Clinical Videos

Normal response to R ear cold water caloric

Right ear warm water caloric, horizontal nystagmus to right (same) side, normal response. Recorded with mobile phone on tripod stand. Hallpike caloric test

Normal response to left ear warm water caloric.

Left ear, wet, with discharge from attic, pulsating. Pulsation probably secondary to extensive mucosal inflammation in middle ear and attic. Could also be transmitted from exposed dura due to possible tegmen tympani defect. Small bleeding granulations seen around lower margin of attic defect.

Attic cholesteatoma, with granulations and wet Keratin in a moderate sized bony erosion of outer attic wall /scutum, in left ear.

Wet erosion of attic with keratin cholesteatoma flakes. Further cholesteatoma in posterior middle ear is bulging the drum and making it white in colour.

Intact ear drum, thick scarred anterior part, thin healed perforation of posterior part. through the thin scar a possible cholesteatoma pearl or possibly a block of tympanosclerosis can be see in the middle ear. Left ear.

The entire drum has retracted onto the medial wall of the middle ear. The retraction is wrapped around the malleus handle. The retraction extends up into the posterior attic and beyond this, probably going back into the mastoid. The poster-superior quadrant and attic are full of wet cholesteatoma and granulations. The stapes and incus appear eroded. The ear canal skin is excoriated, wet, and inflamed due to the chronic discharge.

There is a crust of dry secretions and keratin covering the pars flaccida and nearby roof of the ear canal. This covers a bone erosion of out er attic wall and cholesteatoma. Such findings are very suspicious of underlying disease and should not be mistaken for wax. The rest of the drum, the past tensa, has some patches of tympanosclerosis but otherwise appears healthy and the middle ear aerated. this ear needs careful examination with removal of the crust to inspect the attic. The patient will probably need surgery for cholesteatoma.

A large bone erosion exposing all the attic of middle ear and malleus head. incus body has been eroded. the cavity is partially self-cleansing and only contains some flakes of cholesteatoma. The drum has some patches of thickened scar and tympanosclerosis, together with a thinner area antero-inferiorly.

An auto-cavity of the attic/epitympanum, due to self-healed cholesteatoma. Bone of outer attic wall has been eroded, exposing the partially eroded malleus head and the incus body. Can also see the anterior malleolar ligament and the chorda tympani nerve, as it passes lateral to the long process of the incus and the forwards, medial to the malleus handle where it passes just inferior to the tendon of the tensor tympani muscle. As it crosses the LPI, it lies medial to the posterior malleolar ligament. there is sone dried keratin lying on the remnant of the head of malleus. The cavity appears self-cleansing and may be managed conservatively, with regular follow up.

There is large clean erosion of the lateral epitympanic wall (outer wall of attic or scutum). The result of a self-healed cholesteatoma, probably after some years of ear discharge. Fortunately, the cholesteatoma exteriorised and resolved, leaving similar result to some surgical atticotomies, where the outer attic wall was not reconstructed. The malleus head has been almost entirely eroded and has a brownish coloured crust of dried keratin attached to it. The incus is intact and the chain is also intact so hearing was normal. Follow up is required to check that keratin is not accumulating in the attic, in which face it may be removed carefully under magnification in out-patients, and the ear should be kept dry as it is at risk of infection and recurrence of active cholesteatoma in the attic.

There is a dry retraction with some erosion of the outer attic wall, exposing the attic itself, where the malleus head and incus body are absent. Active cholesteatoma in the past has erode the ossicles and attic wall, but eventually became dry and created an almost self-cleaning cavity. Some dried debris can be seen inside, and it is possible that this could become recurrently infected and that the cholesteatoma could reactivate. The debris may extend posteriorly through the aditus into the mastoid antrum. The remainder of the tympani membrane is relatively normal, it is just a little scarred and opaque from past infections. It does not appear to be connected to the stapes, and so there is likely to be significant conductive hearing loss. Occluding the ear with a hearing aid could increase humidity and may lead to damp, and infection again in the attic.

