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Aims
Recap of basic anatomy Understand therefore what you are looking for when looking at the eardrum Recognise important signs Recognise what you must not miss
Ear Wax
Wax is not normally present in the inner third of the ear canal. So its presence there may indicate inappropriate use of cotton buds to clean the ears OR it may be a dried up crust, overlying more significant pathology such as a perforation or cholesteatoma (beware!)
Malleus
Normal
The normal tympanic membrane should appear pearly grey with a light reflex generally concave and you should be able to make out the malleus Tip: If you can make out the malleus, then you can figure out whether something is worth worrying over by noting its relation to it. Its simple really. More later.
The impression the malleus makes on the eardrum looks like (to me) an arm with an upper arm, a bent elbow, a forearm, and a blobby bit at the end like a hand.
Click to the next pic to see what I mean
Another normal
Some people like to be real fancy and label the individual parts.
The only bits you really should be able to label is 1 = pars flaccida (=attic) 5 = light reflex 6 = eardrum margin and treat 2,3 and 4 as the malleus.
Okay, for you buffs 2 = lat process of malleus 3 = handle of malleus 4 = end of malleus
There is another EASIER way you can figure out whether something is in the anterior or posterior segment. When youre looking down an earhole, just figure out whether the lesion is at the face end of the patient or not. If it is, it is anterior easy peasy lemon squeezy! The clever ones amongst you will have figured out that the picture above is in fact the right ear drum.
Bubbles
You may see bubbles behind the drum. This represents a resolving middle ear effusion, as air gradually re-enters the middle ear. In this image, the bubbles appear much larger
Glomus Tumour
This small blurry red lesion at the tip of the malleus handle is a vascular lesion called a glomus tumour. This might cause pulsatile tinnitus, but is rare. Im showing you this lesion because you need to look out for it. Its rare but needs surgical treatment. If you were thinking of a clear red bulge sticking out towards you, think again. Once seen, like in this pic, youre unlikely to forget it.
Glomus tumour
This red bulge in the canal is another glomus tumour (glomus jugulare). this is the tip of a much larger lesion involving the temporal bone. But remember, not all of them will be as clear as this.
Notes My ears have been popping for two weeks and occasionally hurt. Treatment includes pinching your nose and blowing - this forces air up the tube and pops the ear drum back into place.
1. 2. 3.
Cholesteatoma
These are nasty! They need referral.
In this pic: Eardum is clearly retracted: margin is very clear + drum looks sunken + you can make out some structures underneath (dunno what they are though).
And there is that ugly crusty yellowy thing in the attic region. Remember, attic = serious
Cholesteatoma
Features
Pearl shaped sac or disc yellow in colour Retracted ear drum (so you can see the anatomy easily)
Notes
Must not miss this one! The problem occurs when the dead cells accumulate in the middle ear and can not be expelled. Typically an infection occurs with intermittent drainage from the ear. As this ball of dead cells accumulates it produces enzymes which cause the destruction of bone. Discharge with foul odor, a full feeling or pressure in the ear, hearing loss.
Tympanosclerosis
These are white patches common in the elderly and usually safe. In this picture, you should have notice the eardrum is retracted: Malleus clearly visible Margin clearly visible Looks sunken Do you know which ear it is? Yep, the right ear.
Tympanosclerosis
Features White patches on the eardrum Nothing else really
Notes Deposition of calcium into the drum itself in response to trauma or infection This is not normally of any consequence unless it is severe, which can lead to a mild conductive hearing loss.
Perforation the next set of slides are dead important. So pay attention.
More on UNSAFE
Inspect the attic region (the small area of drum between lateral process of the malleus and the roof of the ext aud canal immediately above it) 1. Any defect or apparent perforation in the attic must be considered unsafe (?cholesteatoma) 2. A posterior perforation where the posterior margin of the drum is also unsafe. This are often linear rather than oval. 3. Any perforation involving the drum margin is also unsafe
Source
Odour Amount Nature
Cholesteatoma
Foul Usually scant, never profuse Purulent
Mucosa
Inoffensive Can be profuse Mucopurulent
Remember what I said: Unsafe perforations are a) In the attic or b) In the posterior region c) Or involve the eardrum margin Anything else is generally safe. i.e. a) In the anterior region or b) In the inferior region c) AND NOT INVOLVING THE EARDRUM MARGIN
If you cant tell whether it is anterior, posterior, inferior or in the attic, go back to slide 13
Granulations
Granulations like this are often associated with underlying disease, particularly if they arise in the attic.
Grommets
Just because you can see a grommet in the ear does not mean it is working. The hole in the middle should be clear of debris.
This one is clearly extruding and on it's way out up the canal. Note the drum visible in the distance
Grommet
This grommet is in the correct position but is covered in infective granulation and blocked up. This will not be doing any good and may be responsible for a chronic discharge. Note also the extensive tympanosclerosis on the drum.
Most of this presentation is taken from http://www.bristol.ac.uk/Depts/ENT/otoscopy_tutorial.htm which is an excellent resource worth looking at in more detail.