The Eardrum Made Simple

1
The Eardrum Made Simple

• Dr. Ramesh Mehay
• Programme Director, Bradford VTS

2
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

3
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.

4
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!)

5
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.
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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. 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.
Malleus
7
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.

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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
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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.
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The malleus looks like an arm
Heres the picture again just to make sure you
can make out the arm.
11
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
6
12
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
13
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.
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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
• Perforations
• Bubbles (glue ear, resolving infection)
• White patches (tympanosclerosis or cholesteatoma)
• Granulations
• Red lesion at tip of malleus (glomus tumour)
• Grommets/FBs

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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
16
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.
17
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.
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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

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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 for yourself first.

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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?

21
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)

22
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). Other abnormalities presence of fluid
levels and bubbles
In summary, what is a non red bulging eardrum
with fluid?
23
Serous otitis media with retraction
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Otitis mediaeffusion-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

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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.
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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.

27
Eustachian Tube dysfunction

• 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

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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

29
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
30
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.

31
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.

32
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.

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Perforation the next set of slides are dead
important. So pay attention.
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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.

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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.

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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)
• Any defect or apparent perforation in the attic
  must be considered unsafe (?cholesteatoma)
• A posterior perforation where the posterior
  margin of the drum is also unsafe. This are
  often linear rather than oval.
• Any perforation involving the drum margin is also
  unsafe

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A note Safe and Unsafe Discharge
Use additional features that may be present to
help you!
38

• Remember what I said
• Unsafe perforations are
• In the attic or
• In the posterior region
• Or involve the eardrum margin
• Anything else is generally safe.
• i.e.
• In the anterior region or
• In the inferior region
• AND NOT INVOLVING THE EARDRUM MARGIN

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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
40
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.
41
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. Theres also
some tympanosclerosis in this picture.
42
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.
43
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!).
44
Monolayer (healed perforation)
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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

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Now for some bits and bobs

• to finish off

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Granulations
Granulations like this are often associated with
underlying disease, particularly if they arise in
the attic.
48
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.

49
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
50
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.
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Finally, if you cant see Jack.

• If you are unable to see the drum, clinical
  features pointing
• towards serious middle ear disease include
• persistent offensive discharge
• long history of middle ear disease
• significant hearing loss
• previous mastoid or middle ear surgery
• Remember, I told you!

52

• Most of this presentation is taken from
  http//www.bristol.ac.uk/Depts/ENT/otoscopy_tutori
  al.htm which is an excellent resource worth
  looking at in more detail.