Examining the Ear Using an Otoscope

Getting to the ear drum…1 4

1. S

   Moving the auricle and tragus constitutes the “tug test”, and is painful in external otitis media, but not in otitits media. Touching behind the ear may be painful in the latter.

   elect largest ear speculum the canal will accommodate.

2. Position head so instrument can be used comfortably.

3. Examine the problematic ear last to avoid spreading.

4. To straighten canal, grasp auricle and pull firmly but gently upward, backward and slightly away from the head.

5. Grasping the handle between your thumb and index finger, brace yourself against the patient’s face using your other fingers, to ensure unexpected movements are followed (pencil grip).

6. Gently insert speculum, aiming slightly down and forward.

7. Inspect the ear canal as you enter for any discharge, foreign bodies, redness of the skin or swelling, note cerumen may interfere with your view.

8. Inspect the ear drum.

Examining the ear drum…2

1. Inspect the eardrum, noting color and contour, the cone of light is useful in orientation.

2. Identify the handle of the malleus and inspect the short process of the malleus.

3. Gently move the speculum to see as much of the drum as possible.

4. The tympanic membrane consists of the pars tensa and pars flaccida, the malleus handle is in the middle of the tensa, superior to this is the lateral process of the malleus, the most easily recongnizable structure. The tip of the handle inferiorly is the umbo with the light reflex normally extending from this.

5. Identify handle, if not present look for the lateral process. Inspect the pars tensa systematically, starting in the posterior superior quadrant and moving forward, downward and backwards. Carefully inspect the pars flaccida.

Useful questions to ask yourself…2

1. Can the external canal clearly be visualized? If filled with debris is it safe to remove this material? If ear is possibly perforated, patient should be referred to ENT.

2. Can the TM and handle of the malleus be seen? Handle gives an idea of where the TM should have been if missing.

3. Is the TM intact? Note the difference between a retracted ear drum and perforation. If there is debris around the pars tensa or over the flaccida, patient may have a cholesteatoma, refer to ENT.

4. Is the TM the right color/transparency? Gold/blue/dull membrane indicates fluid in the middle ear. White patches are tympanosclerosis. Chalk patches and thick patches from prior surgery are not clinically important unless hearing is affected.

Common Problems…2

1. Unable to see properly? Check light and ensure battery is charged.

2. Red drum is all that is visible? Most likely posterior canal wall, try tilting otoscope anteriorly/superiorly or pulling the pinna further.

3. Anatomy is very abnormal? Start by looking for the lateral process of the malleus. Normally this is present despite other processes occurring in ear, orient yourself with it.

4. Is that a perforation? Usually obvious, however deep retractions can look similar. Blood vessels in the middle ear mucoas confirm the presence of a perforation. ENTs will often use pneumatic otoscopes to better evaluate this.

Normal TM Retracted TM Serous Otitis TM Cholesteatoma Perforated TM Ear Tube in place

Clinical Examples of Tympanic Membranes…3

References

1Bickley, Lynn S. Bates’ Guide to Physical Examination and History Taking: Eight Edition. Lippincort Williams and

Wilkins, 2003. 156-7.

2”Photographs of Ear Tubes, Eardrums, Infections, Cholesteatmas, and Acute Otitis Media.”

http://www.entusa.com/eardrum_and_middle_ear.htm. Accessed June 4, 2007.

3”How to Use an Otoscope.” http://www.comdis.wisc.edu/staff/mrchial/howotoscope.htm. Accessed June 4, 2007.

4“External Ear.” http://www.infovisual.info/03/048_en.html. Accessed June 4, 2007.

Category: ENT Notes