What is the name of the instrument used to examine the external ear canal in tympanic membrane?

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves

Approach the examination in a systematic way, starting from the outer parts of the ear before moving to the inner parts of the ear; be prepared to be instructed to move on quickly to certain sections by any examiner.

Pinna and Post Auricular Area

Inspect the pinna and the mastoid:

• Obvious deformities or abnormal cartilaginous fragments
• Scars or skin changes
  • Including for skin malignancies
• Signs of inflammation
  • An inflamed mastoid may push the pinna forward

Palpate the lymph nodes and pinna, specifically:

• Pre- and post-auricular lymph nodes
• Tragus
  • Tragal tenderness is a sign of otitis externa

Figure 1 – A basal cell carcinoma located on the posterior aspect of the outer ear

External Ear Canal

Inspect the outer aspect of the external ear canal using the otoscope as a light source

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

Look for signs of:

• Wax or a foreign body
• Skin changes or erythema
• Discharge

Tympanic Membrane

Hold the otoscope like a pen between thumb and index finger, left hand for left ear and right hand for right ear, resting your little finger on the patient’s cheek – this acts as a pivot.

Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly

For a normal tympanic membrane, you should be able to observe*:

• Lateral process of malleus
• Cone of light
• Pars tensa and pars flaccida

*The cone of light can be used to orientate; it is located in the 5 o’clock position when viewing a normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic membrane.

Adapted from work by Michael Hawke MD [CC BY 4.0], via Wikimedia Commons

Figure 2 – A normal right tympanic membrane

For an abnormal tympanic membrane, common signs may include:

• Perforations
• Tympanosclerosis
• Red and bulging membrane
• Retraction of the membrane

Ensure to check the function of the facial nerve

By Michael Hawke MD / CC BY (https://creativecommons.org/licenses/by/4.0)

Figure 3 – A traumatic perforation of the left tympanic membrane

Assessment of Hearing

Rinne Test

Strike the tuning fork (512Hz) against your elbow and place against the mastoid process (bone conduction), then once patient stops hearing it, hold it near the external ear canal (air conduction)

• For normal hearing or sensorineural hearing loss, air conduction is heard better than bone conduction (Rinne positive)
• For conductive hearing loss, bone conduction is heard better than air conduction (Rinne negative)

Weber Test

Strike the tuning fork (512Hz) against your elbow and place on the patient’s forehead in the midline. Ask the patient whether the sound is heard in the midline or has lateralised

• For normal hearing, the sound is heard in the midline
• For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing deficit
• For sensorineural hearing loss, the sound is loudest on the contralateral side to the hearing deficit

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this.

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Tympanogram
• Pure tone audiometry

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Chole RA, Sharon JD. Chronic otitis media, mastoiditis, and petrositis. In: Flint PW, Francis HW, Haughey BH, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Philadelphia, PA: Elsevier; 2021:chap 140.

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• What Does It Do?
• Center

An otoscope

An otoscope is an instrument used for examining the eardrum (tympanic membrane) and ear canal. The instrument has a light source and magnifying system at one end that help better examine the ear structures. The examination of the ear using an otoscope is called otoscopy. Besides examining the ear, the otoscope can also be used for examining the inside of the nose. The first description of otoscopes dates back to the 14th century when the French physician and surgeon Guy de Chauliac proposed a tool that could help diagnose patients reporting ear or nose pain. Modern otoscopes started appearing in the 19th century. An otoscope using air pressure, called a pneumatic otoscope, was invented in Germany in 1864.

Otoscopy may be done as a part of routine medical examination or when you have symptoms such as:

Modern-day otoscopes are lighter and sleeker than their predecessors. An otoscope consists of two main parts: a head and handle. It helps examine the external auditory canal (EAC), tympanic membrane (eardrum), and middle ear. The ear is divided into the inner, middle, and external ear. The external ear has a passage called the external auditory canal, which is separated from the middle ear by the eardrum. The otoscope also has magnifying lens that enhances the clinician’s view. The head of the otoscope may be of either of the two types:

1. Diagnostic head: As the name suggests, a diagnostic head is fixed to the otoscope and is used for examining the ear. It does not allow the use of micro-instruments through the scope.
2. Working (or operating) head: This head carries a magnifying lens that can slide to the side. It enables the passage of micro-instruments through the speculum into the EAC and middle ear for performing procedures such as foreign body or wax removal.

An attachment for applying air pressure called the pneumatic attachment can be connected to the diagnostic head. It allows the assessment of tympanic membrane motion by generating positive pressure in the external auditory canal. The increase in pressure deflects the eardrum inward (medially). On releasing the pressure, the eardrum expands outward (laterally). Pneumatic otoscopy is important for diagnosing fluid certain conditions such as:

• Middle ear effusions (collection of fluid in the middle ear)
• Vascular lesions
• Inner ear fistulas (abnormal connection between the inner ear and middle ear)

You do not need to do any special preparation for an otoscopy. During the procedure:

• The provider may dim the lights in the room.
• A young child is generally asked to lie on their back with their head turned to the side. Alternatively, the child's head may rest against an adult's chest.
• Adults and older children may sit with their heads tilted toward the shoulder opposite the ear being examined.
• The provider will gently pull the pinna or auricle upward and backward (just backward in case of a child) to straighten the ear canal and visualizing the eardrum.
• They may remove any debris or ear wax to allow an adequate examination.
• They will then gently place the tip of the otoscope into your ear.
• A light beam then shines through the otoscope into the ear canal.
• The scope is gently moved in different directions to examine the inside of the ear and eardrum.
• A binocular microscope may sometimes be used to get a magnified view of the structures in the ear.
• Air pressure may be applied through the bulb of the pneumatic attachment to see the movement of the eardrum.

Otoscopy is generally a painless procedure. There may be pain when there is an infection or inflammation. If you have any discomfort during the examination, you must inform your doctor.

Medically Reviewed on 3/9/2021

References

https://medlineplus.gov/ency/imagepages/8771.htm#:~:text=An%20otoscope%20is%20a%20tool,feeling%20full%2C%20or%20hearing%20loss. https://emedicine.medscape.com/article/994550-workup#c9