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 (I’ll 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 it’s unlikely you’ll see anything else.

6. Almost too good to be true (but good for illustration) Books will show you a picture like this claiming this is what you’ll see in the normal eardrum. It’s a lie! You won’t. 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, it’s retracted. Okay, let’s 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. It’s simple really. More later….

8. The Normal Eardrum Now this is what you’re 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

9. 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 I’ve outlined the malleus. Now do you see what I mean when I say it looks like an arm? Even if you can’t quite clearly see the malleus, you can usually make out the elbow bit in the normal eardrum.

10. The malleus looks like an arm Here’s 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. Umumbo - 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 Hmhandle 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, it’s 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 you’re 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.

14. 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

15. 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. I’m showing you this lesion because you need to look out for it. It’s 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, you’re 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.

18. 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

19. Now onto the pictures. You’ve 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.

20. Acute Otitis Media • First describe what you see using the method I outline previously: • Eardrum shape • Eardrum colour • Light reflex • Anything that shouldn’t be there • You should have noticed • Bulging eardrum (can’t see the malleus well + margin isn’t 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 Don’t forget, describe the eardrum according to how I taught you! Eardrum shape– bulging? Because can’t 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 don’t 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

24. Otitis media+effusion-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

25. Eustachian Tube Dysfunction Okay, in all honesty, I didn’t 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 don’t know what the top bit is, but who cares? That’s for an ENT boff to work out.

26. 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

28. 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.

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

34. 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.

35. 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.

36. 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

37. 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

39. Safe anterior perforation Is this safe or unsafe? You decide? It’s 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 can’t 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. There’s 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)

45. 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

46. Now for some bits and bobs to finish off

47. 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.