How to Examine the Ear — A Systematic Approach

Ear examination is one of the first clinical skills an ENT posting demands and one of the most poorly taught in preclinical years. The difficulty is not conceptual — the steps are straightforward — but practical: the ear canal is narrow, the tympanic membrane sits at an angle, the light source must be controlled, and the normal landmarks must be recognised before abnormalities become legible. This article provides a systematic, step-by-step approach to examining the ear that works on real patients.

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Equipment

A working otoscope with a charged battery (dim light makes TM interpretation impossible), the correct speculum size (the largest that fits comfortably — typically 4 mm for adults, 2.5–3 mm for children), and clean technique. Video otoscopes show the drum on a screen and are excellent for teaching. In practice, a well-maintained standard otoscope is sufficient for most clinical assessments.

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Step 1 — Inspection Before Otoscopy

Before reaching for the otoscope, look at the ear with your eyes:

Auricle (pinna): Look for skin lesions, deformity, surgical scars (post-auricular, endaural). Examine the antihelix, helix, and tragus for tophi (urate deposits — gout), gouty tophi are yellow-white nodules. Feel the mastoid — mastoid tenderness on palpation is a sign of mastoiditis; erythema, oedema, or fluctuance over the mastoid suggests an abscess. Look for auricular haematoma (an undrained pinna haematoma becomes a “cauliflower ear” from cartilage destruction — important in children and contact sport athletes).

Pre-auricular region: Pre-auricular sinuses or pits (a congenital remnant of the first pharyngeal arch, visible as a small dimple or pit just anterior to the root of the helix) are a common finding; they may become infected.

Post-auricular region: Scars (previous mastoid surgery), swelling (mastoiditis), retro-auricular erythema (Battle’s sign — bruising over the mastoid after temporal bone fracture, appears 24–48 hours after injury).

Ear canal opening (meatus): Any discharge visible at the opening (otorrhoea)? Colour, character (serous, mucoid, mucopurulent, blood-stained, foul-smelling), and quantity should be noted.

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Step 2 — Straightening the Ear Canal

The external auditory canal follows an S-shaped curve (see anatomy of the ear). To visualise the tympanic membrane, the canal must be straightened:

In adults and older children: Pull the auricle upward and backward (superiorly and posteriorly). This aligns the cartilaginous and bony portions of the canal.

In infants and young children: Pull the auricle downward and backward (inferiorly and posteriorly), because the canal is shorter and oriented differently and the tympanic membrane is more horizontal.

Hold the auricle with the hand opposite to the ear being examined (your left hand for the patient’s right ear), leaving your dominant hand free to hold the otoscope.

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Step 3 — Otoscope Technique

Hold the otoscope like a pen — between thumb and index finger, with the ulnar border of the hand resting against the patient’s cheek or temple. This brace is critical: if the patient moves suddenly, your hand moves with their head rather than driving the speculum deeper. Never hold an otoscope with your whole fist.

Insert the speculum gently into the cartilaginous ear canal (the outer ~8 mm). Do not push into the bony canal — the periosteum of the bony canal has no subcutaneous fat and is extremely sensitive; forcing the speculum here causes pain and patient resistance.

Angle the otoscope slightly anteriorly and inferiorly to follow the natural axis of the canal toward the tympanic membrane.

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Step 4 — What to Look for in the Ear Canal

Before focusing on the drum, inspect the canal:

Wax (cerumen): Brown-yellow to dark brown; soft wax can be syringed or micro-suctioned; hard, impacted wax may obstruct the view entirely. Note whether the canal is patent or obscured.

Skin: Look for erythema and oedema of the canal walls (otitis externa — the classic “lighthouse sign” is a tender, oedematous, erythematous canal with no drum visible). Furunculosis (a boil in the cartilaginous canal) appears as a painful, localised raised area.

Foreign bodies: Particularly in children and adults with learning difficulties — insects, seeds, small objects. Always check before assuming the canal is clear.

Discharge: Note whether it is coming from the canal wall (otitis externa) or from behind the tympanic membrane (perforated drum with middle ear disease).

