otoscopy
Tests carried out with a tube of diameter 4.0 mm, vision 30 degrees, placed in the external auditory canal of the patient.
Below we show some pictures taken from video footage S-VHS.
All images were obtained in Cóser Clinic.
Normal tympanic membrane
Buffer cerumen
Osteoma of the external auditory canal
Foreign body in external auditory canal
Cholesteatoma of external auditory canal
Paracentesis of the tympanic membrane
Tympanosclerosis and other sequelae of otitis media
Perforation by chronic otitis media
The normal tympanic membrane is translucent, bright with color like a pearl, is tense and is shaped like the cone of a loudspeaker.
The central part of the cone is marked by the lower end of the cable Hammer (the first of the three middle ear ossicles) in a region called umbus (navel).
The same cable ends in a hammerhead structure protruding, round the upper part of the tympanic membrane, which is called the Lateral Process of the Hammer.
From this process it is observed that the tympanic membrane is much thinner than the rest. This small portion called the pars flaccida and the remainder of the membrane is called Pars tense.
1 a - tympanic membrane LEFT SIDE
1b - tympanic membrane SIDE DIRECT
Note that in the two figures we can identify the incus long arm that appears and then parallel to the malleus. The incus long arm is not as well defined as the malleus being situated in a position deeper in the middle ear, without contact with the tympanic membrane.
The cerumen is produced in the outer third of the external auditory canal. Their presence is normal and necessary for healthy skin of the ear canal. Do not make their removal routine (that is, on the contrary, harmful to health), but only in cases where conduct is completely blocked by excess earwax as shown below.
In the above cases the removal of cerumen is required. At first, the transmission deafness that total blockade of the external auditory canal is causing and, second, because they may be hiding a small perforation of the membrane Schrapnell related to cholesteatoma.
The perichondrium (the lining of the cartilage of the pinna) can infecionar after trauma. In most cases, perichondritis occurs as a complication of a hematoma that forms in the ear after trauma, more rarely, after an injury that includes cutting the skin and perichondrium.
In the photo above shows a perichondritis which occurred after the draining of an aural hematoma.
The skin of the ear canal can become inflamed due to water entering the ear or secondary to its manipulation for removal of earwax or just to scratch the ear. The pain is intense and is not accompanied by nasal symptoms (colds, flu, colds). In most cases there is hearing impairment that comes along with the pain. Rarely is removal of secretions by the external auditory canal
In the pictures above we see hiperhemia and edema (redness) of the skin and the presence of secretions in the ear canal.
Above noted the presence of fungi, but these are not the cause of otitis externa, only shows present concomitantly, after the change of the microenvironment by bacterial infection, and do not invade the skin. When cured bacterial infection of the skin of the external auditory canal they disappear.
Stenosing external otitis (shown above at an early stage on the left and right in an advanced stage) can lead to complete closure of the external auditory canal. This case began as a common external otitis, after washing the ear to remove earwax. Although numerous treatments the end result was the narrowing of the canal.
"Otitis Externa Chronic Atrophic" - Above we see the result of years of self-medication of otitis externa with the use of corticosteroid ointment applied daily. The outer skin where the swab reached, atrophied getting much thinner and more fragile than normal.
Typically the bullous myringitis (inflammation of the tympanic membrane, the Latin miringos) comes with a strong ear pain, usually starting the night of sudden onset. This pain usually remits when there is spontaneous rupture of bubbles accompanied by otorrhea (bleeding from the ear).
Above noted rupture of the squamous epithelium, both in the external auditory canal and the external surface of the tympanic membrane. Ahead and behind the malleus still see two blood-filled blisters.
This aggressive form of otitis externa usually affects people with low immunity as adults with decompensated diabetes and malnourished babies.
Above observed complete destruction of the shell and the external auditory canal. After several weeks of antibiotic treatment the end result was a complete stenosis of the canal. Despite its name, this otitis externa is not a tumor, but highly aggressive infection caused by a bacterium of Pseudomonas aeruginosa name. This form of external otitis is very aggressive, necrotizes invades the soft tissues and bone tissues that could cause facial paralysis, meningitis, brain abscess and death.
7) Osteoma of the external auditory canal
Bone growth from the walls of the external auditory canal is relatively common. Rarely grow to the point of closing the external auditory canal when they should be surgically removed.
8) Foreign body in external auditory canal
They are very common in the emergency services and, in most cases, easily removed with jets of water at 37 degrees centigrade placed in the external auditory canal. When washing does not solve the problem the patient must be referred to the ENT for removal under sedation or general anesthesia for children ..
