

degeneration

If they give you the head to use – use the smallest amount of light possible and the

dimmest light as there’s a lot of glare Closing the Session “That’s the examination over with, thank

you for letting me perform that, if you want to make yourself comfortable, I’m just going to report my findings back to the examiner”

“On examination, this was a … year old patient. On examination, there was …”

“To investigate further, I would do retinal photography and a full cranial nerve

examination”

Wash hands


IN THE OSCE, WILL ONLY HAVE TO DO ONE OF THE ABOVE THINGS IN 5 MINUTES


Pathology Explanation Picture

Normal The rim of the optic disc contains all the nerve fibres – the cup (white part in middle) – contains no nerve fibres

Arteries are thinner and less distinct than veins

Papilloedema Blurred disc margin, pink and swollen disc with the vessels having to curve to go over

the edge of the swelling S/o raised intracranial pressure – eg. meningitis – usually bilateral - refer

immediately. Give Mannitol. Don’t do a lumbar puncture because of risk of coning.

Optic Atrophy Shows a plain, featureless optic disc due to death of all the nerve fibres

Causes: optic neuritis (MS), glaucoma, trauma, lesions compressing optic nerve

(eg. tumour)

Retinitis Pigmentosa

Inherited, degenerative disorder that leads to blindness and tunnel vision

(degeneration of rods) – occurs at any age Get pigmentation of the peripheral retina


4) Cranial Nerve Examination

Hypertension A-V Nipping –

due to an artery crossing a vein and compressing that vein, causing it to bulge

on both sides Exudates - Intraretinal lipid deposition

from leaking retinal vessels. Silver wiring – shows atherosclerosis of the

arteries Haemorrhages – flame haemorrhages due to presence of increased pressure – vessels

burst

Diabetes Cotton wool spots – show ischaemia in the retina – fluffy white patches (also seen in

hypertension) Blot Haemorrhages – similar to

haemorrhages but in deeper layer of the retina so they’re not as distinct

New Vessel Formation – this is due to damage to the retina from the high levels of glucose causing the production of VEGF (Vascular Endothelial Growth Factor) – the

picture on the right shows proliferative disease since there are many vessels –

these vessels aren’t made very well and so haemorrhahge very easily

Laser Scars from laser photocoagulation – since VEGF is mainly produced peripherally,

you can laser these sections to prevent proliferative disease and this shows as

small white dots peripherally (shown in the bottom picture) Different stages:

0) Nothing 1) Background – Microaneurysms

2) Pre-proliferative – Microaneurysms, dot and blot haemorrhages, hard exudates,

cotton wool spots 3) Proliferative – New vessel formation,

macula oedema and vitreous haemorrhage

Part of Examination

What to Say Additional Notes

Introduction “Hello, I’m Sarah Carlton, a … year medical student from the University of East Anglia;

Wash hands Make sure both you and the patient are sat

down at eye level


could I start by confirming your name and date of birth

please?” “Today I’ve been asked to examine the nerves

that supply your face and your neck, I’ll be reporting my findings to the examiner, does



Collect equipment: Pen torch, cotton wool, Snellen chart and

Ophthalmoscope (if provided)

General Inspection

“On general inspection, the patient seems comfortable at rest, there’s no obvious

dropping of the face or eyelid and there didn’t seem to be any abnormalities of speech”

Drooping of face or eyelid – (ptosis) – s/o facial nerve palsy/stroke/UMN lesion

Abnormalities of speech – dysphasia/dysarthria – s/o stroke

CN I - Olfactory “First thing I’d like to ask you now is have you noticed any change in your sense of smell?”

Can use recognisable scents to test this but we won’t have to do this

Most common reason to lose this is a URTI – this will be transient. Can also be caused by

slight trauma due to shredding of the olfactory bulbs

Meningiomas, Parkinson’s disease are other causes

CN II - Optic “And how about your eyesight, has there been any changes?”

“To examine the optic nerve, I would usually use the Snellen chart and test colour vision,

would the examiner like me to do this?” “Okay, now I’m going to test your peripheral vision so please could you keep looking at my nose and I’m going to put my hands up and if

you could just point to which finger I move please?”

“And now could you cover your right eye and just say when you see my finger move?”

