The Eardrum Made Simple
Dr. Ramesh Mehay
Programme Director, Bradford VTS
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
Children & Adults
• The ear canal tends to have a slight anterior bulge and it is
usually easier to see the posterior part of the drum than the
anterior part (I’ll explain ant and post parts later).
• The canal may be partly straightened by pulling the pinna
backwards and upwards during examination.
• In infants pull the pinna more horizontally backwards as the
shape of the ear canal is different.
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!)
The Normal Ear and Surface
Anatomy
1= Helix
2=Triangular fossa
3= Antihelix
4=Tragus
5=Antitragus
6=Lobe
7=Crus of helix
8=Concha
9=External auditory canal
Quick recap of ear anatomy
You can see that only
the malleus is the only
bone normally in direct
contact with the
eardrum.
The stapes transmits
sound waves to the
cochlear organ through
the round window.
So, when looking at a
normal eardrum (which
is partly translucent),
you should be able to
make out the malleus
but it’s unlikely you’ll
see anything else.
Almost too good to be true (but
good for illustration)
Books will show you a picture like
this claiming this is what you’ll see
in the normal eardrum.
Malleus
It’s a lie! You won’t. This is just
showing off.
Remember, I said you can usually
make out the malleus but not much
else.
If you can see these other things, it
is likely the eardrum is not normal
but retracted (more about that
later)
This eardrum is not normal, it’s
retracted. Okay, let’s look at what
YOU are really going to see.
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. It’s simple really. More later….
The Normal Eardrum
Now this is what you’re
gonna see. Can you
make out the malleus?
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
The malleus looks like an arm
The malleus looks like an
arm.
Upper arm
Bent elbow
Forearm
Hand
This is the same picture as
before but I’ve outlined the
malleus.
Now do you see what I mean
when I say it looks like an
arm?
Even if you can’t quite clearly
see the malleus, you can
usually make out the elbow bit
in the normal eardrum.
The malleus looks like an arm
Here’s the picture again
just to make sure you
can make out the arm.
Another normal
Some people like to be real
fancy and label the individual
parts.
6
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
And yet another normal
An annulus fibrosus or more
commonly referred to as the
eardrum margin. This is
important. Note how smooth
and how ever so slightly blurry
it is.
Um umbo - the end of the
malleus handle and usually
marks the centre of the drum
Lr light reflex –is usually seen
antero-inferioirly
At Attic also known as pars
flaccida. Any perforations here
are serious and need referral.
Lp Lateral process of the malleus
Hm handle of the malleus
Lpi long process of incus sometimes visible through a healthy
translucent drum
Where are the anterior, posterior,
inferior regions?
Attic – this area is located above
the elbow.
Like I said before, it’s important
because perforations here are
serious.
Anterior – this is the area the
elbow is point towards
Posterior – this is the area
opposite the elbow.
Inferior – this is the area below the
hand.
There is another EASIER way you can figure out whether something is in the anterior or posterior segment.
When you’re 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.
What are you looking at?
• Shape of the eardrum – bulging or retracted
• Colour of the eardrum – red (infection), yellow (glue ear),
brown (blood), presence of blood vessels (injected?)
• Light reflex present or not? (usually absent in bulging EDs)
• Things that should not be there
1.
2.
3.
4.
5.
6.
Perforations
Bubbles (glue ear, resolving infection)
White patches (tympanosclerosis or cholesteatoma)
Granulations
Red lesion at tip of malleus (glomus tumour)
Grommets/FBs
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.
I’m showing you this lesion
because you need to look out for
it. It’s 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, you’re
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.
The Retracted Eardrum
• The normal drum is slightly convex.
• Recognising the retracted eardrum is important and this is
how to do it:
• Mild retraction may be difficult to identify. The margin of the
drum (annulus may become more pronounced)
• More significant retraction: The lateral process will also
become much more prominent than normal
• As the drum becomes increasingly retracted, it drapes over
the ossicular chain, and the incus and stapes head may be
outlined
Now onto the pictures.
You’ve grasped the theory. Now here
is where you really learn your stuff
and not feel unconfident again!
Try and work out the pictures for
yourself first.
What is this ?
Acute Otitis Media
First describe what you see
using the method I outline
previously:
•Eardrum shape
•Eardrum colour
•Light reflex
•Anything that shouldn’t be
there
You should have noticed
Bulging eardrum (can’t see the
malleus well + margin isn’t
very clear + it looks bulging)
Inflammation – looks red and
there is an injection of blood
vessels in the eardrum itself.
