TM Images

Question 1

Answer 1

Normal

• This a normal right tympanic membrane
• The handle of the malleus runs from the lateral process at the top to the umbo in the middle of the membrane – the pars tensa
• Posterior, i.e. to the left as you view the image, is the long process of the incus
• Above the white bump at the top of the malleus handle the lateral process of the malleus - is the so called attic region of the ear drum - the pars flaccida

Question 2

Answer 2

Normal

• Normal membrane
• The anterior recess cannot be seen as it is obscured by a prominent ear canal wall

Question 3

Answer 3

Ear Wax (Cerumen)

• Ear wax present that completely obscures the TM
• No signs of inflammation or irregularitis in the external auditory canal

Question 4

Answer 4

Swimmers Osteoma

• Swimmers osteomas, bony swellings in the ear canal
• The image also shows some tympanosclerosis of the
  membrane

Question 5

Answer 5

Fungal Ear

• There is a perforation of the tympanic membrane in the background
• Earlier infections had been treated with antibiotic ear-
  drops causing a fungal infestation of the external ear canal with white fungal hyphae and yellow spores
• More commonly the spores are black – from Aspergillus niger – but these are not so photogenic

Question 6

Answer 6

Fungal Ear

• Fungal collection -Aspergillus niger -in a mastoid
  cavity
• Past the collection of white hyphae and black spores is the membrane with an anterior inferior perforation

Question 7

Answer 7

Acute viral ear

• The deep canal is reddened but there is no fluid behind membrane
• Dilation of the blood vessel on the membrane
• The light reflex is in the correct place

Question 8

Answer 8

Otitis Media

• The tympanic membrane appears dull
• Light reflex is altered and there are a few blood vessels on the surface

Question 9

Answer 9

Resolving secretory otitis media

• Bubbles can be seen in the residual fluid in the middle ear through the TM as ET started to function again
• Two patches of tympanosclerosis in the tympanic
  membrane

Question 10

Answer 10

Acute secretory otitis media

• The membrane is bulging, and reddened with involvement of the attic and deep ear canal skin

Question 11

Answer 11

Acute secretory otitis media

• There is a red inflamed membrane with blisters which is about to breakdown and discharge a muco-pus

Question 12

Answer 12

PERFORATION FOLLOWING AN ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)

• Posterior perforation of the Typanic Membrane
• Small granulation on scarred rim of perforation
• Patches of tympanosclerosis in the rest of the drum and middle ear mucosa, visible through the perforation is healthy

Question 13

Answer 13

Glue Ear

• The membrane is grey, dull and retracted with the malleus handle looking short because of the retraction
• There are radial blood vessels within the membrane
• There is no active infection

Question 14

Answer 14

Glue ear with dermoid cyst

• This child has glue ear, with a dull, retracted membrane, loss of the light reflex and radial blood vessels
• There is also a small dermoid cyst in the
  membrane just posterior to the tip of the malleus handle

Question 15

Answer 15

Adult glue ear

• The membrane is not inflamed but is yellow and dull
• There is an air bubble in the anterior superior quadrant

Question 16

Answer 16

Grommet in the TM

• This image shows a standard Shah type ventilation tube, also called a grommet

Question 17

Answer 17

Infected mini grommet with otitis externa secdonary to a mucus discharge

• This ear has a “mini” grommet in the inferior segment
• Clear mucus is filling the lumen of the tube
• Discharge from the ear canal

Question 18

Answer 18

Permanent ventilation tube in place

• The image shows an example of a Triune tube which contains three flanges at the end of the tube which sit on the inside of the eardrum and anchor the tube in place

Question 19

Answer 19

Large perforation of the TM

• Large perforation of the membrane showing stapedius tendon and stapes head with a good connection between the incus and the stapes head

Question 20

Answer 20

Posterior perforation of TM

• A posterior perforation of the membrane
• The incudo stapedial joint has been eroded

Question 21

Answer 21

Two small traumatic perforations

• Traumatic perforations from acute pressure changes slaps, blast injuries, diving injuries - are usually in the anterior half of the membrane
• Perforations from infections are often in the posterior segment
• The light reflex is in the correct location

Question 22

Answer 22

Subtotal perforation of the TM

• There is a large perforation revealing the round window and the opening to the ET
• The handle of the malleus is intact and the head of the stapes is just visible

Question 23

Answer 23

Perforation with tympanosclerosis

• A longstanding posterior perforation in a retraction with extensive tympanosclerosis involving the remnants of the membrane but also involving the middle ear
• There is tympanosclerosis on the head of the stapes and also the anterior arch as well as behind the malleus handle
• It appears that there is also tympanosclerosis involving the stapes footplate just below the facial nerve
• The long process of the incus is missing

Question 24

Answer 24

Grommet scar healed

• There is a triangular thin scar in the anterior inferior quadrant of the membrane
• This membrane is particularly thin and the chorda tympani can be clearly seen as can the long process of the incus
• There is also a small attic erosion that looks as if there is a perforation

