1.
Online Teaching Rounds: Otoscopy
Dr. Millora
PRIME 2
December 15, 2022
Submitted by:
PRIME 2 JUNIOR INTERNS

2.
Animas, Archie J. ✓
Aquino, Janjer Bon M. *
Aquino, Trisha Mae V. ✓
Arzaga, John Joel C. ✓
Ascano, John Christian *
Aslam, Areej D. *
Asprer, Calman Jan M. ✓
Atienza, Marielle M. ✓
Bartolome, Nimrod Ramil II C. ✓
Fortes, Hannah Selina V. *
Francisco, Jenica Vianca Loren
G.
*
Francisco, Krizza Mae A. *
Fule, Sofia Gabrielle B. *
Gabriel, Mark Joseph D. ✓
Gaceta, Chelsea Denise T. ✓
Gaite, Summer Marionne ✓
Gamilde, Lourdes Gayle R. ✓
Garcia, Jan Rossana S. ✓
Garcia, Marc Wilhelm M. ✓
Garong, Maria Ana Therese D. ✓
Gille, Genree Ann B. ✓
Gonzales, Jan Chloe C. ✓
*F2F Duty
✓= DONE

3.
JI Animas, Archie J.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
HOLDING OF INSTRUMENT
● Hold it like a pen, with fingers close to the end, then turn the light on.
● If you are examining the left ear, the pen should be held with your left hand, and the right
hand will be the one used for pulling of the ear.
POSITIONING:
● Straighten the ear canal of the patient, and most of the time, this maneuver doesn't hurt.
● Make the patients’ head lean over to the opposite side for optimal view of the canal.
PROCEDURE:
● Place the speculum gently on the ear canal, just at the area of the tragus. It provides an
area to rest the instrument before looking at the lens. Do not go any deeper before
looking through the lens
● Hands holding the speculum should be pressed on the cheek of the patient so that
sudden movements won’t cause the speculum to be pushed inside the ear canal.
● Look through the lens; changing of angle of vision might be required for optimal viewing.
Observe the short process of the malleus, the malleus itself, umbo, and the light reflex.
● Examine the other ear. If the ear to be examined is the right, hold the pen with the right
hand, and pull the ear with the left hand.
Other notes:
● For small children, the canal is smaller and wax could accumulate making it difficult for
examination; however, pulling on the auricle and straightening the canal helps a lot in
examining.

4.
JI Aquino, Trisha Mae V.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
INTRODUCTION
● Otoscopy is a clinical procedure used to examine structures of the ear (external
auditory canal, tympanic membrane, and middle ear)
● One of the primary methods used for diagnosing patient complaints for the entire
ear-nose-throat complex
● A well-designed otoscope will provide illumination, magnification, and air
pressure capability for checking tympanic membrane mobility.
● Pneumatic otoscopy - Can indicate the presence of effusion even when the
appearance of the eardrum otherwise gives no indication of middle ear pathology
POINTERS
● Hold the otoscope like a pen, not a hammer
● The part with the lens is the tip. Hold with fingers close to the end
● Evaluating the tympanic membrane:
○ Color (red, white, yellow)
○ Translucency (transparent, opaque)
○ Position (retracted, neutral or bulging) of the drum
○ Identify the pars tensa with its cone of light, the handle and short process
of malleus, and the anterior and posterior folds of the pars flaccida and
position of the malleus handle.
PROCEDURES
● Straighten out the ear canal of the patient. Most of the time it does not hurt. Pull
the patient’s ear upward and backward to straighten the canal. For better
visualization, tilt the patient’s head
● Gently place the speculum in the patient’s ear. Do not shove the speculum into
the ear. You do not have to put in the whole length of the speculum. Place the
speculum just inside the ear canal, at the tragus
● Steady the speculum in one place before looking through the lens. Brace the
hand holding the speculum against the patient’s cheek to prevent further
insertion of speculum
● Look into the lens and assess the inner structures

5.
● Adjust your angle of vision by moving your own head, not the patient’s. Be the
one to adjust. The examiner should move and not the patient.
● Visualize the short process of the malleus, malleus itself, umbo, and the light
reflex
● Do the same for the patient’s other ear, with the otoscope in the opposite hand.
Left hand for left ear, right hand for right ear
● Smaller children have smaller canals and are more likely to have wax
accumulation.
NORMAL FINDINGS:
● Auditory canal contains some hair with yellow to brown cerumen
Tympanic membrane color: pinkish gray, translucent and in neutral position. Malleus lies
in an oblique position behind the upper part of the drum and is mobile with air inflation

