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 (Ill
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!)

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 its unlikely youll
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 youll see
in the normal eardrum.

Malleus

Its a lie! You wont. 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, its
retracted. Okay, lets 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. Its simple really. More
later.

The Normal Eardrum

Now this is what youre
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 Ive outlined the
malleus.
Now do you see what I mean
when I say it looks like an
arm?
Even if you cant quite clearly
see the malleus, you can
usually make out the elbow bit
in the normal eardrum.

The malleus looks like an

arm
Heres 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.

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
AtAttic 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, its 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 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.

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.
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.

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.

Youve grasped the theory.
Now here is where you really
learn your stuff and not feel
unconfident again!
Try and work out the pictures

Acute Otitis Media

First describe what you see
using the method I outline
previously:
Eardrum shape
Eardrum colour
Light reflex
Anything that shouldnt be
there
You should have noticed
Bulging eardrum (cant see the
malleus well + margin isnt
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)

Serous Otitis Media

Dont forget, describe the
eardrum according to how I
taught you!
Eardrum shape bulging?
Because cant 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 dont
believe me).

In summary, what is a non red bulging eardrum with fluid?

Other abnormalities
presence of fluid levels and
bubbles

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

Eustachian Tube
Dysfunction

Okay, in all honesty, I didnt 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 dont know what the top bit is, but
who cares? Thats 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.

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.
2.
Others: pollution, cigarette smoke, allergic rhinitis, obesity
3.
Rarely nasal polyps, cleft palate, skull base tumour

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

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

Useadditionalfeaturesthatmaybepresenttohelpyou!

Remember what I said:

Unsafeperforations 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?
Its 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 cant 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) areoften
posteriorandlinear,
likeatearratherthan
aroundhole.
Theres 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 cant see

Jack.
If you are unable to see the drum, clinical features
pointing
towards serious middle ear disease include:
1. persistent offensive discharge
2. long history of middle ear disease
3. significant hearing loss
4. 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_tutor
ial.htm
which is an excellent resource worth looking at
in more detail.