The photo above shows a foreign body in the ear canal easily removed with washing.
Here, the presence of a live insect in the ear canal.
The photo above shows the result of a failed attempt to remove a foreign body without the right conditions. The tympanic membrane is presented with a large cable drilling hammer and anvil dislocated amputee.
9) Cholesteatoma of external auditory canal
The skin lining the ear canal is renewed continuously (as all the skin covering the body) in this case young replace the old cells are eliminated. In the case of the external ear, young cells appear on the external surface of the tympanic membrane and, in so far as they mature, migrate towards its outermost part. The dead cells are then eliminated in the skin of the ear, outside the ear canal.
If the dead cells desquamated have not where to go (retained by a plug of earwax or an acquired stenosis of the external auditory canal, for example) they accumulate in the ear canal forming the pseudo-tumor called Cholesteatoma that with your growth, causes bone resorption extending around the external auditory canal.
The photo above shows marked enlargement of the inner third of the external auditory canal with exposure of the anulus timpanicus (fibrous cord at the periphery of the tympanic membrane, white, surrounding membrane) and some cells the hypotympanum. Such an extension was caused by a large canal cholesteatoma. The photograph was taken after the aspiration.
The middle ear is a space between the tympanic membrane and inner ear (also known as maze). It contains the same air pressure of the atmosphere during normal operation of the Eustachian tube.
When the Eustachian tube does not work properly just place a negative air pressure in relation to the environment in the middle ear. This is a retraction of the tympanic membrane which may follow a stroke of liquid produced by the mucous membrane lining the cavity.
This condition is known as serous otitis media is also called secretory otitis media, otitis media with effusion, sputum tubotympanic and other synonyms.
The main symptom is hearing loss, the feeling of full ear that causes discomfort, but never an earache. The baby generally does a leading hand in the ear often gets restless, but do not cry and not stop breastfeeding.
The picture shows the above initial phase of serous otitis media in the left ear (or a final ...) where the air and serous are present simultaneously. Note the line winding vertical separates air (posterior) of serous (previous). Note also the position of the malleus which shows markedly horizontal position.
The photo above shows a typical serous otitis media, the air is completely replaced by the liquid that makes them transparent and reduce glare.
The photo above shows a serous otitis media of long evolution. The liquid is too thick, there is a dilatation of the capillaries of the tympanic membrane. This ear is beginning to show signs of acute infection, because of its bulging membrane rather than retraction.
This is a serous otitis media of long evolution. Note the severe atrophy and retraction of the anterior portion of the tympanic membrane, calcification present in the posterior portion and hyperemia (redness) diffuse.
Here a much more advanced case of no otitis media, but its sequels permanent atrophy of the tympanic membrane (with the loss of their central fibrous layer, it is formed only by the mucosal epithelial layers making it completely transparent; aspiration complete the eardrum to the middle ear allowing you to see (around the position of 11:00 hours) the tendon of the stapes and the head of the stapes, one can also observe that the incus long arm, which should articulate with the stapes is absent.
This sequel to the case of serous otitis media is more serious than the previous one, because besides the long arm of the incus, the stapes is also absent. It is possible to see the tympanic portion of the channel of the picture across the facial nerve from the position of 04 hours until the malleus, where it ends in a position transverse to it. Immediately below the central portion of canal portion of the facial nerve, there is a dark area corresponding to the oval window. Down the vision can be seen on the headland sequence (smooth surface, rounded, lighter, corresponding to the cochlear basal turn) and the round window niche.
Here a case of serous otitis media which did not respond to treatment and an observation period of more than 03 months. Perform the opening and indicate the tympanic membrane (paracentesis) with the intention of placing a ventilation tube (small spool shaped part which prevents the premature closure of the opening by paracentesis). The procedure was interrupted by the appearance of a major bleeding that had to be controlled by packing the external auditory canal.
After the surgical procedure for treatment of otitis media serosa, resulting in the elimination of the middle ear secretion, one can see the long arm of the anvil, the head of the stirrup and the tendon of the stirrup and the source of bleeding: The bulb internal jugular vein, extremely high, occupying the bottom of the tympanic cavity making direct contact with the tympanic membrane.
CT scans confirming the presence of the jugular bulb in the middle ear and tympanic membrane retraction and the malleus appears that touching the promontory (rounded elevation of the medial wall of the tympanic cavity corresponding to the cochlear basal turn).