6.
JI Arzaga, John Joel C..
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
The otoscopic exam is performed by gently pulling the auricle upward and backward. In
children, the auricle should be pulled downward and backward. This process will move
the acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use
the little finger area as a fulcrum. This prevents injury should the patient turn suddenly.
● Inspect the external auditory canal.
● Evaluate tympanic membrane
○ Note the color (red, white, yellow) and translucency (transparent, opaque)
and position (retracted, neutral or bulging) of the drum
○ Identify the pars tensa with its cone of light, the handle and short process
of malleus, and the anterior and posterior folds of the pars flaccida and
position of the malleus handle..
Air inflation otoscopy (pneumatic-otoscope) is very useful to evaluate middle ear
disease. Assess the mobility of tympanic membrane by applying positive and negative
pressures with the rubber squeeze bulb.
Normal Findings:
● Auditory canal: Some hair, often with yellow to brown cerumen.
● Ear Drum
○ Pinkish gray in color , translucent and in neutral position.
○ Malleus lies in oblique position behind the upper part of drum.
○ Mobile with air inflation.
HOW TO HOLD THE INSTRUMENT
● Hold it like a pen with fingers close to the end
● The part the makes the light and has the lens is at the tip
PROCEDURE
● Straighten out the ear canal of the patient. Most of the time it does not hurt. Pull
out the ear and that will straighten the canal, also tilt the patients head to make
the canal oriented for better visualization.
● Place the speculum. The speculum is not designed to be shoved into the external
canal. You do not have to put in the whole length of the speculum. Have the
speculum stay in one place, at the tragus. Brace the hand holding the speculum
against the patients cheek to prevent further insertion of speculum

7.
● Look into the lens. Move the head and change angle of the vision to visualize the
short process of the malleus, malleus itself, umbo, and the light reflex. The
examiner should move and not the patient. Orient the speculum but not moving it
further in.
● For the other ear, change the hand that holds the otoscope and do the same.

8.
JI Asprer, Calman Jan M.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
OTOSCOPE EXAMINATION
a) Hold the otoscope like a pen
● Fingers are close to the end
● The part that holds the lens and lights up is at the tip
b) Straighten out the ear canal of the patient
● Do this by pulling out the ear
● Have the patient lean his/her head to the opposite side
c) Place the speculum
● It is not designed to be shoved into the external canal
● Have the speculum stay in one place and not go any deeper than the
tragus
● Brace the hand holding the speculum against the patient’s cheek to
prevent pushing the speculum further into the canal
d) Look into the lens
● Move your head to change the angle of vision
● Visualize the short process of the malleus, the malleus, the umbo, and the
light reflex
● The examiner should be the one moving, not the patient
● You may orient the speculum but do not move it further
e) Visualize the other ear
● Hold the otoscope on the other hand
● Right ear, right hand; left ear, left hand
● Do the same as you did in the other ear
By pulling on the auricle and moving it around, one can straighten up the canal a
whole lot and can make the visualization of the tympanic membrane better than trying to
shove the speculum into the ear canal risking damaging the skin or hurting the patients
and making them fear doctors.

9.
JI Atienza, Marielle M.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
OTOSCOPE EXAMINATION
INTRODUCTION
❖ Two types of otoscope heads are available:
➢ Surgical or Operating
■ The surgical head embodies a lens that can swivel over a wide arc
and an unenclosed light source, thus providing ready access of the
examiner's instruments to the external auditory canal and TM.
■ Use of the surgical head is optimal for removing cerumen or debris
from the canal under direct observation.
■ Necessary for satisfactorily performing tympanocentesis or
myringotomy.
➢ Diagnostic or Pneumatic
■ The diagnostic head incorporates a larger lens, an enclosed light
source, and a nipple for the attachment of a rubber bulb and tubing.
■ When an attached speculum is fitted snugly into the external
auditory canal, an airtight chamber is created comprising the vault
of the otoscope head, the bulb and tubing, the speculum, and the
proximal portion of the external canal.
❖ Although examination of the ear in young children is a relatively invasive
procedure that is often met with lack of cooperation by the patient, this task can
be enhanced if done with as little pain as possible.
➢ The outer portion of the ear canal contains hair-bearing skin and
subcutaneous fat and cartilage that allow a speculum to be placed with
relatively little discomfort.
➢ Closer to the TM the ear canal is made of bone and is lined only with skin
and no adnexal structures or subcutaneous fat; a speculum pushed too far
forward and placed in this area often causes skin abrasion and pain.
➢ Using a rubber-tipped speculum or adding a small sleeve of rubber tubing
to the tip of the plastic speculum may serve to minimize patient discomfort
and enhance the ability to achieve a proper fit and an airtight seal,
facilitating pneumatic otoscopy.

