Right ear cold water caloric, nystagmus to left (opposite) side, seen with Fresnel lens, normal response

Normal response to R ear cold water caloric

Left ear cold water caloric, nystagmus to right (opposite) side, seen with Fresnel lens, normal response

Left ear cold water caloric, nystagmus to right (opposite) side, seen with Fresnel butterfly lens, normal response

Right ear warm water caloric, horizontal nystagmus to right (same) side, normal response

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

Left ear warm water caloric, horizontal nystagmus to left (same) side, normal response

Normal response to left ear warm water caloric.


Attic cholesteatoma, pulsatile discharge, bleeding granulations, L ear

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 wet cholesteatoma, granulations in attic, L ear

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

Attic erosion and cholesteatoma, 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.

Ant thick TM, post thin TM, with suspect pearl in ME

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.

Atelectasis with wet cholesteatoma, L 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.

Attic crust and cholesteatoma, R ear

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.

Attic defect, cholesteatoma auto-cavity, L ear

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.

Attic erosion and cholesteatoma, Left ear

Attic erosion and crust, exposed ossicles, R ear

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.

Attic retraction, R ear, dry, auto-cavity, exposed ossicles

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.

Attic retraction pocket, L ear, dry, eroded malleus and incus

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.

Post superior cholesteatoma and attic retraction, right ear

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.

Attic wet cholesteatoma, granulations in attic, L ear attic wet cholesteatoma, granulations in attic, l ear

Cholesteatoma erosions of ear canal floor, L ear lying supine, with wet posterior perforation

Cholesteatoma pearl in middle ear, L ear

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.

Post superior cholesteatoma and attic retraction, right ear

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.


Cholesteatoma of ear canal floor, R ear

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.

Cholesteatoma erosions of ear canal floor, L ear lying supine, with wet posterior perforation

Note: this is a Left ear, patient is lying prone, hence superior is to R side, and posterior at bottom of picture. Perforation seen in posterior part of TM, bony erosions visible in canal floor, due to localised cholesteatomas of bony part of ear canal.

Keratosis Obturans with expanded canal, 50y F, R ear, exposed vertical VII and incus, normal hearing, intermittent discharge

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 sequelae, R ear, auto-atticotomy, canal floor erosions, Female 38y, recurrent discharge, exposed ossicular chain, and recurrent granulation tissue.

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.

Osteo-radionecrosis of ear canal wall, dead bone visible, right ear

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.

Otitis externa, granular myringitis, stenosis of ear canal

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.


Ceruminoma, L ear

Benign soft tissue tumour of left ear canal, subsequently biopsied and shown to be ceruminoma, ceruminous adenoma.

Lumps in External Auditory Meatus, left ear.

Soft lumps in left external auditory meatus. diagnosis uncertain, appear to be tumours or lesions of skin adnexae/glands. Possible Ceruminoma. This case has similar appearance to exostoses, but not hard or bony. Obstructing canal and will need excision biopsy.


Exostosis of ear canal, R ear

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.

Exostosis and Osteoma, white water canoeist, frequent cold water exposure, R ear

Sessile bony exostoses of ear canal. At usual common sites in anterior and posterior walls and running down to floor of canal. Additional frequent finding is a smaller, pedunculate osteoma in the canal roof near drum. often asymptomatic. may grow slowly if there is continued frequent exposure to cold.

Surfer exostosis, left ear canal

Large exostosis of posterior wall of ear canal, with smaller more sessile exostoses in anterior wall and floor. Other ear is similar. Caused by frequent exposure to cold water. If these bony lumps are big enough, wax can collect in the narrowed canal and cause obstruction and reduced hearing or become moist leading to infection (otitis externa). If such problems occur, then ear canalplasty may be indicated to widen the canal and remove the excess bone.


Grommet and attic erosion, tympanosclerosis, left ear

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.

Myringitis, infected grommet, left ear

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.


Fluid level, dull coloured ear drum, glue ear, middle ear effusion, L ear

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.


Normal left ear

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.

Normal left ear canal and drum, 39y M, Nepali

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.

Normal right ear canal and tympanic membrane

Note the healthy ear canal skin with lines or waves of keratin migrating outwards, the malleus handle in the drum, with its lateral process pointing anteriorly, the faint views of the long process of the incus and the promontory seen through the poster-superior part of the drum.