The first photograph shows, in the coronal plane, the external auditory canal (dark image that starts on the right side of the photograph in level 4 hours).
The second photograph, cut more later, also shows the external auditory canal and now the floor of the tympanic cavity opens with the jugular projecting into its interior.
The third shows the same of the previous aspect, now in axial section.
Bacterial infection of the middle ear causes pain. Almost everyone has at least one otitis media in life. It is much more frequent in the early years of life.
The baby with otitis media presents as the main symptoms of painful crying and sucking that forces you to stop breastfeeding. These symptoms appear during or immediately after a cold or other problem that causes nasal obstruction. It can be argued that the vast majority of babies who cry and do not have any nasal symptom has also otitis media.
The diagnosis of acute otitis media is done by finding the presence of red and bulging tympanic membrane accompanied by much pain.
When the pain is very intense and does not decrease with 24 hours of treatment when there is a complication, and when you want to reap purulent material for culture is performed paracentesis of the tympanic membrane (opening for me to discharge to drain the ear canal, with it relieves the pain and prevent complications). In this case there was a lot of output to be put after the paracentesis.
In case of acute otitis media hiperhemia and pain were much less pronounced than in the previous case. There was no need for paracentesis.
12) Paracentesis of the tympanic membrane
Suitable for addition to some cases of acute otitis media (described above) paracentesis can be used to treat secretory otitis media. Can be made in isolation in order to take patient discomfort and speed healing of otitis with as part of the procedure will end with the placement of the vent tube.
In adults, paracentesis can be done in the office seeking immediate relief of symptoms of hearing loss and feeling of blocked ear in a case of recurrent serous otitis media (first photo). Anesthesia is performed with topical application of phenol (second picture) and paracentesis is carried out with an appropriate instrument (third image) allowing the aspiration and removal of liquid present in the middle ear
The two photos above show another case of paracentesis in serous otitis media. Note that the malleus and horizontal position in the first picture, it returns to its normal position immediately (second photo).
Above we see the thick liquid being aspirated from the middle ear of a patient with chronic serous otitis media.
Above there is the presence of the ventilation tube placed above the handle of the hammer in order to maintain open the hole paracentesis a few months and thus maintaining a ventilation of the tympanic cavity.
The tympanic membrane in a few days becomes transparent and disappear all the symptoms of otitis. The drawback of this procedure is the need to prevent the entry of water into the ear.
The vent pipe is eliminated spontaneously with the cerumen, after a few months.
13) tympanosclerosis, and other sequelae of otitis media
The war between bacteria and mucous membrane of the middle ear often ends up leaving permanent sequelae.
The destruction of the fibrous layer of the tympanic membrane can lead to permanent tympanic perforation or perforations closed by a thin membrane forms the remaining layers: the outer (squamous epithelium) and internal (epithelial mucosa).
The deposition of calcium carbonate which has the form Tympanosclerosis aspect of the bone and can be seated on the remnants of the tympanic membrane or across the middle ear.
The necrosis of the ossicles is also relatively common. The incus long arm is less resistant to infection and the malleus is the toughest.
Note the mixture tympanosclerosis areas with atrophy of the tympanic membrane, which lack the fibrous layer.
Here the tympanic membrane was almost completely destroyed in its fibrous layer.
Above there is the strange appearance, bubble-shaped, this membrane scarring that came off the malleus.
In this case, almost all of the tympanic membrane is calcified.
Here the membrane is so thin it seems to be a perforated eardrum.
Transparency here is so great that you can see the anulus timpanicus 06-12 hours. At the top of the tympanic membrane at the level immediately below the anulus can see perfectly the chorda tympani nerve heading for the back of the neck of the hammer on his way to the anterior third of the tongue.
14) Perforation tympanic chronic otitis media
The tympanic membrane perforations are classified according to their location.
Central perforation: is that which occurs in the pars tensa of the tympanic membrane without reaching the edge. It has no connection with the cholesteatoma of middle ear and mastoid
Marginal perforation: is also the part tense and involve your board. Can give rise to a secondary cholesteatoma.
Drilling Schrapnell membrane (pars flaccida) always associated with the formation of primary cholesteatoma.
The perforations, contrary to popular thinking, not lead to "total deafness" in fact, when the perforation is the only condition, the hearing is compromised very little. Deafness becomes greater when there is destruction or immobilization of the ossicles of the middle ear. In all these cases the hearing will be called "Hearing loss transmission" and is theoretically reversible with surgery.