10.
❖ Learning to perform pneumatic otoscopy is a critical skill in being able to assess
a child's ear and in making an accurate diagnosis of AOM. By observing as the
bulb is alternately squeezed gently and released, the degree of TM mobility in
response to both positive and negative pressure can be estimated, providing a
critical assessment of middle-ear fluid, which is a hallmark sign of both AOM and
OME.
❖ With both types of otoscope heads, bright illumination is also critical for adequate
visualization of the TM.
HOW TO HOLD THE INSTRUMENT
❖ Hold the otoscope like a pen with fingers close to the end.
❖ The part that makes the light and has the lens is at the tip.
PROCEDURE
1. First, straighten out the ear canal of the patient.
○ Most of the time the procedure does not hurt.
○ To avoid ear trauma with movement, the examiner should hold the
otoscope with the hand placed firmly against the child's head or face, so
that the otoscope moves with the head.
○ Pulling up and out on the pinna straightens the ear canal and allows better
exposure of the tympanic membrane, OR
○ Pull out the ear and that will straighten the canal, also tilt the patient's
head to make the canal oriented for better visualization.
2. Place the speculum.
○ The speculum is not designed to be shoved into the external canal.
○ You do not have to put in the whole length of the speculum. Have the
speculum stay in one place, at the tragus.
○ Brace the hand holding the speculum against the patient's cheek to
prevent further insertion of speculum
3. Look into the lens.
○ Move the head and change angle of the vision to visualize the short
process of the malleus, malleus itself, umbo, and the light reflex.
○ The examiner should move and not the patient. Orient the speculum but
not move it further in.
4. For the other ear, change the hand that holds the otoscope and repeat the
procedure.

11.
JI Bartolome, Nimrod Ramil II C.
Prime 2(Written Output under Dr. Millora)
Otoscopy
December 14, 2022
OTOSCOPY
This is an ear examination that utilizes a tool called an otoscope, which is used to
look at the outer ear canal and eardrum. This can be done as part of the routine
physical examination or for screening of ear problems, such as hearing loss, ear pain,
discharge, lumps, or objects in the ear.
Things to remember when holding an otoscope:
● Hold the otoscope like a pen, not a hammer
● The part with the lens is the tip. Hold with fingers close to the end
● Evaluating the tympanic membrane:
○ Color (red, white, yellow)
○ Translucency (transparent, opaque)
○ Position (retracted, neutral or bulging) of the drum.
● Identify the pars tensa with its cone of light, the handle and short process of malleus,
and the anterior and posterior folds of the pars flaccida and position of the malleus
handle.
Steps:
1. Hold the otoscope like a pen, with fingers close to the tip, then turn on the light to
begin examining the ear. The tip of the otoscope includes the light and the lens.
2. Straighten out the ear canal of the patient. Pull out the ear and that will straighten
the canal. Tilt the patient’s head to make the canal oriented (for better
visualization)
3. Gently place the speculum into the ear canal and look into the lens. The
speculum is not designed to be shoved into the external canal. Have the
speculum stay at the tragus
4. Try moving the head and changing the angle of your vision to visualize the short
process of the malleus, malleus itself, umbo, and the light reflex.
5. Move and pull the auricle around to straighten up the canal and have a better
visualization of the tympanic membrane. The examiner should be the one to
move and not the patient. Orient the speculum but do not move it further in.
remember not to shove the speculum,coz it can damage the skin and hurt the
patient.
6. For the other ear, change the hand that holds the otoscope and do the same
procedure.

12.
JI Gabriel, Mark Joseph D.
Prime 2 (Written Output under Dr. Urtula)
Otoscopy
November 9, 2022
OTOSCOPY
● Clinical procedure used to examine structures of the ear (external auditory canal,
tympanic membrane, and middle ear)
● Used for diagnosing patient complaints for the entire ear-nose-throat complex
● Hold the otoscope like a pen, not a hammer
● The part with the lens is the tip. Hold with fingers close to the end
● Evaluating the tympanic membrane:
○ Color (red, white, yellow)
○ Translucency (transparent, opaque)
○ Position (retracted, neutral or bulging) of the drum
○ Identify the pars tensa with its cone of light, the handle and short process
of malleus, and the anterior and posterior folds of the pars flaccida and
position of the malleus handle.
PROCEDURES
● Straighten out the ear canal of the patient.
● Pull the patient’s ear upward and backward to straighten the canal.
● For better visualization, tilt the patient’s head
● Gently place the speculum in the patient’s ear.
● Do not shove the speculum into the ear. You do not have to put in the whole
length of the speculum.
● Place the speculum just inside the ear canal, at the tragus
● Steady the speculum in one place before looking through the lens.
● Brace the hand holding the speculum against the patient’s cheek to prevent
further insertion of speculum
● Do the same for the patient’s other ear,
NORMAL FINDINGS:
● Auditory canal contains some hair with yellow to brown cerumen
● Tympanic membrane color: pinkish gray, translucent and in neutral position.
Malleus lies in an oblique position behind the upper part of the drum and is mobile with
air inflation

