Otoscopy: technique and the normal eardrum
- Examination
Otoscopy shows the ear canal and eardrum; reading them well separates wax, infection, fluid, perforation and cholesteatoma.
What it is
Otoscopy is the core ENT examination of the ear. With a light and a speculum the examiner straightens the canal, looks at its skin and contents, and then reads the eardrum: colour, translucency, position, landmarks and mobility. Pneumatic otoscopy adds a puff of air to test mobility, the single most useful sign of fluid behind the drum. This page goes beyond the basic semiology (see the Rinne and Weber page) to the findings that decide the next step: acute otitis media, otitis media with effusion, chronic perforation and cholesteatoma.
Findings and interpretation
- A displaced or absent light reflex means the drum is not in its normal position (bulging or retracted); it is a clue, not a diagnosis.
- Diagnosis of acute otitis media needs acute onset of pain plus a bulging drum or signs of effusion; a red drum alone does not make it.
- A retracted drum with accentuated landmarks points to negative middle-ear pressure or effusion; tympanometry can confirm reduced mobility.
- A perforation with painless, often foul-smelling discharge for more than about 6 weeks is chronic suppurative otitis media.
- White chalky plaques in the drum (tympanosclerosis) are scars from old inflammation and also reduce mobility.
- In an adult, a one-sided effusion that persists must raise the question of a nasopharyngeal tumour blocking the eustachian tube.
How it is done
- Ask about pain, discharge, previous surgery or a known perforation; examine the better ear first and look at the auricle and mastoid.
- Choose the largest speculum that fits comfortably; hold the otoscope like a pen with the hand braced on the patient's cheek.
- Straighten the canal: pull the auricle up and back in adults, down and back in infants and small children.
- Advance under direct vision and look at the canal skin: wax, swelling, discharge, granulation tissue or a foreign body.
- Find the landmarks: handle of the malleus ending at the umbo, short process, light reflex, pars tensa and pars flaccida.
- Describe colour, translucency, position (neutral, retracted or bulging) and any perforation or debris, by quadrant.
- Pneumatic otoscopy: with the speculum sealing the canal, squeeze the bulb gently; fluid, perforation or scarring reduce movement.
- Record the findings for each ear, ideally with a simple drawing of the drum.
What the eardrum shows and what to do
| Finding | Suggests | Next step |
|---|---|---|
| Pearly, translucent, mobile drum with clear landmarks | Normal middle ear | Nothing further if hearing is normal |
| Bulging, red drum, blurred landmarks, poor mobility, acute pain | Acute otitis media | Treat per guideline; urgent referral if facial weakness, vertigo or signs of spread |
| Amber or grey, retracted drum, air–fluid level or bubbles | Otitis media with effusion | Hearing test and tympanometry; in an adult with a one-sided effusion, examine the nasopharynx |
| Perforation with chronic, foul-smelling discharge | Chronic suppurative otitis media | Clean the canal, topical quinolone drops, ENT referral |
| White debris, retraction pocket or aural polyp | Cholesteatoma | ENT referral (surgery; temporal bone CT) |
Common mistakes
- Calling every red eardrum acute otitis media leads to unnecessary antibiotics.
- Reporting a «normal» ear when wax hides the drum: the exam is incomplete until the drum is seen.
- Insufflating or irrigating an ear with a possible perforation or after trauma.
- Missing a persistent one-sided effusion in an adult, which can be the first sign of nasopharyngeal cancer.
Next step / Initial management
- First workup: tuning forks, and audiometry with tympanometry if hearing is reduced or an effusion persists.
- Acute otitis media: pain relief and, when indicated, the antibiotic the local guideline recommends (amoxicillin is the usual first choice in children) or watchful waiting.
- Chronic perforation with discharge: clean the canal and use topical quinolone drops; avoid aminoglycoside drops when the drum is perforated.
- Refer the same day if there is facial weakness, vertigo, severe headache, confusion or mastoid swelling: suspect a complication.
- Refer to ENT (priority, within weeks) for suspected cholesteatoma, an aural polyp, chronic discharge or an adult one-sided effusion lasting more than 8 weeks.
Test yourself
Think of the answer, then tap the question to see it.
A 3-year-old has had ear pain and fever for one day; the eardrum is red, bulging and does not move with insufflation. What is the diagnosis?
Acute otitis media: acute pain with a bulging drum and signs of effusion (reduced mobility).
In which direction is the auricle pulled to straighten the canal in an adult, and in an infant?
Up and back in adults; down and back in infants and small children.
An adult has a one-sided middle-ear effusion that has lasted three months. Which examination must not be missed?
Examination of the nasopharynx (endoscopy) to exclude a tumour blocking the eustachian tube.
What does an aural polyp seen through a perforation usually mean?
It almost always suggests cholesteatoma: refer to ENT.
Elsewhere in DurgiPedia
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Ear Infections in Children (NIDCD, National Institutes of Health, 2022); Otitis Media (Acute) (MSD Manual Professional Edition, 2026); Otitis Media (Serous) (MSD Manual Professional Edition, 2026); Otitis Media (Chronic Suppurative) (MSD Manual Professional Edition, 2026); Cholesteatoma (MSD Manual Professional Edition, 2026).
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Representative model, for educational purposes only.