So, what is a red, bulging
eardrum?
Acute Otitis Media
Features
• change of colour of the tympanic membrane to pink/red
• bulging drum
• loss of outline of drum and landmarks
Notes
• Approximately 40% of children suffer one or more episodes
before the age of 10 years. More cases are seen in the winter
months.
• Mostly viral
• Symptoms niggle for 3-5 days
• No antibiotics (unless ill child)
Cates plot of pain at 2-3 days in children given antibiotics
versus placebo for acute otitis media
• The 5 yellow faces are the
only children who show a
benefit; they would have
been in pain without the
antibiotic but are not when
they receive one. Since it is
not possible to identify
which children will benefit
all 100 need to be given the
antibiotic for 5 to benefit.
• NNT = 21 to benefit one
child from being free of pain
at 2-3 days.
Cates plot of diarrhoea, vomiting or rash over the study period
in children given antibiotics versus placebo for acute otitis
media
• In the control group 20 people
out of 100 had diarrhoea,
vomiting or rash over the
duration of the trial, compared
to 27 (95% CI 23 to 31) out of
100 for the active treatment
group.
• Number needed to cause a
harmful outcome in one child
(NNH) is 14.
Treatment of acute OM.
•
•
•
•
Antibiotics may reduce severity and duration a little
Best to use if child is unwell and/ or fever > 39C
Consider if no improvement after 4-5 days.
None of this means the infection is bacterial.
•
•
•
•
Also Consider antibiotics if:
Baby under 3/12 old (narrow canals ++)
Discharging ear full of pus.
Children under 2 with bilateral infections.
What is this
Serous Otitis Media
Don’t forget, describe the
eardrum according to how I
taught you!
Eardrum shape– bulging?
Because can’t see the margin
v. well and the malleus
normally looks a lot more
clearer.
Eardrum colour – nothing to
say really ?okay You might
think there is an injection of
blood vessels, but what your
looking at is blood vessels in
the ear canal NOT on the
eardrum (compare with
previous pic if you don’t
believe me).
Other abnormalities –
In summary, what is a non red bulging eardrum with fluid? presence of fluid levels and
bubbles
Glue ear
• Glue ear is fluid in the middle ear, often a
consequence of acute OM. 1 in 4 children affected at
some stage in their lives.
• Risk factors are age, day care nursery, FH of glue ear
(parents, sibs) and passive smoking.
• Main effect of glue ear is reduced hearing. This can
often present as educational difficulties or altered
behaviour.
• Often referred to ENT/ audiology for hearing tests
and tympanograms.
Serous otitis media with retraction
Otitis media+effusion-Glue ear
Features
• Dull retracted TM
• May show air-fluid level
• Conductive hearing loss(whisper test, Rinne/weber tests)
Notes
• Common in children; often after AOM and can persist for
weeks
• Reduced hearing noticed by parents/teacher
• Unsteadiness- child falling over
• 80% clear at 8 weeks
Treatment for glue ear
• Individual to the child- how much are they affected,
in social situations and in education.
• NICE CG recommend hearing assessments at first
clinic and 3 months after.
• Allow time to resolve which occurs in about 90% of
cases and take simple measures to help.
• If persistent and other problems such as learning
difficulties or cleft palate, consider grommets and /
or adenoidectomy.
• Do not give antibiotics
What is this ?
Eustachian Tube Dysfunction
Okay, in all honesty, I didn’t expect
you to get the diagnosis here. In
fact, the patient would come in
complaining of his ears popping and
sometimes pain and together with
this picture, you should get the
diagnosis. But on the picture alone
= diagnosis is difficult.
Lesson = always use other
symptoms and signs to help you.
You should at least have been able
to spot that this is a severely
retracted eardrum. Margins are very
clear as is the malleus and it looks
very sunken.
I don’t know what the top bit is, but
who cares? That’s for an ENT boff to
work out.
Eustachian Tube Dysfunction
Features
• Retracted eardrum – you can see the “bones” clearly
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.
Eustachian Tube dysfunction
•
•
1.
2.
3.
Chronic blockage of the Eustachian tube is called Eustachian tube dysfunction. The
eustachian tube becomes congested and swollen so that it may temporarily close;
this prevents air flow behind the ear drum and causes ear pressure, pain or
popping just as you experience with altitude change when traveling on an airplane
or an elevator.
This can occur when the lining of the nose becomes irritated and inflamed,
narrowing the Eustachian tube opening or its passageway.