“And for the other eye” “So that showed normal visual fields with no

neglect” “I’m going to examine your pupils so I’ll shine this light in your eye but first I’m just going to

look at the pupil, checking that they’re the same size”

“Looking for the direct and consensual reflex” “Now I’m going to move the light quickly in

between the eyes” “Testing the swinging light test”

“And please could you follow my finger towards your nose?”

“Watching the accommodation of the pupils” “Would the examiner like me to do

fundoscopy?”

Useful way to remember the order – AFRO Acuity, Fields, Reflexes (pupillary),

Ophthalmoscopy It is unlikely that we’ll have to do this but if

you do use the Snellen chart (the paper with letters on to test eye-sight), make sure the

patient is wearing their glasses If they can’t read this, can also test vision by holding up your fingers and asking them how

many fingers you’re holding up Can also test colour blindness with a Ishihara

chart but again won’t have to do this Visual field testing

First test with eyes open tests neglect – if they can’t see you moving your hands at the same time, this is visual neglect and usually comes from stroke to the right side of the brain in

the MCA territory Visual field defects are below

Pupillary reflex controlled by the oculomotor nerve – This should ideally be done in a dark

room Put your hand over the patient’s nose to stop

any light shining from the other side Shine the torch into one eye and watch if the

pupil constricts – this is direct reflex Then shine the torch into the same eye and

watch the opposite eye constrict – this is the consensual reflex


Accommodation of the pupils – hold your finger out in front of the patient and then slowly touch their nose, their

eyes should constrict as they follow you to their nose

Unlikely you’ll have to do fundoscopy in the

exam CN III, IV and VI –

Oculomotor, Trochlear and

Abducens

“Now I’m going to test your eye movements” “Just looking at the eyes, there’s no obvious

misalignment” “How many fingers do you see me holding

up?” “And here” etc.

“I didn’t notice any ptosis, difference in eye movements or nystagmus”

Eye movements Hold up one finger

Draw an H with your finger and watch their eyes while doing this

Each time you stop, ask them if they’re seeing double by asking how many fingers they’re

seeing Eye movements are done mainly by 3 –

Oculomotor Apart from LR6SO4 – Lateral rectus muscle is

innervated by 6 (Abducens) and superior oblique is done by 4 (Trochlear)

Picture of eye movements underneath Ptosis – drooping eyelid – shows oculomotor

nerve pathology Nystagmus – involuntary eye movement – can

be caused by stroke/MS/trauma/tumour Saccades – saccadic hypometria –

undershooting – cerebellar problem CN V – Trigeminal “So I’m going to test the sensation of the face

if that’s okay?” “I’m just going to touch this cotton wool onto your chest so you know what normal feels like

and then if you can close your eyes and tell me when you can feel the cotton wool on

your face” “That was normal sensation. Would the

examiner like me to test the corneal reflex?” “Would the examiner like me to use a

pinprick?” (Repeat as above with cotton wool)

“Now could you clench your jaw please and I’m just going to feel the muscles?”

“Muscles of mastication are functioning fine”

Sensory – Don’t touch them in an order – touch temporal areas, cheeks and chin – testing the ophthalmic, mandibular and

maxillary branches Corneal reflex – very unlikely to have to do

this - roll the cotton into a point, come in from the side to the patient and place on their

cornea – they should blink Jaw muscle – Masseter – feel just in front and down from the ear. Tempor – temporal area.

CN VII - Facial “Would the examiner like me to test the corneal reflex?”

“Now I’m going to ask you to do some face movements so if you just copy me so please

screw up your eyes tight, blow out your cheeks, frown and now show me your teeth”

“Muscles of facial expression are working”

Corneal reflex – very unlikely to have to do this - roll the cotton into a point, come in from

the side to the patient and place on their cornea – they should blink

Facial movements - do the actions to show them what to do

In an upper motor neuron lesion – they will not be able to move the lower half of their

face but will be able to frown and raise their


eyebrows – this is because the frontalis muscle of the forehead

is supplied by the facial nerve and some brainstem nerves so it’s covered by two

different things In lower motor neuron palsy, such as Bell’s,

they cannot move their any of their face CN VIII –

Vestibulocochlear “Have you noticed any changes in your

hearing or balance?” “Would the examiner like me to test the

vestibulocochlear nerve?”

