PNEUMATIC OTOSCOPY

Definition:

Pneumatic otoscopy is a diagnostic technique used to assess the landmarks, mobility,

transparency, color and vascularity, and position of the tympanic membrane as well as the
presence of pathologic middle ear abnormalities.

The pneumatic otoscope: This photograph shows two views of a pneumatic otoscope
head which are separated by a size oo metal ear curette. The otoscope head attaches to
handle containing a power source. The otoscope head consists of a plastic ear speculum, a
unit which contains a light bulb and fiberoptic illumination system, a retractable
magnification lens, and a smaller operating lens. A rubber bulb is attached to the head of
the otoscope with a piece of plastic tubing.

The otoscope head is a closed air system except for the opening of the ear speculum
which is inserted in the ear canal. In order to assess tympanic membrane mobility, the tip
of the ear speculum must make an adequate seal with the ear canal. Failure to make an
adequate seal is the most common reason that clinicians have difficulty in accurately
determining membrane mobility. Attaching a small piece of rubber tubing snugly around
the ear speculum as shown in the picture will help to achieve a good seal while
minimizing the child's discomfort.

Visualization of tympanic membrane landmarks:

The first step in becoming a skilled otoscopist is learning to recognize the tympanic
membrane landmarks. This schematic diagram of a left tympanic membrane shows how
the membrane can be divided into four quadrants by a line drawn through the long
process of the malleus and its perpendicular line through the center of the umbo.
Views

External View Internal View

The photographs show two views of the middle ear; one external view as seen with an
otoscope and another internal view as seen with an endoscope passed through the
Eustachian tube. The landmarks include the light reflex (1), the umbo of the malleus (2),
long process of the malleus (3), lateral process of the malleus (4), and the incus (5). The
malleus and incus as well as the stapes (8) are ossicles or small bones which play an
important role in conducting sound across the middle ear space. A branch of the facial
nerve called the chorda tympani (9) runs adjacent to the incus. The tympanic membrane
above the short process of the malleus is called the pars flacida (6) while the remainder of
the membrane is called the pars tensa (7).

Light Reflex
The cone light reflex is often the easiest landmark to visualize. Locating it orients you to
the other tympanic membrane landmarks. Note that the cone light reflex appears as a
cone in the anterior inferior quadrant of the tympanic membrane. The broad base of the
light reflex points anteriorly while the narrower section of the cone points to the end of
the malleus named the umbo.
 External View Schematic View

After locating the cone light reflex, follow the narrow end of the cone light reflex to the
umbo and then visualize the malleus. Follow the long process of the malleus superiorly
where it forms the short or lateral process in the anterior superior quadrant.

Incus
After viewing the lateral process of the malleus, look at the area in the posterior superior
quadrant just posterior to the short process and malleus. When the membrane is
translucent you often can see a small whitish bone called the incus.

It is important to get a good view of

this area because this is the location where most retraction pockets and cholesteatomas
develop. Next look at the entire membrane to identify tympanosclerosis or a perforation.

Color
Tympanic Membrane Appearance: Transparency, Color and Vascularity

Look to see if light diffuses through the membrane so that the bony landmarks are clearly
visible. The membrane is transparent when light passes through the membrane as shown
in the image above. When some light passes through the membrane is translucent. The
membrane is opaque when light does not pass through the membrane so that the bony
landmarks can not be clearly seen. (as shown below)

The color of the tympanic membrane can be considered red, amber, or yellow. The
membrane may also appear colorless in the absence of inflammation. The tympanic
membrane shown above, is both a yellow and red color. Increased vascularity present on
the tympanic membrane can produce injection. This is often most prominent on the
malleus. (as shown below) Increased vascularity may result when a child cries, or from
irritation associated with removing cerumen from the ear canal. It is a common reason for
overdiagnosing Acute Otitis Media.
Bulging
Tympanic Membrane Position:

The tympanic membrane can appear to be bulging outward, retracted, or in its normal
location.

Bulging:

When the middle ear space contains a large amount of fluid, the membrane is forced
outward. Note that the membrane seems to bulge around the umbo creating a donut like
appearance. The bulging often impairs the visibility of the bony landmarks.