Normal ear drum, young person, right ear

Healthy ear canal and tympanic membrane. no scarring or blemishes, drum has good light reflex, and lucency, so that some of contents of middle ear can be seen through the semi-transparent drum. All the pars tensa and also the pars flaccida of TM are well seen.


Atticotomy with tympanoplasty, and titanium ossiculoplasty with TORP, Tympanosclerosis of stapes

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


Central perforation, active mucosal, R ear

Inflamed wet large perforation with granular margins. thicket red middle ear mucosa on promontory

Dry posterior perforation, exposed LPI, Stapes, Stapedius, chorda and tympanic nerves, RW, promontory, R ear

Moderate sized 'central' perforation. Mucosal COM, good view of structures in posterior half of middle ear.

Dry perforation, inactive CSOM, tympanosclerosis, R ear

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.

Dry perforation of tympanic membrane, with tympanosclerosis, L ear

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.

Dry double perforations, R ear

Mucosal CSOM, two perforations. one is anteriorly between malleus handle and anterior annulus. the other is posterior and may represent perforated retraction pocket. although occasionally associated with TB of middle ear, most multiple perforations are simply associated with mucosal chronic otitis media or atelectasis.

Double perforations of ear drum, active CSOM, R ear

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.

Perforated TM, dry, eroded ISJ, R ear

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.

Perforated atelectasis, exposed middle ear anatomy, left ear

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.

Perforations of atelectatic tympanic membrane, eroded LPI, R ear

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.

Perforation of inflamed thick ear drum, bleeding granulation, L ear

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

Subtotal dry perforation, right ear

Perforation of entire ear drum except pars flaccida in attic. Malleus handle, shortened long process of incus, stapes superstructure, oval window niche, stapedius tendon and pyramid, round window niche, hypotympanic air cells, entrance to Eustachian tube, canal of tensor tympani, promontory, annulus of tympanic membrane, all well seen.


Extruding stapes prosthesis, late complication, 30yrs after stapedectomy, with granulations, R ear

After many years good hearing result from stapedectomy for otosclerosis, the TM formed a retraction over the Teflon stapes. The prostheses became dislocated form the incus and stated to extrude through the drum, the infected granulations developed around the prosthesis. The ear was explored, and the prosthesis carefully removed. It was no longer in the oval window. The drum was reconstructed with cartilage.

R and L ears, Clean pocket on stapes, L ear, Post-op Tympanoplasty and incus interposition with closed AB gap, R ear

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.

Post-op Tympanoplasty, incus interposition and cartilage graft over attic, right ear

Several years after tympanoplasty with small posterior atticotomy and ossiculoplasty. the white area is the cartilage graft placed as underlay to cover the atticotomy. the incus autograft is seen linked to malleus handle anteriorly. It's posterior part was carved to fit around stapes head. Good hearing outcome. Stable dry ear. Small area of tympanosclerosis in TM inferiorly. Intact drum.

T tube, post-op Tympanoplasty and Ossiculoplasty, right ear

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.

Previous atticotomy, right ear, attic retraction, residual cholesteatoma pearl in attic

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.


Dehiscent internal carotid artery pulsation in antero-medial middle ear, scarred thin TM, dried secretion trail coming from hidden posterior drum perforation

Look closely, through the thin section of drum anteriorly, just inferior to the patch of tympanosclerosis. the whitish wall of the exposed ICA can be seen to pulsate. In most people there is bone covering the artery at this point, but rarely the bone is dehiscent, and the artery wall is visible. in this L ear, there is scar of drum due to past infections, and a small trail of dried secretions running out along ear canal posterior wall, it probably conceals a dry pinhole perforation in the posterior part of the drum.

Pulsating TM, left ear, dehiscent internal carotid artery in middle ear, left ear

Rapid pulsating movement of tympanic membrane. Thin drum due to childhood ear infections. CT scan confirms bony dehiscence over internal carotid artery in anterior part of middle ear. Asymptomatic other than mild pulsatile tinnitus. No intervention required.

Thin TM moves with swallowing, Left ear

Very thin tympanic membrane with absent malleus handle. Drum moves in and out briskly when patient swallows. Left ear.

Thin TM moves with swallowing, Right ear

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

Recurrent pulsatile Glomus tumour in left ear mastoid cavity

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.


