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NB in textbooks and on this website, images of the ear are usually taken with an endoscope which has a wide angle lens on the end. Hold the otoscope at the end nearer the eyepiece, this way movement of your hand and arm is not translated into as much movement of the tip of the otoscope in the ear canal which may cause discomfort. Holding the otoscope at the end like this can lead to increased discomfort if you move your hand suddenly.
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. Larger deposits may obscure the view of the drum, but this does not necessarily imply that the wax is causing deafness. In swimmers, divers and surfers, chronic cold water exposure can lead to the growth of bony swellings in the canal known asexostoses. These black dots (spores) are the appearance of fungal infection (aspergillus niger) with other fungi the spores may be white or yellow. Foreign body in the canal of a child (wax crayon) note the drum visible distal to the foreign body.
As the drum retracts so does the handle of the malleus and it may appear to be shortened on otoscopy.
As the drum becomes increasingly retracted, it drapes over the ossicular chain, and the incus and stapes head may be outlined. Eventually, nearly all the middle ear space may be lost and the drum comes into contact with the medial wall of the middle ear (this is known as atelectasis).
Bulging ear drums are usually fairly obvious and a result of increased middle ear pressure.
The normal drum is quite translucent and does not really appear to be any colour except perhaps grey. If the white patch is behind the drum, this may represent cholesteatoma (keratin in the middle ear).
Unsafe perforations are not in fact holes in the drum, they represent a retraction of the tympanic membrane. Granulations like this are often associated with underlying disease, particularly if they arise in the attic. Realistically speaking, in primary care consultation it may not be possible to make out much of the anatomy of the drum in cholesteatoma as the ear is filled with infected discharge.

This grommet is in the correct position but is covered in infective granulation and blocked up. This gives us an image which contains the whole tympanic membrane and much of the ear canal. Run down batteries and dim lights will make you job even more difficult and will sometimes alter your perception of the image you see.If you are handed an otoscope with worn out batteries, insist that they are replaced. The canal may be partly straightened by pulling the pinna backwards and upwards during examination.
It’s presence there may indicate inappropriate use of cotton buds to clean the ears of it may be a dried up crust, overlying more significant pathology such as a perforation or cholesteatoma. These are generally asymptomatic when small, but when larger can interfere with the drainage of wax and predispose to infections such as otitis externa.
There is no substitute for looking at as many drums as you can to give you an idea of what is normal and what is abnormal. Abnormalities of shape are important, the drum may be bulging our, suggesting increased middle ear pressure, such as in acute otitis media, or retracted inwards with negative middle ear pressure, which is one of the otoscopic findings in glue ear. The most likely cause of this is acute otitis media when the drum will not only bulge outwards, but is usually very red because of hyperaemia and infection.
The colour of the drum can be changed by thickening of the drum itself, injection of blood vessels, or the presence of something behind it such as glue, pus or blood. Note also how retracted this drum is and how prominent the lateral process of the malleus appears.
White patches actually on the drum or within the drum itself are usually tympanosclerosis, which is deposition of calcium into the drum itself in response to trauma or infection.
More localised areas of discoloration can represent infection or vascular abnormalities behind the drum.This small red lesion at the tip of the malleus handle is a vascular lesion called a glomus tumour. Granulations are a localised infective process and may be a sign of more serious underlying disease such as cholesteatoma. A common cause of perforations in this position is a persistent defect after the extrusion of a grommet. Although posterior perforations may represent more serious disease such as cholesteatoma, this is well described and dry. In this image, not only is the posterior margin of the drum not visible (you can imagine a retraction disappearing behind the posterior margin to the right of the picture) but there are granulations and crusting in the attic.

These are not commonly used as they lead to a greater risk of perforation after removal, but in selected cases are preferable to repeated insertions of standard pattern tubes. When using an otoscope, you will NEVER get a view as good as this, not because it is your fault, but because of the optics of most endoscopes. Most modern hand held otoscope have a very bright bulb that is more than adequate for the job.se the biggest earpiece that you can fit in to the ear canal. In infants pull the pinna more horizontally backwards as the shape of the ear canal is different. Unfortunately I have found good images of acute otitis media hard to come by because the patients are usually very young and not over disposed to sit still to have pictures taken!
Blood in the middle ear will give the ear a blue or brown colour, this is called ahaemotympanum. This represents a resolving middle ear effusion, as air gradually re-enters the middle ear.
This is not normally of any consequence unless it is severe, which can lead to a mild conductive hearing loss. The main risk of safe perforations are that they may allow infection to enter the middle ear but there are rarely more serious sequelae.
When the retraction becomes extensive, keratinous debris builds up in the retraction and may become infected. Note a small dried crust above the grommet which is unimportant and may be a small clot remaining from surgery. Small earpieces may be easy to use but the amount of visual information you get is very limited.
In addition, the angle of the drum may appear different in small children, with the top of the drum appearing more lateral than the inferior part.
Traumatic perforations (eg barotrauma) are often posterior and liner, like a tear rather than a round hole.
To see all aspects of the drum you will need to change position and move the tip of the otoscope.

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