Illnesses like the common cold or influenza are often to blame.
Others: pollution, cigarette smoke, allergic rhinitis, obesity
Rarely nasal polyps, cleft palate, skull base tumour
ETD.
ETD & Children
•
•
•
Young children (especially ages 1 to 6 years) are at particular risk because they
have very narrow Eustachian tubes. Also, they may have adenoid enlargement that
can block the opening of the Eustachian tube. Since children in daycare are highly
prone to getting upper respiratory tract infections, they tend to get more ear
infections compared to children that are cared for at home.
Interestingly, the anatomy of the Eustachian tube in infants and young children is
different than in adults. It runs horizontally, rather than sloping downward from
the middle ear. Thus, bottle-feeding should be performed with the infants’ head
elevated, in order to reduce the risk of milk entering the middle ear space. The
horizontal course of the Eustachian tube also permits easy transfer of bacteria
from the nose to the middle ear space. This is another reason that children are so
prone to middle ear infections.
Most children older than 6 years have outgrown this problem and their frequency
of ear infections should drop substantially
What is this ?
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.
Safe vs Unsafe Perforations
• You need to be able to distinguish between safe and unsafe
perorations.
SAFE PERFORATIONS
• A safe perforation is exactly what it sounds like: a hole in the
tympanic membrane.
• The main risk of safe perforations are that they may allow
infection to enter the middle ear
• But there are rarely more serious sequelae.
Safe vs Unsafe Perforations
UNSAFE PERFORATIONS
• Unsafe perforations are not in fact holes in the drum, they
represent a retraction of the tympanic membrane.
• Essentially a part of the drum becomes sucked inwards and
may gradually enlarge.
• When the retraction becomes extensive, keratinous debris
builds up in the retraction and may become infected. This is
essentially how acquired cholesteatoma develops.
• Cholesteatoma is a dangerous lesion because it is capable of
eroding through bone and may cause serious and even life
threatening complications - hence the use of the term unsafe.
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
A note: Safe and Unsafe Discharge
UNSAFE
SAFE
Source
Cholesteatoma
Mucosa
Odour
Foul
Inoffensive
Amount
Usually scant, never
profuse
Can be profuse
Nature
Purulent
Mucopurulent
Use additional features that may be present to help you!
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
Safe anterior perforation
Is this safe or unsafe? You
decide?
It’s a safe perforation of the
anterior part of the drum. A
common cause of
perforations in this position
is a persistent defect after
the extrusion of a grommet.
You can tell it is a
perforation and not a
retraction pocket because
you can make out some of
the structures through it.
If you can’t tell whether it is anterior, posterior, inferior or in the attic, go back to slide 13
Safe inferior perforation
Is this safe or unsafe?
You decide?
Safe Inferior
perforation. This is
more likely to be as a
result of chronic middle
ear infection.
Unsafe posterior perforation
Is this safe or unsafe?
You decide?
Posterior perforation.
Although posterior
perforations may
represent more serious
disease such as
cholesteatoma, this is
well described and dry. It
is possible to make out
the posterior margin of
this defect. Traumatic
perforations (e.g
barotrauma) are often
posterior and linear,
like a tear rather than a
round hole.
There’s also some
tympanosclerosis in this
picture.
Unsafe attic perforation
Is this safe or unsafe?
You decide?
Miss this and you need
help!
Any defect or apparent
perforation in the attic
must be considered
unsafe and should be
referred for ENT
assessment. This crust
in the attic represents a
large underlying
cholesteatoma sac.
Note the bulging
eardrum too.
Marginal perforation plus
cholesteatoma formation
Is this safe or unsafe? You
decide?
Unsafe because it is a
perforation involving the drum
margin (the yellowy white
flakes indicating a
cholesteatoma also gives it
away!).
‘Monolayer’ (healed perforation)
How To Spot The Serious Eardrum
Features
• Recurrent ear discharge
• Perforation of the TM – central
• Presence of cholesteatoma
• Marginal, Attic perforation
• Offensive discharge, bleeding, granulations
Notes
• May have hearing loss
Now for some bits and bobs
to finish off
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.
Grommet on its way out
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.
Finally, if you can’t see Jack….
If you are unable to see the drum, clinical features pointing
towards serious middle ear disease include:
1.
2.
3.
4.
persistent offensive discharge
long history of middle ear disease
significant hearing loss
previous mastoid or middle ear surgery
Remember, I told you!
• 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.