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Step 5 — Systematic Inspection of the Tympanic Membrane

The tympanic membrane should be examined in a systematic order so that nothing is missed. The drum is divided into four quadrants by an imaginary vertical line through the handle of the malleus and a horizontal line through the umbo:

• Anterosuperior (AS)
• Anteroinferior (AI)
• Posterosuperior (PS)
• Posteroinferior (PI)

Systematically inspect:

Pars Flaccida (Shrapnell’s Membrane)

The small, loosely supported area above the short process of the malleus. This is the site of attic retraction pockets and pars flaccida cholesteatoma. Any crust, keratin, or retraction here must be noted. This area is often partially hidden and requires deliberate angling of the otoscope.

Handle and Short Process of the Malleus

The handle (manubrium) is the most reliable landmark — it runs from the short process (a knob-like protrusion visible at roughly 1 o’clock in the right drum) downward to the umbo (the point of maximum inward concavity). If the drum is severely retracted, the short process becomes more prominent and the handle appears foreshortened and more horizontal.

Umbo and Cone of Light

The umbo is the most medial point of the drum. The cone of light (light reflex) is the triangular reflection visible from the umbo extending anteroinferiorly — this reflection is produced by the smooth concave surface of the drum. It is present in a normal drum and absent or distorted in retracted or inflamed drums, but its absence alone is not pathognomonic.

Pars Tensa

Examine all four quadrants for:

• Perforations: Size, location (central vs marginal — central = safe; marginal = dangerous until cholesteatoma is excluded), shape
• Retraction: Inward displacement — grade retractions; a severely retracted drum may contact the promontory or incudostapedial joint
• Bulging: Outward displacement — the most important sign of acute otitis media (AOM)
• Colour: Normal is translucent pearly grey. Erythema alone (without bulging) can be normal with crying. Chalk-white plaques = tympanosclerosis.
• Scarring: Healed perforations may leave a monomeric (single-layer) scar area — thin and dull, may be difficult to distinguish from a thin drum

Posterior Quadrants

The posterosuperior quadrant is where early cholesteatoma retraction most commonly begins, and where the long process of the incus and the incudostapedial joint are visible through a normal (or thin) drum. An absence of the expected ossicular shadow here warrants note.

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Step 6 — Documenting What You See

Write a brief, systematic description of the ear in your notes. A complete ear examination note covers:

1. Auricle: Normal / tender / lesion / scar
2. Canal: Patent / wax (degree) / discharge (character) / otitis externa
3. Tympanic membrane:
   • Pars flaccida: normal / retraction / crust
   • Landmarks: visible / foreshortened / absent
   • Pars tensa: intact / perforated (location, size) / bulging / retracted / tympanosclerosis
   • Cone of light: present / absent / distorted
4. Impression: What you think you see (e.g., “Right drum intact, mild retraction posterosuperiorly, no perforation or effusion”)

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Key Numbers

Parameter	Value
Auricle traction direction (adult)	Upward and backward
Auricle traction direction (infant)	Downward and backward
Ear canal length — cartilaginous portion	~8 mm
Ear canal length — bony portion	~16 mm
Tympanic membrane diameter	~9–10 mm
Tympanic membrane angle to canal axis	~45–55°
Speculum size (typical adult)	4 mm
Speculum size (child)	2.5–3 mm

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Frequently Asked Questions

Why does the cone of light matter? The cone of light is a teaching landmark that helps orient the examiner to the drum’s position and surface characteristics. A normal cone reflects the drum’s smooth, slightly concave surface. Its absence or distortion suggests the drum surface is abnormal (inflamed, retracted, perforated, or thickened), but it is a soft sign — do not diagnose or exclude pathology on the cone of light alone. Focus on drum colour, mobility, and structural integrity instead.

How do I know if I’m looking at the drum or the canal wall? The tympanic membrane has a characteristic translucent, grey, slightly shiny appearance with visible landmarks (malleus handle). The canal wall is skin-coloured, matte, and has no landmarks. If the view is unclear, reduce the angle of otoscope insertion slightly, change the speculum size, or (if safe to do so) attempt gentle microsuction to clear wax. If still uncertain after adequate preparation, refer for microscopic examination.

Should I use the largest speculum that fits? Yes — a larger speculum provides a wider field of view, seals the canal better for pneumatic otoscopy, and causes less discomfort per unit of canal wall contact than a small speculum forced in too deeply. Use the largest that passes the meatus without discomfort.