13.
JI Gaceta, Chelsea Denise T
Prime 2 (Written Output under Dr. Millora)
Topic: Otoscopy
Date: December 12, 2022
Otoscopy - is part of comprehensive ear health and hearing screening for children. Screening
may also include video otoscopy, audiometry and/or tympanometry.
● Physical inspection and assessment of the pinna, ear canal and the tympanic membrane
● Normally the canal is pink with a small amount of fine hairs and cerumen
● Deviations from normal include inflammation, infection, lesions, scaling, scratches,
swelling, occlusion, drainage, discharge, foreign bodies, offensive odor and excessive or
impacted cerumen
Accurate diagnosis of ear disorders such as Otitis Media requires assessment of the
appearance of tympanic membrane by otoscope (or video otoscope) plus compliance or mobility
of the tympanic membrane by pneumatic otoscopy or tympanometry. The tympanic membrane
is assessed for color, translucency, anatomic landmarks, light reflex, contour (position) and for
the presence of perforations.
Normally the tympanic membrane is pearly gray to light pink and peripheral blood vessels may
be evident. The contour of the tympanic membrane is normally neutral or concave and will be
intact. There should be no signs of scarring, opacity or lesions.
Anatomical landmarks include identifying the long process of the malleus, the cone of light reflex
reflected from where the long process of the malleus connects to the tympanic membrane, and
the short process of the malleus. These landmarks may become distorted or absent when fluid
has accumulated behind the membrane
Procedure:
4. The provider may dim the lights in the room.
5. A young child will be asked to lie on their back with the head turned to the side, or the
child's head may rest against an adult's chest.
6. Older children and adults may sit with the head tilted toward the shoulder opposite the
ear being examined.
7. The provider will gently pull up, back, or forward on the ear to straighten the ear canal.
Then, the tip of the otoscope will be placed gently into your ear. A light beam shines
through the otoscope into the ear canal. The provider will carefully move the scope in
different directions to see the inside of the ear and eardrum. Sometimes, this view may

14.
be blocked by earwax. An ear specialist may use a binocular microscope to get a
magnified look at the ear.
8. The otoscope may have a plastic bulb on it, which delivers a tiny puff of air into the outer
ear canal when pressed. This is done to see how the eardrum moves. Decreased
movement can mean that there is fluid in the middle ear.
Normal Result:
● Auditory canal: Some hair, often with yellow to brown cerumen.
● Ear drum: Pinkish gray in color , translucent and in neutral position. Malleus lies in an
oblique position behind the upper part of the drum. Mobile with air inflation.
JI Gaite, Summer Marionne F.
Prime 2 (Written Output under Dr.Millora)
Otoscopy
December 15, 2022
Otoscopy
● Part of comprehensive ear health and hearing screening for children.
● Screening may also include video otoscopy, audiometry and/or tympanometry.
○ Physical inspection and assessment of the pinna, ear canal and the tympanic
membrane
○ Normally the canal is pink with a small amount of fine hairs and cerumen
○ Deviations from normal include inflammation, infection, lesions, scaling,
scratches, swelling, occlusion, drainage, discharge, foreign bodies, offensive
odor and excessive or impacted cerumen
● Ear disorders are accurately diagnosed by assessment of the appearance of tympanic
membrane by otoscope (or video otoscope) plus compliance or mobility of the tympanic
membrane by pneumatic otoscopy or tympanometry.
○ The tympanic membrane is assessed for color, translucency, anatomic
landmarks, light reflex, contour (position) and for the presence of perforations.
Normally the tympanic membrane is pearly gray to light pink and peripheral blood
vessels may be evident. The contour of the tympanic membrane is normally
neutral or concave and will be intact. There should be no signs of scarring,
opacity or lesions.
Anatomical landmarks:
● Long process of the malleus,
● The cone of light reflex reflected from where the long process of the malleus
connects to the tympanic membrane,
● The short process of the malleus.