Retraction:

The key to recognizing retraction of the tympanic membrane is the position of the lateral
process of the malleus and foreshortening of the long process of the malleus. Note in the
left diagram that the lateral process is very prominent and that the long process appears
rotated upward. The lateral process is usually oriented in the direction that corresponds to
about 8 o'clock in a circular watch dial. When negative pressure in the middle ear space
retracts the tympanic membrane the lateral process may be pulled superiorly so that the
orientation of the lateral process becomes shifted towards 9 or 10 o'clock. When the
membrane is more severely retracted the short process becomes very prominent. Another
sign of negative pressure in the middle ear space and retraction of the membrane is the
loss of space between the lateral process and the pars flacida (see green arrow on right
diagram). The lateral process appears to almost touch the pars tensa.
Retraction with Negative Middle Ear Pressure
Normal Middle Ear Pressure

Tympanic Membrane Mobility:

The best way to determine the presence of middle ear fluid is by assessing membrane
mobility. Squeezing the rubber bulb introduces air into the pneumatic otoscope system
and creates a positive pressure on the outside surface of the tympanic membrane. The
positive pressure normally displaces the tympanic membrane inward. When the rubber
bulb is released air is sucked out of the ear canal creating a negative pressure outside the
tympanic membrane. This negative pressure displaces the tympanic membrane outward.
Thus alternating squeezing and releasing of the rubber bulb will cause the tympanic
membrane to move briskly if no fluid is present.

Normal Mobility

The diagram and video shown below demonstrate brisk movement equally in both
directions associated with normal mobility.

Decreased Mobility

When fluid is present in the middle ear space the mobility will be diminished or absent. It
is important to remember that excessive pressure produced by the rubber bulb may result
in some mobility of the tympanic membrane even in the presence of middle ear fluid. The
diagram and video shown below demonstrate this concept.

Increased Mobility with Negative Pressure

When the tympanic membrane is retracted with negative middle ear pressure, the
movement is greater when the bulb is released than when it is compressed. Therefore
mobility is increased with negative pressure compared to positive pressure. The diagram
and video shown below demonstrate this concept.

Middle Ear Conditions:

Pneumatic otoscopy is useful in identifying pathologic conditions such as acute otitis

media, middle ear effusions (residual and persistent), eustachian tube dysfunction with
negative middle ear pressure, tympanosclerosis, tympanic membrane perforations,
retraction pockets, adhesive otitis media, and cholesteatomas.

Acute Otitis Media:

Acute otitis media is characterized by inflammation of the middle ear space which
presents with the rapid onset of symptoms such as otalgia, fever, irritability, anorexia, or
vomiting.

Acute otitis media is often associated with an upper respiratory infection or cold.
Findings of middle ear inflammation include middle ear fluid causing decreased
tympanic membrane mobility and bulging with impaired visibility of bony landmarks, a
red or reddish yellow color, exudate on the membrane, or bullae.

Otitis media with effusion

Otitis media with effusion is characterized by an asymptomatic middle ear effusion, that
may be associated with a "plugged ear" feeling. The membrane often appears translucent
but may be opaque when children have experienced frequent episodes of acute otitis
media. There is diminished membrane mobility which is often associated with a retracted
position.

As the fluid clears air fluid levels or bubbles may be seen through the membrane as seen
in the images below.

Fluid present from 3 to 16

weeks following the
diagnosis of acute otitis
media without otoscopic
signs of inflammation is a
residual effusion. After 16
weeks the fluid can be
classified as a persistent
effusion.

Tympanosclerosis

Tympanosclerosis is a form of membrane thickening produced by hyalization. It results

from chronic inflammation or trauma; often in association with the insertion of
ventilating tubes.

Perforations

Tympanic membrane
perforations can occur
in the pars tensa or pars
flacida.
Most perforations produced by acute otitis media heal within a few days when the
tympanic membrane is otherwise normal. The persistence of drainage, called otorrhea, for
6 weeks or longer is classified as chronic suppurative otitis media.

Tympanic Membrane Atalectasis, Retraction Pockets and Adhesive Otitis Media

Retraction pockets occur when chronic inflammation and negative middle ear pressure
produce atrophy and atelectasis of the tympanic membrane. This
produces a defect or pocket which is usually located in the
posterior superior area of the pars tensa or in the pars flacida. The
tympanic membrane may adhere to the medial wall of the middle
ear. Atrophy of the tympanic membrane can occur without a
retraction pocket because of chronic inflammation with or without
prior perforations.

When adhesions develop between the retraction pocket and

ossicles, insertion of a ventilating tube fails to restore normal
ventilation and the pocket will persist (see diagram above). This condition is called
adhesive otitis media, which may lead to erosion of the ossicles and ossicular
discontinuity, or the development of a cholesteatoma.

Cholesteatoma

A cholesteatoma is a greasy-looking mass or accumulation of debris that is seen in a

retraction pocket or perforation. It often presents as chronic otorrhea unresponsive to
antibiotic therapy. The diagram below shows how a retraction pocket can enlarge and
accumulate debris to form an acquired cholesteatoma. Cholesteatomas also may be
congenital.