Pneumatic otoscopy is a test that allows a healthcare provider to visually examine a patient’s eardrum (tympanic membrane) to see how well it moves in response to pressure changes inside the ear.

The test is performed with a pneumatic otoscope, a handheld instrument with a light that the examiner uses to look into the ear. This instrument is similar to a more traditional otoscope, but has a rubber bulb attached that allows the examiner to send a small puff of air into the ear. This changes the pressure inside, and the healthcare professional can watch how the eardrum responds to pressure changes.

While a traditional otoscopic exam is a standard part of any routine health examination, pneumatic otoscopy will not be performed unless a physician suspects that the patient suffers from recurring ear infections (otitis media) or fluid in the middle ear (otitis media with effusion).

Allergic conditions, such as allergic rhinitis (hay fever), can trigger many symptoms related to people’s ears. Sometimes, severe nasal allergies cause inflammation and blockage of the eustachian tube, which connects the nose to the middle ear. The tube is designed to allow air into the middle ear, and to drain fluid from the ears into the nasal cavity. When the eustachian tube fails to work properly, a number of ear conditions can develop including fluid collection, recurrent ear infections, ear pressure and pain, decreased hearing, ringing in the ears (tinnitus) and dizziness (vertigo).

Physicians perform a pneumatic otoscopy to see how well the eardrum (tympanic membrane) responds to changes in pressure.

The ear is made up of three sections: the outer ear, middle ear and inner ear. The outer ear begins with the visible, exposed part of the ear. It ends inside the head at the eardrum, a circular piece of tissue the size of a fingertip. Behind the eardrum is a space filled with air known as the middle ear. The small eustachian tube connects the middle ear to the back of the nose.

Three tiny bones (the malleus, incus and stapes – more commonly known as the hammer, anvil and stirrup) are collectively called the auditory ossicles. These connect the eardrum through the middle ear and into the inner ear. The inner ear is furthest inside the head and is important for hearing and balance.

The various components of the ear work together to conduct sound. As sound waves enter the ear, they cause the eardrum to move back and forth. This moves the three bones inside the middle ear, sending the sound waves across the middle ear to the inner ear, and finally on to the brain.

Physicians use a pneumatic otoscope when they suspect a patient has recurring ear infections (otitis media) or fluid behind the eardrum (otitis media with effusion). Such ear infections can result from severe nasal allergies (e.g., allergic rhinitis). Allergic reactions can produce mucus in the nasal passages that can flow back into the eustachian tube, creating a blockage. The tube becomes inflamed, which keeps air from passing to the middle ear and prevents fluid from draining away from the middle ear – increasing the risk of infection. A blocked eustachian tube can also cause ear pressure and pain, decreased hearing, ringing in the ears (tinnitus) and dizziness (vertigo).

Pneumatic otoscopy allows the physician to test the patient’s eardrum (tympanic membrane) for abnormalities. As in an exam with a traditional otoscope, the examiner looks through the speculum attached to a handheld device with a light. However, a pneumatic otoscope also allows the exam to be taken a step further.

While studying the eardrum, the physician can squeeze a bulb attached to the pneumatic otoscope. This sends a small puff of air into the ear, allowing the physician to see how well the eardrum moves in response to pressure changes inside the ear.

Poor eardrum response to pressure changes indicates fluid in the middle ear, which prevents the eardrum and middle ear bones from moving properly and causes a corresponding impairment of hearing.

Pneumatic otoscopy is a quick test that takes just a few minutes to complete. The test is usually painless. However, the patient may experience some discomfort or pain if an ear infection is present. Patients are not required to take any special steps in preparation for the procedure.

The physician will begin by dimming the light in the examination room. Young children will be instructed to lie down with their head turned to one side. Smaller children may sit on a parent’s lap and rest their head on the parent’s chest while the physician checks the other ear. Older children and adults will be asked to sit with their head tilted toward one shoulder, allowing the ear on the opposite side to be examined.

For the pneumatic otoscopy to be a success, the patient must hold very still. Because children make up the majority of patients needing these exams, parents can provide valuable help in keeping the child calm during the procedure. For example, parents may hold their child’s hand and sit on one side of the child while the examiner checks the opposite ear.

The physician will ask the patient to hold very still before peering into the ear through a speculum attached to a handheld, lighted device called a pneumatic otoscope. The physician will hold the device in one hand, while using the other to gently pull the ear up, back or forward. This straightens the ear canal and enables the physician to get a better view of the inside of the ear. The otoscope is then slowly inserted into the ear canal. As the physician examines the ear through the otoscope, he or she is careful not to insert the device too deeply.

If the patient has excessive amounts of earwax (cerumen), the physician will need to remove it before continuing with the pneumatic otoscopy.  

Initially, the physician will do a simple visual exam of the eardrum (tympanic membrane). When there is infection or fluid behind the eardrum, the physician or other healthcare provider may see one or more of the following indicators:

• The eardrum may bulge, or may be sucked in.
  
  
• The eardrum may be opaque or dull in appearance. A healthy eardrum should be translucent and have a shiny appearance. It will be difficult for the physician to see through an unhealthy eardrum.
  
  
• The eardrum may look yellow, gray or red. However, it should be noted that children’s eardrums often turn red when they cry, or when they have a cold or other respiratory infection. So, redness does not necessarily indicate infection.
  
  
• Amber fluid or bubbles behind the eardrum.
  
  
• Other irregularities in the eardrum may appear, including swelling, lesions, discharge, foreign bodies and perforation.

After completing the initial visual inspection, the physician will squeeze a small, rubber bulb attached to the pneumatic otoscope. This sends a puff of air into the ear, increasing pressure. A healthy eardrum will respond to this change by moving easily. If the eardrum does not appear to move or moves sluggishly, the presence of fluid in the middle ear is likely. Scarring or thickening of an inflamed eardrum also can restrict its ability to move.

Pneumatic otoscopy is a safe, painless procedure with no significant risks. The only possible risk for patients is the spread of infection from one ear to another. However, this may only occur if the otoscope is not disinfected before being placed in each ear.

A hearing test may be recommended if a pneumatic otoscopy finds evidence of fluid in the middle ear (otitis media with effusion), as this often affects a patient’s hearing capacity. A more precise test of middle ear function called tympanometry also may follow.

Antibiotics may be prescribed if a physician finds evidence of fluid or of an ear infection (otitis media), but often these conditions will clear by themselves with time.

If middle ear fluid or ear infections persist, a physician may suggest a procedure called myringotomy. Myringotomy is an outpatient surgical procedure to place tubes into the ears. It most often is recommended for children who have recurring ear infections (otitis media) or hearing problems due to fluid buildup in the middle ear space behind the eardrum (tympanic membrane). The tubes help fluid drain out of the middle ear and into the ear canal.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to pneumatic otoscopy:

1. Do my symptoms indicate the need for a pneumatic otoscopy?
   
   
2. Can you explain the procedure to me in detail?
   
   
3. Will I experience any pain during the procedure?
   
   
4. How long should I expect the test to take?
   
   
5. Are there any special steps I should take before, during or after the test?
   
   
6. Does the procedure pose any danger to me?
   
   
7. What will be the next step if you find evidence of an infection in my ear?
   
   
8. What will be the next step if you find evidence of fluid in my middle ear?
   
   
9. How can I make the test easier on my child?
   
   
10. What did you discover about my ear during the procedure?