When examining the ear with an otoscope What is the normal appearance of the tympanic membrane?

An ear exam is performed when a health care provider looks inside your ear using an instrument called an otoscope.

Alternative Names

Otoscopy

How the Test is Performed

The provider may dim the lights in the room.

A young child will be asked to lie on their back with the head turned to the side, or the child's head may rest against an adult's chest.

Older children and adults may sit with the head tilted toward the shoulder opposite the ear being examined.

The provider will gently pull up, back, or forward on the ear to straighten the ear canal. Then, the tip of the otoscope will be placed gently into your ear. A light beam shines through the otoscope into the ear canal. The provider will carefully move the scope in different directions to see the inside of the ear and eardrum. Sometimes, this view may be blocked by earwax. An ear specialist may use a binocular microscope to get a magnified look at the ear.

The otoscope may have a plastic bulb on it, which delivers a tiny puff of air into the outer ear canal when pressed. This is done to see how the eardrum moves. Decreased movement can mean that there is fluid in the middle ear.

How to Prepare for the Test

No preparation is needed for this test.

How the Test will Feel

If there is an ear infection, there may be some discomfort or pain. The provider will stop the test if the pain worsens.

Why the Test is Performed

An ear exam may be done if you have an earache, ear infection, hearing loss, or other ear symptoms.

Examining the ear also helps the provider see if treatment for an ear problem is working.

Normal Results

The ear canal differs in size, shape, and color from person to person. Normally, the canal is skin-colored and has small hairs. Yellowish-brown earwax may be present. The eardrum is a light-gray color or a shiny pearly-white. Light should reflect off the eardrum surface.

What Abnormal Results Mean

Ear infections are a common problem, especially with small children. A dull or absent light reflex from the eardrum may be a sign of a middle ear infection or fluid. The eardrum may be red and bulging if there is an infection. Amber liquid or bubbles behind the eardrum are often seen if fluid collects in the middle ear.

Abnormal results may also be due to an external ear infection. You might feel pain when the outer ear is pulled or wiggled. The ear canal may be red, tender, swollen, or filled with yellowish-green pus.

The test may also be done for the following conditions:

• Cholesteatoma
• External ear infection - chronic
• Head injury
• Ruptured or perforated eardrum

Risks

An infection can be spread from one ear to the other if the instrument used to look inside the ear has not been cleaned well.

Considerations

Not all ear problems can be detected by looking through an otoscope. Other ear and hearing tests may be needed.

Otoscopes sold for at-home use are lower quality than the ones used at the provider's office. Parents may not be able to recognize some of the subtle signs of an ear problem. See a provider if there are symptoms of:

• Severe ear pain
• Hearing loss
• Dizziness
• Fever
• Ringing in the ears
• Ear discharge or bleeding

References

King EF, Couch ME. History, physical examination, and the preoperative evaluation. In: Flint PW, Haughey BH, Lund V, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 4.

Murr AH. Approach to the patient with nose, sinus, and ear disorders. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 426.

Review Date: 02/27/2019

Otoscopy is a clinical procedure used to examine structures of the ear, particularly the external auditory canal, tympanic membrane, and middle ear. Clinicians use the process during routine wellness physical exams and the evaluation of specific ear complaints.[1] During the otoscopic examination, the provider utilizes an otoscope, also known as an auriscope, to visualize the ear anatomy. While performing the otoscopic examination, the provider holds the handle of the otoscope and inserts the cone of the otoscope into the patient’s external auditory canal. The otoscope contains a light and magnifying lens to illuminate and enlarge ear structures to help the provider accurately visualize and evaluate the health of the visible anatomical structures.

Otoscopy is routinely performed during wellness check-ups and in evaluating specific ear complaints by both specialists, such as ear, nose, and throat physicians (ENTs) and primary care providers.[1] Otoscopy plays a significant role in diagnosing several ear conditions and is a key step for the diagnosis of some conditions such as acute otitis media.[1][2][3] As such, familiarity with otoscopy and the conditions for which otoscopic examination aids in diagnosis is important for health care providers in a variety of fields.

Examination of the tympanic membrane and middle ear by otoscopic examination can help providers diagnose a wide variety of conditions, including acute otitis media, traumatic perforation of the tympanic membrane, and cholesteatoma. Delayed diagnosis of various pathologies of the ear can facilitate progression to more serious conditions, highlighting the importance of otoscopy. For example, untreated acute otitis media can advance to feared complications such as mastoiditis, brain abscesses, or meningitis.[1][4][5][6][7]

Before beginning the otoscopic examination, the provider can ask the patient to demonstrate the strength of their facial muscles by smiling, frowning, elevating the eyebrows, closing the eyes and keeping the eyes closed against resistance, and puffing out the cheeks. Successful completion of these movements demonstrates the integrity of cranial nerve VII, the facial nerve. The facial nerve travels through the middle ear and can be affected by ear pathologies such as acute otitis media.[8] Following the evaluation of the facial nerve, the provider can visually examine the health of the external ear, the pinna, noting signs such as wounds, scars, and inflammation.