15.
These landmarks may become distorted or absent when fluid has accumulated behind the
membrane
Procedure:
1. The provider may dim the lights in the room.
2. A young child will be asked to lie on their back with the head turned to the side, or the
child's head may rest against an adult's chest.
3. Older children and adults may sit with the head tilted toward the shoulder opposite the
ear being examined.
4. The provider will gently pull up, back, or forward on the ear to straighten the ear canal.
Then, the tip of the otoscope will be placed gently into your ear. A light beam shines
through the otoscope into the ear canal. The provider will carefully move the scope in
different directions to see the inside of the ear and eardrum. Sometimes, this view may
be blocked by earwax. An ear specialist may use a binocular microscope to get a
magnified look at the ear.
5. The otoscope may have a plastic bulb on it, which delivers a tiny puff of air into the outer
ear canal when pressed. This is done to see how the eardrum moves. Decreased
movement can mean that there is fluid in the middle ear.
Normal Result:
● Auditory canal: Some hair, often with yellow to brown cerumen.
● Ear drum: Pinkish gray in color , translucent and in neutral position. Malleus lies in an
oblique position behind the upper part of the drum. Mobile with air inflation.
JI Gamilde, Lourdes Gayle R
Prime 2 (Written Output under)
Topic Otoscopy
Date dec 12 2022
PEDIA ROTATION
OTOSCOPE EXAMINATION

16.
HOW TO HOLD THE INSTRUMENT
● Hold it like a pen with fingers close to the end
● The part the makes the light and has the lens is at the tip
●
PROCEDURE
● Straighten out the ear canal of the patient. Most of the time it does not hurt. Pull
out the ear and that will straighten the canal, also tilt the patient's head to make
the canal oriented for better visualization.
● Place the speculum. The speculum is not designed to be shoved into the external
canal. You do not have to put in the whole length of the speculum. Have the
speculum stay in one place, at the tragus. Brace the hand holding the speculum
against the patient's cheek to prevent further insertion of speculum
● Look into the lens. Move the head and change angle of the vision to visualize the
short process of the malleus, malleus itself, umbo, and the light reflex. The
examiner should move and not the patient. Orient the speculum but not move it
further in.
● For the other ear, change the hand that holds the otoscope and do the same.
JI Garcia, Jan Rossanna S.
Prime 2 (Written Output under)
Topic: Otoscopy
Date: Dec 12, 2022
Learning to perform pneumatic otoscopy is a critical skill in being able to assess
a child's ear and in making an accurate diagnosis of AOM. By observing as the bulb is
alternately squeezed gently and released, the degree of TM mobility in response to both
positive and negative pressure can be estimated, providing a critical assessment of
middle-ear fluid, which is a hallmark sign of both AOM and OME. With both types of
otoscope heads, bright illumination is also critical for adequate visualization of the TM.
There are two types of otoscope heads available: surgical or operating , and
diagnostic or pneumatic.
★ The surgical head embodies a lens that can swivel over a wide arc and an
unenclosed light source, thus providing ready access of the examiner's
instruments to the external auditory canal and TM. Use of the surgical head is
optimal for removing cerumen or debris from the canal under direct observation
and is necessary for satisfactorily performing tympanocentesis or myringotomy.

17.
★ The diagnostic head incorporates a larger lens, an enclosed light source, and a
nipple for the attachment of a rubber bulb and tubing. When an attached
speculum is fitted snugly into the external auditory canal, an airtight chamber is
created comprising the vault of the otoscope head, the bulb and tubing, the
speculum, and the proximal portion of the external canal.
Although examination of the ear in young children is a relatively invasive
procedure that is often met with lack of cooperation by the patient, this task can be
enhanced if done with as little pain as possible.
The outer portion of the ear canal contains hair-bearing skin and subcutaneous
fat and cartilage that allow a speculum to be placed with relatively little discomfort.
Closer to the TM the ear canal is made of bone and is lined only with skin and no
adnexal structures or subcutaneous fat; a speculum pushed too far forward and placed
in this area often causes skin abrasion and pain. Using a rubber-tipped speculum or
adding a small sleeve of rubber tubing to the tip of the plastic speculum may serve to
minimize patient discomfort and enhance the ability to achieve a proper fit and an airtight
seal, facilitating pneumatic otoscopy.
Reference: Kliegman, R., Stanton, B., W., S. G. J., Schor, N. F., Behrman, R. E., Nelson, W. E., & Kerschner, J.
(2020). Otitis Media. In Nelson Textbook of Pediatrics (pp. 3418–3431). essay, Elsevier.
★ HOW TO HOLD THE INSTRUMENT
○ Hold it like a pen with fingers close to the end
○ The part the makes the light and has the lens is at the tip
★ PROCEDURE
○ Straighten out the ear canal of the patient. Most of the time it does not hurt. Pull
out the ear and that will straighten the canal, also tilt the patient's head to make
the canal oriented for better visualization.
○ Place the speculum. The speculum is not designed to be shoved into the external
canal. You do not have to put in the whole length of the speculum. Have the
speculum stay in one place, at the tragus. Brace the hand holding the speculum
against the patient's cheek to prevent further insertion of speculum
○ Look into the lens. Move the head and change angle of the vision to visualize the
short process of the malleus, malleus itself, umbo, and the light reflex. The
examiner should move and not the patient. Orient the speculum but not move it
further in.
○ For the other ear, change the hand that holds the otoscope and do the same.

