Photos above from Tasman W, Jaeger E (eds): The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2001.

Papilledema signals increased intracranial pressure from such serious conditions as trauma, mass lesions, subarachnoid hemorrhage, or meningitis.

Vitreous floaters may be seen as dark specks or strands between the fundus and the lens. Cataracts are densities in the lens (see p. 180).

The Ears

The Auricle. Inspect each auricle and surrounding tissues for deformities, lumps, or skin lesions.

If ear pain, discharge, or inflammation is present, move the auricle up and down, press the tragus, and press firmly just behind the ear.

Ear Canal and Drum. To see the ear canal and drum, use an otoscope with the largest ear speculum that the canal will accommodate. Position the patient's head so that you can see comfortably through the instrument. To straighten the ear canal, grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head.

Tragus Tug

Holding the otoscope handle between your thumb and fingers, brace your hand against the patient's face. Your hand and instrument thus follow unexpected movements by the patient. (If you are uncomfortable switching hands for the left ear, as shown below, you may reach over that ear to pull it up and back with your left hand and rest your otoscope-holding right hand on the head behind the ear.)

Insert the speculum gently into the ear canal, directing it somewhat down and forward and through the hairs, if any.

Otoscopy Brace PositionEar Examination Tug Test

See Table 5-17, Lumps On or Near the Ear (pp. 192-193).

Movement of the auricle and tragus (the "tug test") is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear may be present in otitis media.

Nontender nodular swellings covered by normal skin deep in the ear canals suggest exostoses. These are nonmalignant overgrowths, which may obscure the drum.

Exostose Hear

Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or swelling. Cerumen, which varies in color and consistency from yellow and flaky to brown and sticky or even to dark and hard, may wholly or partly obscure your view.

In acute otitis externa, shown below, the canal is often swollen, narrowed, moist, pale, and tender. It may be reddened.

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