Next, the provider can begin the otoscopic exam. There are often multiple speculum sizes for attachment to the otoscope. The provider should select the largest speculum that the patient’s external auditory canal can accommodate, as this will provide maximum lighting for optimal visualization of the ear anatomy. Providers may have their own preferences regarding how to grasp the otoscope. However, it is generally advisable to hold the otoscope like a pen in between the first and second fingers. The otoscope is usually held in the right hand when evaluating the patient’s right ear and the left hand when assessing the patient’s left ear. The provider should place their free fifth finger of the hand, holding the otoscope against the patient’s cheek to support and brace the hand during the examination.

With the hand that is not holding the otoscope, the provider should grasp and gently pull the patient’s pinna to help straighten the patient’s external auditory canal. This step will facilitate visualization of the tympanic membrane. In a child, the examiner should pull the pinna posteriorly and inferiorly. In an adult, the examiner should pull the pinna posteriorly and superiorly. Next, the provider can gently insert the speculum into the patient’s external auditory canal. The provider should inspect the health of the external auditory canal and evaluate factors such as the presence of inflammation, discharge, cerumen, and infection.

The provider should then slowly progress the speculum into the canal until the tympanic membrane becomes visible. The provider should evaluate the health of the tympanic membrane and observe factors such as color, presence of perforation, and a bulging appearance.[9] The provider should also observe tympanic membrane landmarks, including the pars flaccida on the superior aspect of the tympanic membrane, the pars tensa on the posterior aspect, the light reflex on the inferior and anterior aspect, and the handle of the malleus on the anterior aspect. Observation of tympanic membrane landmarks can help the provider evaluate the health of the middle ear. Following the inspection of the tympanic membrane, the provider can slowly remove the otoscope from the patient’s auditory canal. While removing the otoscope, the provider can continue to observe the auditory canal for evaluation of its health.

Otoscopic examination is an important part of the diagnosis of several pathologies of the ear. There are multiple factors; however, that can make successful otoscopic examination difficult. For example, factors such as poor lighting of the ear canal, suboptimal positioning of the otoscope, cerumen blockage, insufficient training in otoscopic technique, and lack of confidence in performing the otoscopic examination can hinder the successful completion of the procedure.[1][10] Such factors can subsequently lead to ineffective care, as the belief is that approximately 75% of the tympanic membrane must be visualized by otoscopy for a reliable diagnosis.[1]

To alleviate some of these difficulties in performing a successful otoscopic examination, video-otoscopes have been introduced in recent years and studied for their efficacy in diagnosing ear conditions. Video otoscopes allow the provider to introduce a small camera into the patient’s external auditory canal to visualize the tympanic membrane. Research into the effectiveness of video-otoscopy suggests that this technique may be superior compared to conventional otoscopy in assessing pathological conditions of the tympanic membrane.[1]

Another development in otoscopy involves telemedical otoscopic examination. Telemedicine, which refers to the remote care of patients by using telecommunication technologies, is becoming increasingly prominent in various fields of medicine. Several brands of video-otoscopes exist to remotely convey images of the tympanic membrane to providers for telemedical evaluation. These systems often function as smartphone attachments that allow for capturing and transmitting a patient’s otoscopic images to a provider remotely. Current research suggests that the quality of otoscopic images obtained for telemedicine seems to vary based on the video-otoscope system used.[11] Further, the appropriateness of the telemedical evaluation of the tympanic membrane also varies based on the specific condition of the tympanic membrane. For example, telemedical evaluation currently appears to be more accurate in evaluating a healthy tympanic membrane or cases of ear canal exostoses than in evaluating a perforated tympanic membrane.[11] As such, it seems there is potential for telemedical evaluation of ear conditions via video-based otoscopy; however, the appropriateness of this method of evaluation may depend on the specific clinical scenario.

Otoscopy is a routine exam performed by many health practitioners for both screening purposes and evaluating specific ear complaints. Given the frequent use of otoscopes, they represent a potential source for the spread of infection. Research suggests that over 40% of otoscopes may become contaminated with potentially pathogenic microbial organisms such as pseudomonas, staphylococcus, aspergillus, and candida species.[12] As such, otoscopes require regular cleaning. The cleaning and maintenance of equipment used in the otoscopic exam is an important task that can be performed by various members of the health care team. Otoscope heads can be disinfected by cleaning with a cloth dampened by aldehydes, surfactants, or alcohols.[12] Clinicians can consult the otoscope manufacturer instructions for more specific cleaning protocols. Such a practice can contribute to decreasing nosocomial infections.