Very unlikely you’ll have to do this but if you do, can cover one ear and rub fingers together

in the other ear to see if they can hear it

CN IX, X and XII – Glossopharyngeal,

Vagus and Hypoglossal

“Now could you say “Ahhh” please?” “And stick your tongue out and move it form

side-to-side” “Would the examiner like me to examine the

gag reflex?” “On observation, the soft palate moved

normally showing the glossopharyngeal is functioning and the hypoglossal nerve was

able to move the tongue”

When they say “ahh”, look in their mouth with a pen torch and look for the palate at the top rising and the whether the uvula deviates – the uvula will deviate away from the lesion –

this tests glossopharyngeal Testing the gag reflex tests the vagus

Hypoglossal moves the tongue from side to side – if the tongue is deviated to one side – it

means a lesion is on this side

CN XI - Accessory “And finally, can I get you to shrug your shoulders and don’t let me push them down”

“And push your cheek against my hand” “Shows the accessory nerve is working”

Testing the trapezius and SCM

Conclusion “Thank you very much for allowing me to perform that exam, if you would like to make

yourself comfortable while I report my findings back to the examiner”

“On cranial nerve examination…” “To investigate further, I would perform a full

neurological examination”

Wash hands

Location of Lesion Field Defect Causes

1 – Partial Optic Nerve

Ipsilateral Scotoma (patch of blindness)

Lesions of optic nerve – eg. MS

2 – Complete Optic Nerve

Blindness in ipsilateral eye Head injury or other trauma

3 – Optic Chiasm Bitemporal hemianopia Compression of the middle of the chiasm is most often caused by an adenoma (benign tumour) of the pituitary gland

4 – Optic Tract Homonymous hemianopia Lesions of the optic tract are rare

5 – Meyer’s Loop Homonymous upper quadrantanopia

Meyer’s is the name for the temporal division of the optic radiation The lesion could be caused by a tumour in the temporal lobe

6 – Optic Radiation Homonymous hemianopia Haemorrhage or ischaemia of the middle cerebral artery Can also come from tumours in temporal, parietal or occipital lobe

7 – Visual Cortex Homonymous hemianopia Haemorrhage or ischaemia of the posterior cerebral artery


5) Peripheral Nervous System Examination

Upper Limb

The notches in both the 6 and 7 are from macular sparing; this doesn’t always happen however

8 – Bilateral Macular Cortex

Bilateral central scotomas Most often caused by a backward fall

Part of Examination What to Say Additional Notes


“Today I’ve been asked to examine the nerves that in your upper body which

will include me moving the arms around a bit and testing the sensation, does

that sound okay?” “I’ll be reporting my findings to the examiner throughout if that’s okay”

“For this examination, I’m going to need you to remove your top but I’ve got this

blanket to cover your chest” “Are you in any pain at all?”


Wash hands Exposure – in women, can keep bra on – need to

be able to see both arms and shoulders

General Inspection “Looking at the patient form the end of the bed, they seem well”

“Please could you hold your arms out in front of you”

“Now spin them over so they’re facing up and hold them there while you close

your eyes”

Pronator drift – with supinated arms held out and eyes are closed, if there’s an UMN lesion, the arm will drift down and pronate – this is because the

pronators are naturally stronger than the supinators and so get affected later in UMN lesions Scars – form any previous surgery eg. carpal tunnel

decompression surgery


“Looking for pronator drift”

“Okay, you can open your eyes and relax your arms now”

“Looking more closely at the arms and shoulders for any scars, muscle wasting/atrophy, involuntary

movements, fasciculations and tremor”

Muscle wasting/atrophy:

Wasting = loss of muscle due to disuse. Seen in LMN lesions rather than UMN

Atrophy = loss of muscle due to lack of innervation. Involuntary movements eg. dystonia, chorea or

myoclonus Dystonia = sustained involuntary movement, can be of just one part of the body or many/all and

often affects posture https://www.youtube.com/watch?v=peb2ow14AN

M Chorea = Brief, non- repetitive, rhythmic jerks of

individual muscles https://www.youtube.com/watch?v=OveGZdZ_sVs

Myoclonus = sudden, involuntary jerking of muscles

https://www.youtube.com/watch?v=2V3Nlxor-mw Fasciculations = small, involuntary contractions

seen within the muscle. Occur in LMN lesions and widespread fasciculations at rest are associated

with Motor Neurone Disease https://www.youtube.com/watch?v=iQ99xgrsjQI Tremor = 3 types; resting tremor, postural tremor

and action tremor Resting tremor – occurs when muscles are at rest. Decreases with muscle activity and increases with

mental activity. Example is Parkinson’s disease (in which they may

have a pill-rolling tremor Postural tremor – tremor when skeletal muscle is held in one position eg. if you hold your arms out