A pearl of cholesteatoma is easily seen through the drum, in the posterior middle ear. Aetiology could be congenital cholesteatoma. There is a small scar on drum over the pearl, so it could also have invaded from a small perforation, which then healed. Incidental finding, but will require tympanotomy and removal, else it may enlarge and cause ossicular erosion or other complications.

Posterior half of drum deeply retracted and this pocket is full of keratin flakes. Active poster-superior cholesteatoma. There is an attic erosion partially exposing the head of malleus. No attic cholesteatoma. Skin of posterior canal wall is inflamed due to adjacent active cholesteatoma. there is a piece of wax near the anterior margin of tympanic membrane.

Deep erosion of ear canal floor, typical for cholesteatoma ring in ear canal. Tends to leave sharp pushed out undermined margins, especially on side nearest TM. May contain areas of exposed or necrotic sequestrating bone. erosion occasionally very extensive and may expose mastoid air cells of vertical portion of VII. the erosion need careful cleansing with micro suction to ascertain limits and plan treatment.
Distinguished from keratosis obturans, which tends to expand entire canal and push drum and ossicles medially and does not have such distinct localised erosions.

Grossly expanded right ear canal, exposed vertical segment of facial nerve in posterior canal wall. Thin medicalised tympanic membrane. malleus handle and long process of incus seen in drum. all wax and keratin has been cleared form the canal, the patient comes for regular check up and careful removal of nay wax or keratin accumulating in canal. great care to avoid injuring expose VII.

Keratosis Obturans usually presents with hard wax filling an expanded ear canal. It is thought to develop because of a failure of the normal mechanism of migration of wax out of the canal. Thus it is builds up, filling the canal, often getting infected and gradually eroding and expanding the canal. It also pushes the ear drum medially, plastering it to structures in the middle ear. Here the patient presented with these sequelae of long term wax and keratin build up the canal leading to bone erosion, exposing the ossicles and leading to recurrent infections and impaired hearing.

Had radiotherapy for parotid tumour many years earlier. Chronic ear discharge. Large sequestrating dead area of bone in posterior wall of ear canal. requires wide canal and meat-pasty with viable skin flap cover. TM can be seen anteriorly, and small granulation on poster-inferior canal wall. Blackened dead bone fragment seen in posterior canal wall, extending back into mastoid bone, near vertical portion of facial nerve.

Dense granulations lining the deep part of ear canal and surface of tympanic membrane. A specific form of otitis external. It often leads to stenosis then atresia (blockage) of the external auditory canal. Eventually forming a skin lined blind pit and causing significant conductive hearing loss.

Hard bony exostoses at typical positions in ear canal. sessile lumps, in anterior and posterior walls at three sites. usually related to extensive exposure to cold water, thought to cause inflammation of periosteum and new bone growth. Common among surfers. Many are asymptomatic. Wax or debris may become trapped behind the growths and cause blockage with hearing loss, or infection. Occasionally require surgical removal by canalplasty.

Attic erosion with retraction pocket exposing neck of malleus and partially eroded incus, no long process. Chorda tympani nerve visible in pocket. Extensive tympanosclerosis of ear drum. white Teflon grommet ventilation tube in lower part of drum.

Small white grommet ventilation tube in lower part of ear drum. infected ear with wet keratin on drum and lining deep canal. otitis externa. skin of ear canal red and inflamed. Patch of mucoid myringitic skin and a small perforation in postero-superior part of tympanic membrane.

The drum is dull and fluid is filling the lower part of middle ear, the serous yellow effusion can be seen with a fluid level, like water in a glass, through lower part of drum. There is also a small attic retraction pocket, within normal limits. There is some early formation of tympanosclerosis (chalky white calcified area) in lower part of drum, an indication of past inflammation.

The entire tympanic membrane including pars tensa and pars flaccida are well seen. The white annular ligament runs round edge of pars tensa. Good light reflex. Through the drum is seen the chorda tympani nerve and the promontory. Malleus handle with lateral process.

