THE WORLD OF EAR THE WORLD OF EAR DRUMDRUM

Mild retraction may be difficult to identify. The margin of the drum (annulus may become more pronounced as in this image

Larger deposits may obscure the view of the drum, but this does not necessarily imply that the wax is causing deafness. The canal

needs to be almost completely obstructed to case hearing loss.

As the drum retracts so does the handle of the malleus and it may As the drum retracts so does the handle of the malleus and it may appear to be shortened on otoscopy. The lateral process will also appear to be shortened on otoscopy. The lateral process will also

become much more prominent than normalbecome 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

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)

Compare this drum with the normal one. It is opaque and pale. There is slight injection of blood vessels. This is one

appearance of glue ear

This red raised lesion on the posterior aspect of the drum is likely to be a granulation. Granulations are a localised infective process and may be a sign of more serious underlying disease such as

cholesteatoma.

You need to be able to distinguish between safe and unsafe perorations. 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.

Inferior perforation. This is more likely to be as a result of chronic middle ear infection.

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 liner, like a tear rather than a round hole.

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.

A posterior perforation where the posterior margin of the drum is also potentially unsafe. 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

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. An ear looking like this will need to be referred for ENT clinic and aural toilet and microscopy.

This is a T-tube which is a permanent sort of grommet designed not to extrude on it's own. 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.

Grommet – tympanostomy tube. Grommets can be inserted in the tympanic membrane if medical treatment and myringotomy are

unsuccessful and the child has persistent middle ear effusion. The illustration is a silicone tube retained in an opening in the drum by

inner and outer flanges.

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.

Just because you can see a grommet in the ear does not mean it is working. This one is clearly extruding and on it's way out up the canal. Note the drum visible in the distance.

Traumatic perforation, AS, posterior inferior quadrant. F., blow to face from husband

Subtotal perforation of the tympanic membrane, AD

Glue ear (1), AS [adhesive otitis media]

Glue ear (2), AD [adhesive otitis media]

KOLESTEATOMA

Otitis media, acute,(1) AD

Otitis media, acute (2), AD

otitis media acute, in regression (1), AS

otitis media acute, in regression (2), AS

otitis media, secretory (1), AD

otitis media, secretory (2), AS

otitis media, secretory (3), AD

insect (ant) in external auditory meatus, AD

Serous otitis media. There is indrawing of a dull ear drum and the handle of the malleus is characteristically horizontal. Eustachian tube obstruction had led to failure of replacement of air which is normally absorbed from

the middle ear resulting in vacuum formation and effusion of fluid

Resolution of middle ear effusion. The handle of the malleus is still foreshortened and the horizontal. Signs in the upper

half of the ear drum suggest that fluid is still present in the middle ear.

Central perforation of the ear drum. Perforations are usually single but may be multiple. Spontaneous rupture of the drum can occur

in association with acute infection when the tense drum perforates and releases pus. The ear drum illustrated has a long standing

perforation accompanied by tympanosclerosis of the drum.

Tympanosclerosis. In some cases of otitis media healing may not be completed and the inflammatory process leads to

the formation of scar tissue. This can take the form of calcified plaques on the tympanic membrane.

Fluid behind the ear drum in an asymptomatic child. Effusion is visible with a fluid level in the lower half of the ear drum. The handle of the malleus is also difficult to visualise.

Appearance of serous (secretory) otitis media. The ear drum has lost its lustre and an effusion is visible through the ear

drum with a fluid meniscus defining the upper margin.

Acute otitis media with no recognisable landmarks. There is considerable bulging of the ear drum with purulent fluid behind a tense tympanic membrane which sometimes heralds perforation.

In some cases incision of the drum is require

Acute middle ear infection with effusion. The handle of the malleus is obscured, and fluid levels are obvious behind the

drum.

Acute otitis media with effusion. There is distortion of the drum, prominent blood vessels in the upper half, with dullness of the

lower half. There is also bulging of the upper half of the drum and the outline of the malleus is obscured.

Wax, or cerumen, is a normal secretion in the cerumenous glands in the outer part of the meatus, and can obscure or partially obscure the drum.  When it is first produced it is colourless and semi-liquid in consistency, but with time it changes from pale yellow,

to golden yellow, to light brown and finally black.  As the wax darkens it also hardens,  and the darker the colour the denser the consistency.