Examples are Essential tremor, exercise tremor and Wilson’s disease

Action tremor – tremor when in process of voluntary contraction of muscles eg. finger to nose

Examples – cerebellar disease, MS and chronic alcohol abuse

Tone “I’m now just going to move your joints through a few movements so please could you relax your arms and let me

take the weight of them” “And the other arm”

“Tone is normal/hypertonic/hypotonic/ cogwheeling”

Ensure the patient is and stays fully relaxed Elbow tone – support the arm just above the

elbow and, holding the patient’s hand, fully flex and extend the elbow.

Spasticity can be detected here (the movement is at first very stiff and then suddenly becomes very

loose), and is associated with UMN lesions Wrist tone – Support the arm at the elbow, hold

the patient’s hand as if you’re going to shake it and rotate the wrist back and forth in a circular motion

Parkinson’s disease classically produces a cog wheel rigidity which is caused by the fact there is both a tremor and lead pipe rigidity – it feels like

https://www.youtube.com/watch?v=peb2ow14ANM

https://www.youtube.com/watch?v=peb2ow14ANM

https://www.youtube.com/watch?v=OveGZdZ_sVs

https://www.youtube.com/watch?v=2V3Nlxor-mw

https://www.youtube.com/watch?v=iQ99xgrsjQI


two cogs are moving together, producing short, rigid steps

Hypotonic = LMN lesion Hypertonic = UMN lesion

Power “I’m now going to ask you to do some movements while I push against the movement, does that sound okay?”

“Please could you start by holding both your arms out like this and push up

against me” “Testing shoulder abduction so C5” “Now please could you bend your

elbows like this and pull in against my hands”

“Testing elbow flexion so C5-C6” “Now push the other way against me”

“Testing elbow extension so C7” “And could you cock your wrists back

like this and push against me” “And on the other wrist”

“Testing wrist extension so C7” “And now straighten your fingers and

don’t let me push them down” “And on the other hand”

“Testing finger extension which is C8” “And please could you grip my fingers

and stop me pulling them away” “Testing grip strength”

“Please could you point your thumb to the ceiling and don’t let me push it

down” “And on the other hand”

“Testing thumb abduction which is T1” “And finally, spread your fingers wide and keep them open while I push on

them” “And on the other hand”

“Testing finger abduction which is also T1”

“All power was 5/5”

To document: 0 – no contraction

1 – Flicker or trace of contraction 2 – Full range of active movement, with gravity

eliminated 3 – Active movement against gravity

4 – Active movement against gravity and resistance 5 – Normal power

Always ask the patient to do the movement first

and then push down against them Shoulder Abduction

Muscle = Deltoid. Nerve = Axillary. Nerve root = C5 Elbow Flexion

Muscle = Biceps brachii. Nerve = Musculocutaneous. Nerve root = C5-6.

Elbow Extension Muscle = Triceps. Nerve = Radial. Nerve root = C7

Wrist Extension Muscle = Extensor carpi ulnaris and radialis. Nerve

= Median. Nerve root = C7. Finger Extension

Muscle = Extensor digitorum. Nerve = Radial. Nerve root = C8.

Grip (finger flexion, thumb opposition) Muscle = Flexor digitorum superficialis and brevis and opponens brevis. Nerve = Median and ulnar.

Nerve root = C8/T1. Thumb Abduction

Muscle = Abductor pollicis brevis. Nerve = Median. Nerve root = T1.

Finger Abduction Muscle = Dorsal interossi. Nerve = Ulnar. Nerve

root = T1. Power will often be weaker in UMN lesion

(especially in the upper limb) Can also be focal to a LMN lesion

Reflexes “I’m now going to test your reflexes which will include me tapping this on

your arm, is that okay?” “Relax your arm completely and let me take the weight, I’m just going to move

the arm around a bit but just keep it relaxed”

“Testing the biceps reflex C5,6 which is normal”

To document: ++ = normal

+++ = exaggerated + = diminished

+/- = reflex had to be reinforced eg. by getting patient to clench fist

0 = no reflex


“Testing triceps reflex C7,8 which is normal”