Let's take the opportunity to use the perforations below as a window into the middle ear structures (ossicles, muscles, tendons and nerves) that would not be visible if the membranes were intact.
Here you can see through this perforation of the right ear, the air cells of the hypotympanum that are identical to the mastoid.
This perforation of the left ear of the same patient of the previous picture, allows you to see (at position 03 hours) of the tendon of the stapes, followed by the head of the stapes. Are clearly visible their anterior and posterior crura diving in the niche of the oval window (next to the raw posterior tendon above and below the previous head of the stapes).
Below the oval window is possible the vision of the region where the round window. Between the two windows is a structure with smooth rounded shape that is called the promontory and corresponds to the basal turn of cochlea.
Much earlier, in the darkest area in the 11 o'clock position is the bony portion of the Eustachian tube that, unlike all suggest that schematic drawings of the middle ear is not above and below but above and beyond.
Through this perforation of the right ear you can see signs of tympanosclerosis in the air cells hypotympanum. The tip of the malleus is exposed, without tympanic membrane, and crossing it with the tympanic portion of facial nerve.
Moving closer perforation of the facial nerve becomes more visible, the promontory (base of the cochlea) is between him and the round window niche, visible in the position of 07 hours. The stirrup and the anvil begin to appear (just above the round window)
Approaching further drilling can better see all the structures mentioned above and still (at 11 hours) the tendon of the stapes, his head and incus long arm partially destroyed, but in connection with the stapes.
This perforation is also a right ear. In the center of the hole you can see the promontory (rounded elevation corresponding to the basal turn of cochlea) and behind the region of the round window.
Getting closer to the perforation is possible an excellent view of the tendon of the muscle of the stapes out of the pyramidal eminence and inserting the neck of the stapes, above the posterior crus. The incus long arm is perfectly normal and articulated by the articulation with the stapes, stapedial incudo (incus = anvil, stapes = stirrup)
Still closer the perforation can see part of the stapedial crura and, crossing above the stapes, the tympanic portion of facial nerve. A level closer to the remnant of the tympanic membrane, a little out of focus its branch chorda tympani nerve.
Through this it is possible to drill a very hypotympanum pneumatized and filled with air cells.
The closer this perforation allows this beautiful vision of the tendon of the stapes, posterior crus of the stapes, the head of the stapes, the incus long arm of the tympanic segment of facial nerve canal, the malleus, the headland and the region of the oval and round windows.
The entry of water into the ear should be carefully avoided, as it almost always results in reinfeção middle ear, as in this case
The permanent care not to let in water through drilling, recurrent infections and hearing loss transmission can solved by tympanoplasty (surgery to repair the damage of the middle ear and tympanic membrane).
Above a sample before (left) and post surgery (right).
15) Drilling traumatic tympanic
Multiple perforation caused by explosion of fireworks.
Perforation after diving into pond badly done, observe the intense edema and hiperhemia the middle ear mucosa due to infection.
Perforation with fracture and dislocation after ossicular attempt to remove a foreign body in external auditory canal by practitioner, without the right conditions for such procedure.
The vast majority of traumatic perforations close spontaneously. In the example above we see the perforation caused by a rocket explosion in celebration after a football game and its appearance after 02 months. The dark spots in the ear canal are of gore.
The word cholesteatoma suggests that the disease it is a benign tumor ... In fact it is a cyst lined by skin, with the accumulation of scaling due to the maturation and death of squamous epithelial cells, grows gradually destroying the bone structures adjacent. A simplified definition says that "skin cyst is present where it should not exist."
In the case of primary cholesteatoma the origin of this "skin out of place" is the external surface (epithelial) membrane Schrapnel. The theory is that this membrane, also known as the pars flaccida of the tympanic membrane, which is located in a small part of which lies above the top of the hammer, is "drawn toward the middle ear," the case for epitympanum when maintains a sustained negative pressure in the middle ear due to tubal dysfunction.
This type of cholesteatoma is the most common.
The most common symptom in patients with cholesteatoma is a otorrhea (exit of pus from the ear) persistent, painless and smelly.
It is a progressive disease that can lead to varying degrees of hearing loss, vertigo and imbalance (the destruction of the labyrinth), facial palsy (facial nerve as it passes through the middle ear and can be compressed by the cholesteatoma), meningitis, brain abscess and thrombosis of sigmoid sinus (the proximity to the meninges of the middle cranial fossa and posterior).