Question 25

Answer 25

**_Tympanosclerosis_** * The image shows a healthy intact membrane with a small triangular scar in the anterior inferior quadrant typical of earlier grommet insertion * To each side of this is a plaque of tympanosclerosis

Question 26

Answer 26

**_Posterior retraction_** * A healthy looking, but rather thin membrane, with a posterior retraction * The retraction at the posterior margin of the membrane is starting to cause a problem with the normal migrationof the membrane skin. * There is an irregular edge at thejunction of the deep ear canal and the membrane and this altering the migration pattern

Question 27

Answer 27

**_Retraction onto incus_** * There is a significant posterior retraction onto the long process of the incus, the head of the stapes and the tendon of the stapedius muscle * There is a ribbon of keratin arising from the edge of the etracted membrane

Question 28

Answer 28

**_Retraction with loss of long process of incus and keratin trail_** * There is a posterior retraction of the membrane with a trail of keratin running along the posterior wall of the canal * There is loss of the long process of the incus so that the membrane is attached to the head of the stapes * The trail of keratin along the posterior canal wall indicates early failure of migration

Question 29

Answer 29

**_Retraction with loss of long process of incus_** * There is a deep posterior retraction of the membrane onto the head of the stapes and stapedius tendon * There is also a small attic retraction with the thin drum forming a dimple just anterior to the head of the malleus

Question 30

Answer 30

**_Pars tensa cholesteatoma_** * There is a posterior retraction onto the round window and above this is a ball of keratin overlying and probably eroding the long process of the incus and head of the stapes * The bony rim of the ear canal has been partly eroded and the normal migration of the skin of the membrane has been impeded as it cannot migrate around the sharp edges that have been created by the retraction and the erosion

Question 31

Answer 31

CHILDHOOD ATTIC RETRACTION The main clinical features are: * An image of a child with recurrent glue ear * The drum is dull and grey with radial vessels * It is just possible to see a slight retraction at the site of an earlier grommet insertion * Above the lateral process of the malleus is the pars flaccida and this has started to retract and get stuck down to the underlying head of the malleus and the various mem- branes, ligaments and nerves that cross the region

Question 32

Answer 32

DEEP ATTIC RETRACTION The main clinical features are: * The image is from a young adult who has grown out of the glue ear phase and the pars tensa looks normal. * The attic region has become isolated from the middle and retraction of the pars flaccida has continued. * There is a slight failure of migration of the attic skin which is shown as flakes of keratin at the anterior edge of the retraction. * There is also some erosion of the outer attic wall

Question 33

Answer 33

ATTIC RETRACTION ACCUMULATION KERATIN – UNDERLYING CHOLESTEATOMA The main clinical features are: * Failure of migration has occurred from this attic retraction pocket * The dead skin has formed a brown crust with more bone erosion * Beneath this is a cholesteatoma

Question 34

Answer 34

EXTENSIVE ACCUMULATION WITH CHOLESTEATOMA IN MIDDLE EAR The main clinical features are: * There is an extensive attic erosion and an accumulation of keratin with a cholesteatoma deep to the dark surface layers * The cholesteatoma is so extensive that it has expanded into the middle ear behind the pars tensa where it can be seen as a smooth white mass

Question 35

Answer 35

WET CHOLESTEATOMA The main clinical features are: * This image shows the tympanic membrane with some tympanosclerosis * There is a very large attic perforation with an extensive cholesteatoma, shown as the white mass * There is a small red polyp arising from the roof of the attic * The pars tensa is intact with some tympanosclerosis

Question 36

Answer 36

CONGENITAL CHOLESTEATOMA The main clinical features are: * Image shows a congenital cholesteatoma in an eighteen- month old patient * A congenital cholesteatoma is defined as a cholesteatoma in the middle ear without a perforation or retraction of the membrane * There is a smooth rounded pearly white mass behind the membrane

Question 37

Answer 37

LARGE CONGENITAL CHOLESTEATOMA The main clinical features are: * The image shows a large congenital cholesteatoma * There is a pearly white mass bulging the posterior half of the membrane although it can also be seen behind in the anterior superior quadran

Question 38

Answer 38

EAR CANAL CHOLESTEATOMA I The main clinical features are: * This is a rare condition when the skin of the ear canal loses its usual characteristics of being only a few cells deep and of migrating outwards towards the external opening of the canal * In this condition a small area of canal skin reverts to a primitive skin type that does not migrate and starts to erode the underlying bone

Question 39

Answer 39

EAR CANAL CHOLESTEATOMA II The main clinical features are: * The accumulation of keratin has been removed * Erosion of the bone of the floor of the canal, with sharp edges and bare bone

Question 40

Answer 40

FOREIGN BODIES The main clinical features are: * Many foreign bodies can end up in the ear canal * With new technology hearing aids that have the loud- speaker in the ear canal, the dome that covers the loudspeaker sometimes disconnects from the speaker unit when the aid is removed from the ear * Nowadays, this is probably the most common foreign body

Question 41

Answer 41

AURAL POLYP The main clinical features are: * A soft, vascular swelling completely blocking off the ear canal in this case so that it is not possible to see its origin