“And finally testing supinator reflex C5,6 which is normal”

“And now I’m going to do that same on the other side”

If you can’t elicit the reflex after the 2nd time trying, reinforce it – ask

them to clench their teeth – this distracts them and so allows their muscles to relax

Biceps Reflex – C5,6

Rest the arm in the patient’s lap with the hand supinated. Place your fingers on top of the biceps tendon at the anterior cubital fossa and tap your

fingers with the tendon hammer Triceps Reflex – C7,8

Hold the patient’s arm across their chest is that their hand is laying on their opposite shoulder. Tap

proximally to the olecranon Supinator – C5,6

Tests brachioradialis muscle. Rest the patient’s arm in their lap and place 2 fingers over the radius

about 5-10cm proximal to the wrist

Increased, brisk reflexes is a sign of UMN (stroke) and decreased is LMN

Coordination “Now I’m going to test your coordination so could you put your hands together like you’re clapping

please?” “Now could you turn your top hand

over?” “And repeat that as fast as you can”

“And the same in the other hand please?”

“And now could you touch your nose” “And touch my finger”

“And go quickly between the two” “Showing coordination is good and there was no intention tremor or

past-pointing”

Abnormal coordination may indicate a cerebellar lesion

Dysdiadochokinesis – rapid pronation and supination – a patient with a cerebellar lesion will be unable to perform this or can only do it slowly

Finger-Nose Coordination – hold your finger in one position at arms length. Cerebellar lesion will cause

an intention tremor and possibly past-pointing If they struggle with any of these, can go on to test

more cerebellar dysfunction signs such as: Gait (will be ataxic – broad-based), nystagmus, slurred

speech and hypotonia

Sensation “I’m now going to test your sensation with this cotton wool/neurotip”

“I’m just going to tap it on your chest just so you know that’s what normal

feels like” “Now could you close your eyes and tell

me when you fell that tap” “C5, C5-6, C7, C8, T1”

Test each dermatome separately, comparing side to side

C5 – Regimental badge area – Axillary nerve C5-C6 – Thumb – Musculocutaneous

C7 – Middle finger – Radial C8 – Pinky finger – Ulnar

T1 – Under armpit – Median

Unlikely to have to test all the types of sensation but they are as follows:

Light touch (most likely) – use cotton bud Pain – use pin-prick – warn patient it may be sharp

Temperature – won’t have to do this Joint position – tested at a distal joint of the finger. The DIP of the index finger on each hand is isolated


Lower Limb

(held on the side so pressure on the fingernail doesn’t give it away) and

moved. Show the patient with their eyes open their joint up and down and then get them to close

their eyes and ask which way it is. Vibration – uses 128Hz. Strike gently so it can’t be

heard and put it on the patient’s chest to show what normal is. Get the patient to close their eyes and strike it again and place on bony prominence eg. radial styloid. If they can’t feel it here, move

more proximally Closing the Session “Thank you very much for letting me

examine you, that’s the exam over so you can get yourself comfortable and

I’m going to report my findings back to the examiner”

“On examination…” “To investigate further, I would do a lower limb examination and a cranial

nerve exam, thank you”

Wash hands

Part of Examination What to Say Additional Information


“Today I’ve been asked to examine the nerves that in your lower body which

will include me moving the legs around a bit and testing the sensation, does

that sound okay?” “I’ll be reporting my findings to the examiner throughout if that’s okay” “For this examination, I’m going to

need you to remove trousers but I’ve got this blanket to cover the top of your

legs” “Are you in any pain at all?”


Wash hands

General Inspection and Gait

“Would the examiner like me to examine the gait?”

“Please could you stand up, walk towards the curtain and back again?”

“No abnormalities in gait so no Parkinsonian or Hemiplagic gait”

“And now could you stand with your feet together and just stand there”

“And now close your eyes”

Gait Hemiplegic gait – seen in stroke - The patient stands

with affected arm flexed, adducted and internally rotated. Leg on same side is in extension with plantar

flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her

affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor


“That’s Romberg’s negative”

“You can lie down and get yourself comfortable”

“Looking from the end of the bed, the patient looks well”