Atelectasis dry

Atelectatic dry right ear, TM plastered promontory, round window recess, stapedius tendon, pyramid, hypo tympanum. Small air bubble in middle ear near entrance to Eustachian tube. Pars flaccida also retracted, onto neck of malleus.

Atelectasis, left ear drum

Thin retracted ear drum, draped around partially eroded long process of incus. Very thin connection of LPI to stop head. stable but at risk of infection in pocket and of further erosion of the LPI, with increasing conductive hearing loss.

Attic erosion and deep dry pocket, history of recurrent infections, R ear

A dry plug of keratin was removed from the attic area by micro-suction under microscope. This revealed a deep retraction pocket and some bony erosion, exposing part of malleus head. with the endoscopic view the deep part of pocket can be inspected. No active cholesteatoma found, but history of recurrent debris collection and infection in this pocket.

R and L ears, Clean pocket on stapes, L ear, Post-op tplasty and incus interposition with closed gap, R ear

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.

Dry Attic retraction, complete atelectasis, adhesive otitis media, effusion, exposed VII, L ear

The drum is almost completely retracted into middle ear, the stapes superstructure ha resorbed. Malleus head and incus body partially resorbed. The retracted TM is plastered to the horizontal VII canal and stapes footplate. Deep self-cleansing erosion into attic.

Thin retracted TM, right ear

The tympanic membrane is very thin, and retracted around the incudo-stapedial joint, and onto the promontory. Despite this the middle ear appears ventilated. There is erosion of bone in the attic, so that the neck and head of malleus are just visible. The ear has been stable like this for some years. There was probably chronic mild discharge for some time in the past, but fortunately it self-healed and became dry spontaneously.

Thin postero-superior retraction pocket of ear drum, eroded LPI

Dry clean Post.Sup. retraction pocket. the long process of incus ie rode and not in contact with stapes head. retracted drum is touching stages head to provide type III mechanism and hence only minor conductive hearing loss. remainder of drum has widespread tympanosclerosis. Stable ear, no intervention required.

Thin retraction pocket of ear drum on eroded ISJ, left ear

Thin ear drum, retracted and perforated posteriorly. Plastered to eroded incudo-stapedial joint. Keratin flakes migrating out over posterior annulus. Beginning to form cholesteatoma.

Thin retracted ear drum onto Incudo-stapedial joint, right ear

Thin tympanic membrane, moderately retracted, adherent to thinned long process of incus. aerated middle ear. Small clean attic erosion exposing neck of malleus. Round window niche and promontory visible through the thinned drum.

Tympanic Membrane retraction onto promontory, right ear

Almost the entire drum has retracted onto the medial wall of the middle ear. It is plastered to the promontory, exposing the round window overhang. it is also wrapped onto the stapedius tendon, ISJ and the pyramid. There appears to be a fluid level behind the drum anteriorly, near the entrance to the Eustachian tube.


Active CSOM, Posterior and attic retractions, eroded stapes, L ear

This video is rotated 90 degrees, so that superior is towards left side. Posterior is at top of image. There is also some debris on endoscope lens. None the less, we can see deep retractions in the posterior drum and the attic. Both are wet but no obvious cholesteatoma. There is small trail of wet keratin running over the annulus from the stapes remnant. Most of stapes superstructure is absent. Thick wet mucosa overlying the footplate is seen, with canal of horizontal VII above. Some of malleus head is visible in the attic erosion.

Wet keratin in post pocket of ear drum, left ear

Most of this tympanic membrane is retracted/atelectatic White flakes of wet keratin/cholesteatoma can be seen in posterior retracted part of drum. The malleus handle is prominent because the drum has retracted away medially from it. A trail of keratin migrating out of the pocket, and going laterally can be seen on posterior ear canal wall.

Wet attic retraction, right ear drum

There are wet retracted areas of the drum in the attic and the postero-superior quadrant of the drum. The posterior retraction is adherent to the long process of the incus and incudo-stapedial joint. The moist area of the pars flaccida, above the lateral process of the malleus, hides a retraction pocket and may also hide active cholesteatoma.

Wet posterior retraction of tympanic membrane, with myringitis, right ear

Postero-superior retraction pocket of ear drum. Lining of pocket and adjacent canal skin are wet, inflamed and granular. Active myringitis. Anterior part of drum is thick and opaque. Small moist attic retraction pocket also seen.