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FIGURE1 The normal tympanic membrane is thin and semi transparent. When viewed through an otoscope it has a pearlygrey appearance and often some structures within the middle ear, such as the long process of the incus and the opening of the eusta chiantube,canbeseenifitissufficientlytransparent. Where the outer margin of the drum is attached to the external canal it is thickened and called the annulus fibrosa. The upper onefifth of the drum is slackandcalledtheparsflaccidaandthelowerfour fifths called the pars tensa. The handle of the malleus,whichextendsdownwardsandbackwards,is a reliable landmark. The short process of the malleus protrudes forwardsintotheexternalcanal.Theumboisthecentral attachment of the tympanic membrane to the malleus. Fromtheumboaconeoflightextendsdownwardsand forwards. The blood supply of the tympanic membrane comes from the ear canal superiorly. Prominent blood vesselsontherimsuperiorlyarewithinnormallimits. FIGURE2 Wax, or cerumen, is a normal secretion in the cerumenousglandsintheouterpartofthemeatus,and can obscure or partially obscure the drum. When it is first produced it is colourless and semiliquid in con sistency, but with time it changes from pale yellow, to golden yellow, to light brown and finally, black.Asthewaxdarkensitalsohardens,andthedarkerthecolourthedensertheconsistency.

FIGURE4 FIGURE3 Acuteotitismediawitheffusion.Thereisdistor Further example of acute middle ear infection tionofthedrum,prominentbloodvesselsinthe with effusion. The handle of the malleus is upperhalf,withdullnessofthelowerhalf.There obscured,andfluidlevelsareobviousbehindthe isalsobulgingoftheupperhalfofthedrumand eardrum theoutlineofthemalleusisobscured.



FIGURE5 Acute otitis media with no recognisable land marks. There is considerable bulging of the ear drum with purulent fluid behind a tense tymparic membrane which sometimes heralds perforation.Insomecasesincisionofthedrumis required.

FIGURE6 Appearance of serous (secretory) otitis media. Theeardrumhaslostitslustreandaneffusionis visible through the eardrum with a fluid menis cusdefiningtheuppermargin.

FIGURE7 Fluid behind the ear drum in an asymptomatic child. Effusion is visible with a fluid level in the lower half of the ear drum. The handle of the malleusisalsodifficulttovisualise.

FIGURE8 Resolutionofmiddleeareffusion.Thehandleof themalleusisstillforeshortenedandhorizontal. Signs in the upper half of the ear drum suggest thatfluidisstillpresentinthemiddleeat.



FIGURE9 FIGURE10 A further example of serous otitis media. There Tympanoscierosis. In some cases of otitis media isindrawingofadulleardrumandthehandleof healing may not be completed and the the malleus is characteristically horizontal. inflammatory process leads to the formation of Eustacliantubeobstructionhadled tofailureof scar tissue. This can take the form of calcified replacement of air winch is normally absorbed plaquesonthetympanicmembrane. from the middle ear resulting in vacuum form ationandeffusionoffluid.

FIGURE12 FIGURE11 Centralperforationoftheeardrum.Perforations Grommet Tympanostomy tube Grommets can are usually single but may be multiple. Spon be inserted in the tympanic membrane if taneous rupture of the drum can occur in asso medical treatment and myrinaotomy are unsuc ciation with acute infection when the tense cessful and the child has persistent middle ear drumperforatesandreleasespus.Theeardrum effusion. The illustration is a silicone tube illustrated has a long standing perforation retainedinanopeninginthedrumbyinnerand accompaniedbytympanosclerosisofthedrum outerflanges.