“Moving on to look at the legs more carefully, looking for wasting,

fasciculations and the condition of the sink for any ulcers”

hypertonia in lower limb. - https://www.youtube.com/watch?v=y160w4sAQNw

Choreiform gait – seen in Huntington’s disease – involuntary, dance-like, jerky movements and slow gait

https://www.youtube.com/watch?v=_sf86EFdrqc Ataxic Gait – seen in cerebellar dysfunction - clumsy,

staggering movements with a wide-based gait https://www.youtube.com/watch?v=FpiEprzObIU

Parkinson’s gait - He or she will be stooped with the head and neck forward, with flexion at the knees. The whole upper extremity is also in flexion. The patient walks with slow little steps known at marche a petits

pas (walk of little steps). Patient may also have difficulty initiating steps and turning. The patient may show an

involuntary inclination to take accelerating steps, known as festination

https://www.youtube.com/watch?v=sf1N0Zf5IqA General inspection is the same in upper limbs written

above but ulcers may show diabetes which can lead to a peripheral neuropathy (glove and stocking distribution)

Tone “Now try and relax your leg and I’m just going to roll it from side to side”

“And I’m just going to pick it up from the bed, keep I relaxed and let me take

the weight” “Tone is normal”

“And now I’m going to move your ankle around”

“Testing ankle clonus which was normal”

Tone On rolling it side to side, the limb should move steadily

With hypotonia, the limb will be floppy and loose = LMN With hypertonia, the limb will be stiff and difficult to roll

= UMN When picking it up from the bed, pick it up at the knee and slowly lift the leg up, the ankle should willingly stay

on the couch at all times With hypertonia, the ankle will also come off the couch

Ankle clonus Gently flex the knee and, grasp the foot and slowly

move it up and down to loosen it. Then, suddenly jerk it up. Clonus is regular oscillations of the foot where one

or two beats are normal. More than 4 beats indicates an UMN lesion

Power “I’m now going to ask you to do a few movements while I resist you if that’s okay so please lift your leg straight up

off the bed and I’m going to push down on it”

“Same on the other leg” “Testing hip flexion which is L1,2”

“Now bend your knees, and keeping your ankle on the bed, push against my

hand” “Same on the other leg”

“Testing knee extension which is L3,4” “Now push the other way against me” “Testing knee flexion which is L5, S1”

“Pull your foot up and don’t let me push it down”

Record using same scale as with arms (MRC) Hip Flexion:

Muscle: Iliopsoas. Nerve: Lumbar plexus. Nerve root: L1,2.

Knee Flexion: Muscle: Hamstrings. Nerve: Sciatic. Nerve root: L5, S1

Knee Extension: Muscle: Quadriceps. Nerve: Femoral. Nerve root: L3,4

Dorsiflexion: Muscle: Dorsiflexors. Nerve: Deep peroneal. Nerve root:

L4,5 Plantar flexion:

Muscle: Gastrocnemius. Nerve: Posterior tibial. Nerve root: S1

Big Toe Extension:

https://www.youtube.com/watch?v=y160w4sAQNw

https://www.youtube.com/watch?v=_sf86EFdrqc

https://www.youtube.com/watch?v=FpiEprzObIU

https://www.youtube.com/watch?v=sf1N0Zf5IqA


“Same on the other foot”

“Testing dorsiflexion which is L4,5” “And push your foot down against me”

“Same on the other foot” “Testing plantarflexion which is S1”

“And finally could you point your big toe up and don’t let me push it down”

“And same on the other toe” “Testing big toe extension which is

L4,5” “All power was 5/5”

Muscle: Extensor halluces longus. Nerve: Deep peroneal. Nerve root: L4,5.

Reflexes “I’m going to test your reflexes now by tapping you with this, does that sound

okay?” “So just relax your legs and let me take

the weight of them” “Knee jerk which is L3,4”

“And now can you bend you knee and let your leg flop out, I’m just going to

tap your ankle so let your leg relax again”

“Ankle jerk with is S1,2” “Now I’m going to quickly run this

round the bottom of your foot, it might feel a bit ticklish so sorry about that” “Plantar reflex is normal as the toes

curled over”

L3, 4 – Kick down the door S1, 2 – Buckle my shoe

Knee Jerk Take the weight of the patient’s legs onto your arm and

flex the knees at around 30 degrees. Tap the patella tendon and look for either extension of the knee or

contraction of the quadriceps Ankle Jerk

Tests Achilles tendon. Look for plantar flexion of the foot and for contraction of the calf.