18.
JI Garcia, Marc Wilhelm M.
Prime 2 (Written Output under Dr. Urtula)
Topic: Otoscopy
December 15, 2022
Otoscopy is a clinical procedure used to examine structures of the ear, particularly the external
auditory canal, tympanic membrane, and middle ear. Clinicians use the process during routine
wellness physical exams and the evaluation of specific ear complaints. During the otoscopic
examination, the provider utilizes an otoscope, also known as an auriscope, to visualize the ear
anatomy. While performing the otoscopic examination, the provider holds the handle of the
otoscope and inserts the cone of the otoscope into the patient’s external auditory canal. The
otoscope contains a light and magnifying lens to illuminate and enlarge ear structures to help
the provider accurately visualize and evaluate the health of the visible anatomical structures.
Otoscopy is routinely performed during wellness check-ups and in evaluating specific ear
complaints by both specialists, such as ear, nose, and throat physicians (ENTs) and primary
care providers. Otoscopy plays a significant role in diagnosing several ear conditions and is a
key step for the diagnosis of some conditions such as acute otitis media. As such, familiarity
with otoscopy and the conditions for which otoscopic examination aids in diagnosis is important
for health care providers in a variety of fields.
Preprocedure:
a. Before beginning the otoscopic examination, ask the patient to demonstrate the strength
of their facial muscles by smiling, frowning, elevating the eyebrows, closing the eyes and
keeping the eyes closed against resistance, and puffing out the cheeks. Successful
completion of these movements demonstrates the integrity of cranial nerve VII, the facial
nerve. The facial nerve travels through the middle ear and can be affected by ear
pathologies such as acute otitis media.
b. There are often multiple speculum sizes for attachment to the otoscope. The examiner
should select the largest speculum that the patient’s external auditory canal can
accommodate, as this will provide maximum lighting for optimal visualization of the ear
anatomy.
c. The otoscope is usually held in the right hand when evaluating the patient’s right ear and
the left hand when assessing the patient’s left ear. The examiner should place their free
fifth finger of the hand, holding the otoscope against the patient’s cheek to support and
brace the hand during the examination.
Procedure
a. With the hand that is not holding the otoscope, should grasp and gently pull the patient’s
pinna to help straighten the patient’s external auditory canal. This step will facilitate
visualization of the tympanic membrane. In a child, the examiner should pull the pinna
posteriorly and inferiorly. In an adult, the examiner should pull the pinna posteriorly and

19.
superiorly.
b. Gently insert the speculum into the patient’s external auditory canal. The provider should
inspect the health of the external auditory canal and evaluate factors such as the
presence of inflammation, discharge, cerumen, and infection.
c. Slowly progress the speculum into the canal until the tympanic membrane becomes
visible. Evaluate the health of the tympanic membrane and observe factors such as
color, presence of perforation, and a bulging appearance. Also observe tympanic
membrane landmarks, including the pars flaccida on the superior aspect of the tympanic
membrane, the pars tensa on the posterior aspect, the light reflex on the inferior and
anterior aspect, and the handle of the malleus on the anterior aspect. Observation of
tympanic membrane landmarks can help the provider evaluate the health of the middle
ear.
d. Following the inspection of the tympanic membrane, the provider can slowly remove the
otoscope from the patient’s auditory canal. While removing the otoscope, the provider
can continue to observe the auditory canal for evaluation of its health.
Findings:
The External Auditory Canal normally is smooth and pink; it is short and straight in the infant
and younger child, and somewhat longer and more angulated in the older patient.
Tympanic Membranes generally are translucent, occasionally allowing for visualization of
several middle ear structures (umbo, manubrium of the malleus, round window niche, pars
flaccida, and chorda tympani nerve). The normal tympanic membrane varies slightly in color and
appearance.
Middle ear function is evaluated by assessing the degree of mobility of the tympanic membrane
using pneumatic otoscopy or tympanometry. Both techniques require a tight seal between the
speculum or rubber ear piece and the external auditory canal. Movement is best visualized in
the posterosuperior quadrant of the tympanic membrane. The tympanic membrane normally
moves inward with slight positive pressure and outward with slight negative pressure. Significant
negative pressure in the middle ear is noted when applied positive pressure produces no
movement and negative pressure results in exaggerated movement. Negative pressure in the
middle ear is caused by a thick, tenacious middle ear effusion. A bulging tympanic membrane
caused by excessive middle ear effusion with little to no visible air will exhibit nearly complete or
total absence of mobility
The otoscopic findings of acute otitis media and otitis media with effusion are described
separately.
A perforated tympanic membrane in the absence of infection may be indicative of traumatic
injury from a foreign body increased barometric pressure, iatrogenic injury, or previous surgical
incision for ventilating tubes.

