Physical Exam

Otoscopy

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Video coming September 2026

How to Perform

Attach the largest speculum that fits comfortably in the patient’s ear canal and turn on the otoscope. Hold the otoscope like a pen, with the hand or fingers braced against the patient’s cheek or head. With the opposite hand, straighten the ear canal by gently pulling the auricle up and back in an adult or older child, and down and back in an infant or young child. Before looking through the otoscope, gently place the speculum at the rim of the outer ear canal and angle the otoscope down the ear canal. Then look through the otoscope and adjust your angle to examine the ear canal and tympanic membrane, noting the membrane’s color, translucency, position and contour, visible landmarks, integrity, and any fluid or other abnormality. If performing pneumatic otoscopy, obtain an airtight seal and gently squeeze and release the bulb while observing the tympanic membrane for mobility.

How to Interpret

Acute Otitis Media

Bulging tympanic membrane on otoscopy in a child

Rule in

Very helpful

Rule out

—

Evidence:Limited

Cloudy (opacified) tympanic membrane on otoscopy in a child

Rule in

Very helpful

Rule out

—

Evidence:Limited

Distinctly impaired tympanic membrane mobility on pneumatic otoscopy in a child

Rule in

Very helpful

Rule out

—

Evidence:Limited

Distinctly red tympanic membrane on otoscopy in a child

Rule in

Helpful

Rule out

—

Evidence:Limited

Otitis Media with Effusion

Reduced tympanic membrane mobility on pneumatic otoscopy in a child

Rule in

Somewhat helpfulDerived CI

Rule out

Very helpfulDerived CI

Evidence:Strong

References

Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-1640. doi:10.1001/jama.290.12.1633. PMID: 14506123. Karma PH, Penttilä MA, Sipilä MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. Int J Pediatr Otorhinolaryngol. 1989;17(1):37-49.
Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-1640. doi:10.1001/jama.290.12.1633. PMID: 14506123. Free DARE summary at NCBI Bookshelf NBK70308.
Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-1640. PMID: 14506123. Karma PH, Penttila MA, Sipila MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol. 1989;17(1):37-49. PMID: 2707977.
Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA. 2003;290(12):1633-1640. PMID: 14506123.
Takata GS, Chan LS, Morphew T, Mangione-Smith R, Morton SC, Shekelle P. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics. 2003;112(6 Pt 1):1379-1387. PMID: 14654613.
Takata GS, Chan LS, Morphew T, Mangione-Smith R, Morton SC, Shekelle P. Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. Pediatrics. 2003;112(6 Pt 1):1379-1387. doi:10.1542/peds.112.6.1379. PMID: 14654613.
Smith ME, Takwoingi Y, Deeks J, et al. Eustachian tube dysfunction: A diagnostic accuracy study and proposed diagnostic pathway. PLoS One. 2018;13(11):e0206946. PMID: 30408100.
Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24. doi:10.1177/0194599813517083.
Vaca M, Medina MM, Cordero AI, et al. Necrotizing external otitis: diagnostic clues in the emergency department. Eur Arch Otorhinolaryngol. 2024;281(2):737-742. doi:10.1007/s00405-023-08178-4. PMID: 37548705.
Solai C, Domingues CA, Nogueira LS, Sousa RMC. Clinical signs of basilar skull fracture and their predictive value in diagnosis of this injury. J Trauma Nurs. 2018;25(5):301-306. PMID: 30216260.
Saha P, Thomas I, Kunkulol R. Evaluation of Accuracy of Clinical and Preoperative HRCT Diagnostic Findings with Intraoperative Findings in Patients of Cholesteatoma. Indian J Otolaryngol Head Neck Surg. 2025;77(1):371-376. doi:10.1007/s12070-024-05193-7. PMID: 40071005.
Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 9, 2026.