Plantar Flexion (Babinski) With the patient’s lower limb flat and feet relaxed, scrape along the bottom of the foot laterally, going

medially to the big toe once you hit the ball of the foot quickly and firmly. Should use a special wooden stick for

this. A downward or no movement of the big toe is normal but an upward movement suggests UMN lesion.

Coordination “Now can you stroke the heel of your right leg down from your knee to your

ankle please?” “And do the same on the other leg”

“Co-ordination is normal”

Point to them where you want them to put their foot Coordination notes are as above in upper limb

Sensation “Okay, now I’m going to test the feeling in your leg by touching this cotton bud

on different parts of your leg” “This is normal and let me know if your legs feel normal and if they’re the both

on each side” “Testing L2, L3, L4, L5 and S1”

Compare side to side L2 – Upper thigh L3 – Above knee

L4 – Medial lower leg L5 – Top side of foot

S1 – Bottom side of foot Also, look below for nerve distribution

Repeat with pain, vibration, temperature and proprioception

Closing the Session “Thank you very much for letting me examine you, that’s the exam over so you can get yourself comfortable and

I’m going to report my findings back to the examiner”

“On examination…”

Wash hands


Audiometry

● Audiometry shows the quietest sound you can

hear

● Volume - The vertical axis represents volume

(loudness) which is measured in decibels (dB).

Sounds become louder from the top down –

softest near the top of the graph.

● Pitch - The horizontal axis represents frequency

(pitch) which is measured in hertz (Hz). Pitch

goes from low (125Hz) on the left to high

(8000Hz) on the right

● 0 dB does not mean that there is no sound at

all. It is simply the softest sound that a person

with normal hearing ability would be able to

“To investigate further, I would do an upper

limb examination and a cranial nerve exam, thank you”


detect at least 50% of the time. Normal conversational speech is about 45 dB.

Severity of Hearing Loss ● Normal hearing is when the softest sounds heard are between -10 and 20 dB. If the sounds

are louder than 20 dB and you still can’t hear them, then there is a hearing loss. If the

sounds are quieter than 20 dB and you cannot hear them, it may just be that your threshold

of hearing is 20 dB.

● Mild hearing loss is between 21dB and 40dB. You often have difficulty following speech

especially in noisy situations.

● Moderate hearing loss is between 41dB and 70dB. You often have difficulty following

speech and other quiet noises. Amplification can be very successful for this loss but you also

need to use good hearing tactics (e.g. lipreading, expression, gesture).

● Severe hearing loss is between 71dB – 95dB. You are unable to hear speech even in quiet

surroundings and do not hear general noises such as traffic unless it’s loud. Amplification can

also be useful

● Profound hearing loss is greater than 95dB. You are unable to hear most sounds unless

really loud. Amplification is often useful but you need to rely on good communication tactics

including lip-reading, subtitles on TV and possibly signing.

Thresholds ● In the audiology clinic, when testing is done with headphones, we call them ‘air conduction

thresholds’ as the sound must travel through the air of the ear canal to be heard.

● Alternatively, hearing can be tested using a bone conductor – a device that rests on the

bone behind the ear (held in place by a metal band stretching over the top of the head). This

bone conductor transmits sound vibrations through the bones of the skull directly to the

cochlea. This process allows the audiologist to test the hearing of the inner ear directly.

Recording ● Right ear - Sounds heard in the right ear are marked in red. When headphones are used (air

conduction thresholds), they are marked with an O and when a bone conductor is used

(bone conduction thresholds), they are marked with a [ or a triangle Δ. ● Left ear - Sounds heard in the left ear are marked in blue. When headphones are used (air

conduction thresholds) they are marked with an X and when a bone conductor is used they

are marked with a ] or triangle Δ. ● Sometimes the graphs of the each ear are plotted on separate audiograms, sometimes they

are plotted on the same audiogram.