20.
JI Garong, Maria Ana Therese D.R.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
Otoscopy is a clinical procedure used to examine structures of the ear, particularly the
external auditory canal, tympanic membrane, and middle ear. Normally the canal is pink
with a small amount of fine hairs and cerumen. Deviations from normal include
inflammation, infection, lesions, scaling, scratches, swelling, occlusion, drainage,
discharge, foreign bodies, offensive odour and excessive or impacted cerumen.
Procedure:
● Ensure the light is working on the otoscope and apply a sterile speculum (the
largest that will comfortably fit in the external auditory meatus).
● Pull the pinna upwards and backwards with your other hand to straighten the
external auditory canal.
● Position the otoscope at the external auditory meatus:
● The otoscope should be held in your right hand for the patient’s right ear and vice
versa for the left ear.
● Hold the otoscope like a pencil and rest your hand against the patient’s cheek for
stability. This will prevent damage to the ear if there is sudden movement.
● Advance the otoscope under direct vision. Be gentle with the otoscope and
ensure movements are slow and considered otherwise you will cause discomfort.
● Inspect the external auditory canal for:
● Excessive ear wax: the most common cause of conductive hearing loss.
● Erythema and oedema: typically associated with otitis externa.
● Discharge: may suggest otitis externa or otitis media with associated tympanic
membrane perforation.
● Foreign bodies: the
● Systematically inspect the four quadrants of the tympanic membrane (TM) to
avoid missing pathology. Note the color (red, white, yellow) and translucency
(transparent, opaque) and position (retracted, neutral or bulging) of the drum. For
a normal tympanic membrane, you should be able to observe:
○ Lateral process of malleus
○ Cone of light

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○ The cone of light can be used to orientate; it is located in the 5 o’clock
position when viewing a normal right tympanic membrane and in the 7
o’clock position for a normal left tympanic membrane
○ Pars tensa and pars flaccida
● Withdraw the otoscope carefully.
● Repeat your assessment on the other ear, comparing your findings. If the patient
has an infection in one ear, you should change the speculum on the otoscope
before examining the other ear.
Normal Findings
Auditory canal: Some hair, often with yellow to brown cerumen.
Tympanic membrane: Pinkish gray in color , translucent and in neutral position. Malleus
lies in an oblique position behind the upper part of the drum. Mobile with air inflation.

22.
JI Gille, Genree Ann B.
Prime 2 (Written Output under Dr. Millora)
Topic: Otoscopy
Date: December 15, 2022
Otoscopy
● is part of comprehensive ear health and hearing screening for children. Screening may
also include video otoscopy, audiometry and/or tympanometry.
● Physical inspection and assessment of the pinna, ear canal and the tympanic membrane
● Normally the canal is pink with a small amount of fine hairs and cerumen
● Deviations from normal include inflammation, infection, lesions, scaling, scratches,
swelling, occlusion, drainage, discharge, foreign bodies, offensive odor and excessive or
impacted cerumen
Accurate diagnosis of ear disorders such as Otitis Media requires assessment of the
appearance of tympanic membrane by otoscope (or video otoscope) plus compliance or mobility
of the tympanic membrane by pneumatic otoscopy or tympanometry. The tympanic membrane
is assessed for color, translucency, anatomic landmarks, light reflex, contour (position) and for
the presence of perforations.
Normally the tympanic membrane is pearly gray to light pink and peripheral blood vessels may
be evident. The contour of the tympanic membrane is normally neutral or concave and will be
intact. There should be no signs of scarring, opacity or lesions.
Anatomical landmarks include identifying the long process of the malleus, the cone of light reflex
reflected from where the long process of the malleus connects to the tympanic membrane, and
the short process of the malleus. These landmarks may become distorted or absent when fluid
has accumulated behind the membrane
Procedure:
1. The provider may dim the lights in the room.
2. A young child will be asked to lie on their back with the head turned to the side, or the
child's head may rest against an adult's chest.
3. Older children and adults may sit with the head tilted toward the shoulder opposite the
ear being examined.
4. The provider will gently pull up, back, or forward on the ear to straighten the ear canal.
Then, the tip of the otoscope will be placed gently into your ear. A light beam shines
through the otoscope into the ear canal. The provider will carefully move the scope in
different directions to see the inside of the ear and eardrum. Sometimes, this view may
be blocked by earwax. An ear specialist may use a binocular microscope to get a

