MRCS Part B Revision · Physical examination
Ear — MRCS Part B Physical examination
By Dr Richard Miller, MBChB FRCS · Reviewed
Ear is a physical examination station. Three of the seventeen examined stations in the MRCS Part B OSCE are physical examination. The physical examination stations ask you to examine a real patient or a simulated one to a clear sequence, interpret what you find, and present it.
What you need to know for the Ear station
Wash your hands and introduce
Equipment:
Otoscope
Otoscope speculum
512Hz Tuning fork
Position patient:
Seated at same level as you access to both ears
Assess the external ear:
Begin with the pinna.
Examine for any deformity or skin changes.
Look for scars or pits in front of, or behind ear .
Hearing aids should be noted then removed. Tug the pinna gently for any tenderness.
Palpate for pre/post-auricular lymph nodes
Gross hearing test:
Ask the patient if they have noticed any change in their hearing recently.
Explain that you’re going to say a word or number and you’d like them to repeat it back to you.
Whisper a number or word approximately 15cm from their ear. Mask the opposite ear by rubbing the tragus. Ask the patient to repeat the number or word back to you. If the patient repeats the correct word or number, repeat the test at an arm’s length from the ear (normal hearing allows whispers to be perceived at 60cm). Assess the other ear in the same way.
Internal ear and otoscope:
Using an otoscope
Turn on the light
Grip the otoscope like a pencil
For right ear, hold in your right hand, handle pointing forwards
For left ear, hold in your left hand, handle pointing forwards
Pull the pinna up and back to straighten External auditory meatus (EAM)
Look in the ‘good’ ear first
That way, if there is infection present in the ‘bad’ ear you will not transfer it to the other side
Insert speculum tip into the EAM
Gradually move the speculum into EAM under direct vision through the instrument
Look at:
External auditory meatus (EAM)
FB, wax, skin, shape
Tympanic membrane (TM) and ‘Behind’ TM
Tuning Fork Tests
Rinné and Weber tests
Detect and differentiate conductive and sensorineural hearing loss
Give you something to do whilst waiting for the pure tone audiogram (PTA)
Rinne Test
Tap 512Hz tuning fork against bony part, or heel of Gucci loafers
Place base firmly on mastoid process Ask patient to tell you when sound
disappears
Hold fork tips 2cm from EAM Can the patient hear it now?
Interpretation:
Tests whether bone (BC) or air conduction (AC) is better
If can be heard in front of ear, AC>BC Normal
Rinné positive
If cannot be heard in front of ear, AC
Weber test
Strike tuning fork again
Hold somewhere on the head in the midline (firmly)
Usually vertex or forehead Can use upper incisors
Which side is louder?
Interpretation:
Conductive deafness localises to abnormal ear
Sensorineural deafness localises to normal ear
Try it on yourself with a finger in an ear
Where does the sound localise?
What are you asked at the Ear station?
The station runs to 14 questions over nine minutes. These are the questions as they are put to you; the model answers are in the question bank.
- The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this ladies neck. Examination: Ear
- Explain how you would introduce yourself
- Explain how you would begin your examination
- You decide that you would like to utilise Weber and Rinne tests to give further information on the nature of the hearing loss. How would you perform each of these and what information would they give?
- Through the use of Weber and RInne tests, you believe that the patient has a conductive hearing loss in the right ear. With the use of the otoscope, you are able to visualise the tympanic membrane TM. What differentials might be contributing to the patient’s hearing loss?
- How might the appearance of the tympanic membrane differ between your differentials?
- What is the pathogenesis of these conditions?
- You ascertain that there is a pearly white swelling on the superior aspect of the tympanic membrane. You suspect the diagnosis is that of a cholesteatoma. What complications might arise from this lesion?
- The patient notes that she has had a loss of taste over the last few months. What specific nerve branch may be affected?
- What other nerve does this nerve branch hitchhike along? What other fibres other than taste fibres does it carry and where do they synapse?
- On formal audiometry, you establish that there is also a sensorineural element to her hearing loss in the contralateral ear. What may cause her sensorineural hearing loss?
- What nerves run through the internal auditory canal and where do they join the brainstem?
And 2 more at this station.
How is the physical examination station marked in MRCS Part B?
A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
FAQ
What does the Ear station ask?
It opens with "The patient is comfortable, you have washed your hands, introduced yourself and explained what you are going to do. Please examine this ladies neck. Examination: Ear" and runs to 14 questions over nine minutes. A physical examination station is marked out of 20: 8 marks for clinical and technical skill, and 4 each for clinical knowledge and its application, communication and professionalism. More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings.
How many examination stations are there in MRCS Part B?
Three of the seventeen examined stations are physical examination. The number was reduced from four when the exam moved from eighteen stations to seventeen, implemented from the October 2020 diet.
How is a physical examination station marked?
Out of 20, with 8 marks for clinical and technical skill and 4 each for knowledge, communication and professionalism. The station also receives a global rating of pass, borderline or fail.
When do I present my findings?
At six minutes of the nine you are signalled to present. Rehearse the examination to finish inside six minutes, because the presentation carries marks that a rushed or truncated one will not earn.
How many stations are in the MRCS Part B OSCE?
Seventeen examined stations of nine minutes each, with a minute to read the task before each one. Two preparation stations and at least one rest station bring the circuit to about twenty, and the exam takes about three and a half hours.
What is the pass mark for MRCS Part B?
There is no published pass mark. The cut score is set separately for Applied Knowledge and Applied Skills, for each circuit, by borderline regression. Published pass rates across the 2024/25 diets ranged from 51% to 66%.
Can I fail a station and still pass?
Yes. There is no rule about how many stations you may fail: the cut score applies to your total mark in each component, so a weak station costs the marks you lost on it and strong stations elsewhere can make them back. Applied Knowledge and Applied Skills are passed separately and must both be passed at the same sitting, so a strong anatomy performance cannot rescue a weak communication one.
Dr Richard Miller, MBChB FRCS
Station summaries are reviewed against the current intercollegiate MRCS syllabus and the published marking blueprint. Guidance changes between diets: check the royal colleges' own pages before relying on a date, a fee or a threshold.
Practise this station
The question bank carries the model answer to every question above, with the rest of the physical examination stations.
More physical examination stations