Surgery is the only treatment and must be done with the ear without secretions, where possible.
Marked decrease in membrane Schrapnell, local potential for development of primary cholesteatoma.
Above observed a small primary cholesteatoma in the right ear in this region of membrane Schrapnell totally asymptomatic.
Above otoscopy on the left side of the same patient, where there's another far more developed primary cholesteatoma showing destruction of the head of the hammer and the anvil chorus.
This cholesteatoma completely destroyed the body of the anvil and not capriciously destroyed the hammer head.
In this case, the disease progressed too destroying the hammer head, the entire anvil and also possibly the stirrup.
In the case of secondary cholesteatoma the origin of "skin out of place" is the external surface (epithelium) of the posterior pars tensa of the tympanic membrane when it is atrophic, without its fibrous portion, and much retracted to the posterior inferior. In rare cases the presence of a marginal perforation can allow passage of squamous epithelium into the middle ear.
In this case the most common symptom is also otorrhea (exit of pus from the ear) persistent, painless and smelly.
Marked retraction of the inferior-posterior tympanic membrane potential site for a secondary cholesteatoma.
Secondary cholesteatoma in the left ear with active infection and otorrhea.
Here otoscopy above the same patient after treatment with the procedure which was the main emotion of the suction secretions and desquamation. In this clinical experience are rare cases in which one can not control the otorrhea before surgery.
The congenital cholesteatoma is a true epidermal cyst that can be located in various parts of the temporal bone (mastoid, tympanic cavity and petrous portion of temporal bone). It has no relationship to dysfunction or tubal perforation.
In the event of perforation is the result of this pressure that makes the cholesteatoma on the tympanic membrane.
Otoscopy this patient is normal on the right side, left side there is a congenital cholesteatoma, middle ear, completely asymptomatic and discovered on a routine otoscopy.
In this case the hearing loss was the reason for the consultation, the patient never had otorrhea and begin to have a piercing type "explosive" in the anterior to the malleus.
19) Radical Mastoidectomy Cavity
Cholesteatoma has been treated in our clinic with the Modified Radical Mastoidectomy (which retains the tympanic-ossicular system present) and transforms the mastoid cavity and external auditory canal in a single cavity. This surgery aims to preserve existing hearing and in some cases, makes it better. The fact of the cavity resulting from the surgery have a tendency to collect shedding its squamous epithelial lining necessitates constant monitoring patient. The otorrhea is controlled in almost all cases and thus ceases to exist the possibility of complications occur to those mentioned above.
Modified radical mastoidectomy on the right ear. Note the part of the tympanic membrane, the head of the hammer and the anvil part of the body present immediately adjacent to the prominence of the lateral semicircular canal.
Radical mastoidectomy on the left ear. The tympanic membrane is part of the head of the hammer and the anvil absent. Note oc anal facial nerve addressing the position of 03 hours toward 11 o'clock.
Passing the endoscope over the tympanic membrane have a unique view of the anatomy of the middle ear viewed from above! Note the facial nerve canal that runs from 05 hours to 11 hours and is marked by the presence of a vein that follows its path around the tympanic. Immediately below the channel of the facial nerve have the view of the clamp with its crura clearly visible, as well as the tendon of the stirrup.
The three above photos show a cavity in which a radical mastoidectomy fistula the posterior canal (the center of the first image) and large area of the meninges notch middle (area at the top the cavity between 24:05 hours and displayed on the second photo) is protected only by the skin lining the cavity. The same occurs with the sigmoid sinus of the posterior fossa (blue image of the third photo).
Classical radical mastoidectomy, the tympanic membrane and middle ear bones are absent.
In the center of the image that corresponds to the promontory basal turn of the cochlea (inner ear), just above the oval window (where the bracket fits) just below the round window where the secondary tympanic membrane (whose elasticity allows the compression and decompression of net triggered by the inner ear and out the base of the stapes in the oval window). Immediately above the oval window, with lighter color, is visible to the horizontal portion of the fallopian canal through which the facial nerve in the posterior direction is observed relief rounded lateral semicircular canal in the center of which is observed erosion that characterizes the "fistula labyrinthine, "actually a dehiscence (opening) labyrinth without perlinfa flow (liquid contained within the bony labyrinth).
Those who want to use the images:
- Please let us know (cursos@clinicacoser.com)
Thank you-if they mention the source.
Pedro Luis Cóser, January 2011.