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magnified look at the ear.
5. The otoscope may have a plastic bulb on it, which delivers a tiny puff of air into the outer
ear canal when pressed. This is done to see how the eardrum moves. Decreased
movement can mean that there is fluid in the middle ear.
Normal Result:
● Auditory canal: Some hair, often with yellow to brown cerumen.
● Ear drum: Pinkish gray in color , translucent and in neutral position. Malleus lies in an
oblique position behind the upper part of the drum. Mobile with air inflation.

24.
JI Gonzales, Jan Chloe C.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
Otoscopy
Clinicians perform an otoscope exam to assess the condition of the external auditory canal
(EAC), tympanic membrane (TM), and the middle ear. Steps of the otoscope exam include
inspecting the EAC and the TM with its identifying landmarks as outlined below. A pneumatic
attachment is available to apply pressure to assess the mobility (i.e., compliance) of the
tympanic membrane. Mastering the otoscope exam leads to accurate diagnoses, allowing for
targeted treatment and prevention of complications. Early stages of otologic diseases can be
present in the absence of complaints such as ear pain, ear fullness, and hearing loss; therefore,
the otoscope should be part of all routine exams performed by primary care clinicians and not
specific to otolaryngologists
Procedure:
1. Have the child sit in the parents lap or lie down on their side, back, or abdomen
with the ear to be examined facing upwards
a. If lying down, have the parent hold the arms either extended or close
to the sides to limit motion
b. If sitting, place the child's legs between the parents legs and have the
parent place one arm around the child's body and use the other hand
to hold the child's head firmly against the parent's chest
2. Grasp the auricle with your thumb and forefinger of your nondominant hand and
pull to straighten the canal
a. The EAC curves upward in infants so pull down and back to the 6 to 9
o'clock range
b. The EAC curves downward and forward in children >3 years of age so
pull up and back toward a 10 o'clock position
3. Insert the speculum into the meatus between the 3 and 9 o'clock positions in a
downward and forward position no more than 0.23-0.5 inches (in older children)
a. In neonates and infants, the 2 mm speculum may need to be inserted
deeper due to the underdeveloped cartilaginous and bony structures
4. Continue steps 4-11 listed above
Normal:
● Auditory canal: Some hair, often with yellow to brown cerumen.

25.
● Ear drum:
○ Pinkish gray in color , translucent and in neutral position.
○ Malleus lies in oblique position behind the upper part of drum.
○ Mobile with air inflation.

26.
JI Gabriel, Mark Joseph D.
Prime 2 (Written Output under Dr. Millora)
Otoscopy
December 15, 2022
OTOSCOPY
● Clinical procedure used to examine structures of the ear (external auditory canal,
tympanic membrane, and middle ear)
● Used for diagnosing patient complaints for the entire ear-nose-throat complex
● Hold the otoscope like a pen, not a hammer
● The part with the lens is the tip. Hold with fingers close to the end
● Evaluating the tympanic membrane:
○ Color (red, white, yellow)
○ Translucency (transparent, opaque)
○ Position (retracted, neutral or bulging) of the drum
○ Identify the pars tensa with its cone of light, the handle and short process
of malleus, and the anterior and posterior folds of the pars flaccida and
position of the malleus handle.
PROCEDURES
● Straighten out the ear canal of the patient.
● Pull the patient’s ear upward and backward to straighten the canal.
● For better visualization, tilt the patient’s head
● Gently place the speculum in the patient’s ear.
● Do not shove the speculum into the ear. You do not have to put in the whole
length of the speculum.
● Place the speculum just inside the ear canal, at the tragus
● Steady the speculum in one place before looking through the lens.
● Brace the hand holding the speculum against the patient’s cheek to prevent
further insertion of speculum
● Do the same for the patient’s other ear,
NORMAL FINDINGS:
● Auditory canal contains some hair with yellow to brown cerumen
● Tympanic membrane color: pinkish gray, translucent and in neutral position.
● Malleus lies in an oblique position behind the upper part of the drum and is
mobile with air inflation