Examination of the

Fig. 1.4 Retracting the pinna. The meatus is S-shaped. To see the drum more clearly, therefore, the pinna is retracted backwards and outwards. The index finger may be used to hold the tragus forward. If this step of straightening the meatus accentuates the pain in someone presenting with an earache, one can be virtually certain that the diagnosis is either a furuncle or furunculosis (see Fig. 2.43).

Furunculosis Due Skin Lymphomas
Fig. 1.5 Head mirror and speculum. These are used for the initial examination of the meatus and drum.
Ear Furunculosis
Fig. 1.6 The auriscope. This is best held like a pen. In this way, the examiner's little finger can rest on the patient's cheek; if the patient's head moves, the position of the ear speculum is maintained in the meatus.
Pinna Furuncle

Fig. 1.7a Preferred way to hold the auriscope. When the left ear is examined, the auriscope is held in the left hand and vice versa. b Incorrect way to hold the auriscope.

Fig. 1.7a Preferred way to hold the auriscope. When the left ear is examined, the auriscope is held in the left hand and vice versa. b Incorrect way to hold the auriscope.

Fig. 1.8 Pneumatic otoscope. A handheld air-filled bulb attached to the auriscope enables air to be gently inflated against the drum to demonstrate drum mobility.

Reduced mobility is conspicuous and is evidence of middle ear fluid. Reduced mobility is also seen, however, with tympanosclerosis, which increases the rigidity of the drum. Malleus fixation is a rare cause of reduced mobility of a drum of normal appearance.

The fistula test may be done with the pneumatic otoscope. Pressure change by pressing on the bulb will cause dizziness in those with erosion of the labyrinth by cholesteatoma (see Fig. 2.63) or with a perilymph fistula.

Perilymph Fistula

Fig. 1.9 A normal drum. The main landmarks seen on the pars tensa of a normal drum are the lateral process

(top arrow) and handle (middle arrow) of the malleus, and the light reflex

(lower arrow). The drum superior to the short process is the pars flaccida or attic part of the drum. A normal drum is grey and varies in vascularity and translucency.

Fig. 1.9 A normal drum. The main landmarks seen on the pars tensa of a normal drum are the lateral process

(top arrow) and handle (middle arrow) of the malleus, and the light reflex

(lower arrow). The drum superior to the short process is the pars flaccida or attic part of the drum. A normal drum is grey and varies in vascularity and translucency.

Indrawing Handle Malleus

Fig. 1.11 A more vascular drum. This has vessels extending down the handles of the malleus to the umbo (arrow). These vessels may also be more conspicuous following mild barotrauma to the ear, e.g., rapid descent in an airplane in which delayed eustachian tube opening causes pain. More severe trauma leads to hemorrhage into the drum or perforation.

Fig. 1.11 A more vascular drum. This has vessels extending down the handles of the malleus to the umbo (arrow). These vessels may also be more conspicuous following mild barotrauma to the ear, e.g., rapid descent in an airplane in which delayed eustachian tube opening causes pain. More severe trauma leads to hemorrhage into the drum or perforation.

Fig. 1.12 The incus (lower arrow) may show as a shadow through a thin drum, as may the round window and opening of the eustachian tube, although this is less common. The chorda tympani nerve may also be seen through the drum (top arrow).

< Fig. 1.10 A tympanic membrane showing the panoramic view obtained with a fiberoptic endoscope. Fiberoptic auriscopes are not in common use and the conventional auriscope is widely used. For this reason most drums are shown as they are seen with an auriscope. It is interesting to compare the appearance of a normal drum with the auriscope and the appearance with a fiberoptic. A thin posterior scar indrawn onto the stapes is clearly seen (arrow) and would not be so apparent with most conventional aurescopes.

For the most clear view of the eardrum, and for fine use of instruments, the microscope (Fig. 1.14) is used.

Indrawn Eardrum

Fig. 1.13 The chorda tympani nerve is the nerve of taste to the anterior two thirds of the tongue (excluding the cir-cumvallate papillae), and is also the secretomotor nerve to the submandibular and sublingual salivary glands. The chorda tympani nerve usually lies behind the pars flaccida. It is not normally visible, but if the nerve is more inferior, it shows through the drum (arrow).

Fig. 1.13 The chorda tympani nerve is the nerve of taste to the anterior two thirds of the tongue (excluding the cir-cumvallate papillae), and is also the secretomotor nerve to the submandibular and sublingual salivary glands. The chorda tympani nerve usually lies behind the pars flaccida. It is not normally visible, but if the nerve is more inferior, it shows through the drum (arrow).

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