Conductive Hearing Loss ● If air conduction is diminished but bone conduction is normal, this is a conductive hearing

loss

● This is because air conduction tests problems with the outer and middle ear and bone

conduction test the inner ear

● Causes:

- Otitis Media and Glue Ear

- Eustachian Tube Dysfunction

- Perforated eardrum


- Ear wax or foreign body

- Otitis externa

- Ear Microtia – Underdevelopment of the ear

Sensorineural Hearing Loss ● Both air conduction and bone conduction are diminished in this as it’s a problem with the

inner ear and the signals getting to the brain

● Causes:

- Presbycusis

- Acoustic neuroma

- Ototoxic drugs (Gentamicin and other aminoglycosides, loop diuretics and

chemotherapy agents)

- Exposure to loud noise and head trauma

Tympanograms

How It’s Done

● Probe placed snuggly in external ear canal

● Sound generated

● Transmits acoustic energy into canal while vacuum pump introduces positive and negative

pressures into ear canal

● Microphone detects returning sound energy

● The test looks at the flexibility (compliance) of the eardrum to changing air pressures,

indicating how effectively sound is transmitted into the inner ear.

● Tympanometry result indicates the ear canal volume (cm3), the max pressure (daPa) and the

peak compliance (ml).

Interpretation

● 3 main types:

- Type A

o Type A – suggests normal middle ear functioning

▪ Peak is between +/- 100dPa


▪ Compliance is between 0.3-1.5ml

o Type AD – Consistent with normal middle ear pressure with a hypermobile

tympanic membrane

▪ Peak is the same as Type A at +/- 100dPa

▪ Compliance is >1.5ml

o Type AS – Consistent with normal middle ear pressure with a hypermobile

tympanic membrane

▪ Peak is again +/- 100dPa

▪ Compliance is <0.3ml

- Type B

o Type B – Suggests middle ear involvement from fluid (Glue Ear) since there is no

measureable ear pressure. This is because the tympanic membrane is immobile

▪ No identifiable peak

▪ Ear canal volume is normal

o Type B-HIGH – Suggests middle ear involvement from a perforation or a

grommet

▪ There is no identifiable peak

▪ Ear canal volume exceeds normal

- Type C

o Significant negative pressure in the middle ear that suggests Eustachian tube

dysfunction (often just before or after an effusion)


11)Hearing Aids Type of aid What is it? Who are they suitable

for? What does it look like?

Behind-the-ear (BTE) An aid which hooks over the top of the ear and rests

behind it. A tube connects the aid to an earmould which fits in the patient’s ear canal.

Suitable for all ages and most types of

hearing loss.

Receiver-in-ear (RITE) The same as a BTE but with a wire rather than a tube

connecting the hearing aid and earmould. Less visible

than BTE.

People who may want a more discrete

hearing aid.

In-the-canal (ITC) + Completely-in-the-canal (CITC)

An aid which just fits in the outer part of the ear canal.

May not be suitable for patients who have

frequent ear infections or severe hearing loss.

Bone Anchored Hearing Aids (BAHA)

Transmits sound directly to cochlea via vibrations passing

through the skull. A small screw is fixed into the skull and the BAHA fits onto this.

Patients with conductive hearing loss

who have abnormal ear canals/middle ears or discharge in the ear.

Soft-Band Bone Conduction

hearing aid Same as a BAHA but no

surgical intervention needed. Same as BAHA. Useful

for children.

Body-worn (BW) For body worn aids, the microphone in a small box which is clipped to clothing or carried in a pocket. The

microphone is connected by an ear to an earphone.

Better option for people who have poor dexterity, so would find

it different to fit another type of

hearing aid in their ear.


Hearing Implants

Type of implant What is it? Who are they suitable for?

What does it look like?

Middle ear Has an external processor and a surgically implanted

internal part. The processor transmits sound to the

internal part. The implant directly moves bones of the middle ear, which vibrates

the membrane of the window of the cochlear.

Mixed or either type of hearing loss

Suitable alternative for people with

earmould allergies, skin problems in

outer ear, outer ear infections, narrow, collapsed or closed

ear canals or malformed ears.

Cochlear An implant which bypasses damaged or faulty parts of

inner ear to connect to cochlear. It converts acoustic sounds to

electronic pulses which can directly stimulate the

auditory nerve.

People whose hearing loss is not

helped by conventional hearing aids. Often for people

with profound hearing loss.

Auditory Brainstem This implant has an external processor part with a

microphone attached and a surgically implanted internal

part, similar to the middle ear implant. The internal part consists of a receiver just below the skin which

connects to the brainstem. This means sound is picked

up by the microwave, converted into an electrical

signal and bypasses the cochlear and auditory nerve

to reach the brain stem.

People with profound sensorineural hearing

loss.

author: sarah carlton m o dule 7 osce · 2021. 1. 15. · possibly mastoiditis o t o s c o p y...

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