Endoscopic view, normal healthy left ear canal and drum. Note the 'waves' of migrating keratin and wax in canal. Wax is only seen in lateral part of the canal, where the cerumen glands are found. The tympanic membrane is intact and normal.

Atticotomy, tympanoplasty, ossiculoplasty using Kurz titanium 'aerial' Total Ossicular Replacement Prosthesis, Tympanosclerosis fixing stapes removed. Underlay temporalis fascia and cartilage reconstruction of drum.

Fairly small dry inactive central perforation of tympanic membrane. Large plaque of white tympanosclerosis in posterior half of TM. tip of malleus handle exposed by perforation.

Moderate sized inferior central perforation. Inactive mucosal type (Tubo-Tympanic) CSOM. Large plaque of tympanosclerosis affecting upper part of drum. Small attic pocket which is within normal limits.

Almost subtotal, wet perforation. Retains a strand of drum and squamous epithelium extending from the malleus handle to the residual inferior margin of drum. Thick wet slightly cobblestone middle ear mucosa. thick mucosa over slightly eroded incudo-stapedial joint and stapedius tendon. Wet ear canal.

Dry central perforation. Margin of perforation adherent to eroded long process of incus and stapes head. small bead of white tympanosclerosis seen in middle ear hypotympanic air cell, near RW niche.

Thin atelectatic tympanic membrane has broken down posteriorly, to form a large dry perforation. Some of the pocket can be seen adherent to the partially eroded long process of incus. The ossicular chain is intact but the ISJ is fragile and barely in contact. the stapes head with stapedius tendon and promontory are well seen. Also visible are the canal of horizontal VII, chorda tympani nerve, round window recess, annulus, facial recess, entrance to sinus tympani, remnant of TM anteriorly, malleus handle and lateral process, and hypotympanic air cells.

Moist perforations of thin posterior retraction pocket of tympanic membrane. Eroded long process of incus. Exposed stapes head and stapedius tendon. inflamed mucosa at back of perforation, with trail of drying secretion migrating out of middle ear, over posterior annulus. Chordates Tympani nerve well seen, running from beneath posterior annulus to behind handle of malleus, crossing the eroded LPI.

Wet central perforation with granulation on margin which bleeds on contact. Drum is thick, inflamed and almost featureless. Muco-purulent ear discharge.

Description; In the Left ear we see a deeply retracted dry drum, plastered to the eroded ISJ and with tympanosclerosis of remaining part of TM.
In the Right ear we see post-operative appearance after cartilage reconstructions of anterior and posterior drum, with incus interposition from stapes head to malleus handle. This successfully closed the air bone gap on audiogram.

This complex ear shows evidence of past surgery. A blue vent T tube has been placed through the drum anteriorly. Despite this the drum has retracted around an ossicular reconstruction and developed a dry posterior perforation. There seems to be a displaced white ossicular implant (perhaps Hydroxy-Apatite) in the oval window or on the stapes remnant. Since the ear is dry and stable and has only a mild conductive hearing loss, it is best left untouched, but should be reviewed regularly and must avoid water ingress, as it is at risk of infection.

Past history of atticotomy and tympanoplasty. Retraction pockets seen in attic. White area seen deep to posterior retraction, represents probable residual cholesteatoma, forming 'pearl'. Requires scanning and exploration.

Thin tympanic membrane (healed perforation), short malleus handle, drum moves in and out during swallowing.

Large, fairly clean and dry mastoid cavity. Large Glomus Jugulare recurrence around facial ridge. clear pulsation of tumour visible. some wax in ear canal floor. Tympanic membrane only partially seen, just anterior and medial to the tumour. Pulsatile tinnitus.

In the Left ear we see a deeply retracted dry drum, plastered to the eroded ISJ and with tympanosclerosis of remaining part of TM.
In the Right ear we see post-operative appearance after cartilage reconstructions of anterior and posterior drum, with incus interposition from stapes head to malleus handle. This successfully closed the air bone gap on audiogram.