My husband the internist likes to say that we peds MDs are pretending to see the TM, but I say the MDs for adults are pretending to hear diastolic murmurs. Kidding aside, you really can get good at seeing TMs in kids – a useful skill since 60% of kids will have AOM by age 4 years.

Tip 1: Positioning: my most successful position is with the child sitting on parent’s lap, turned 90 degrees to one side, legs held between the parent’s legs, parent restraining child with a “hug”. Rotate the child 180 degrees to face the other way to look at the other ear. Even though the below picture shows a child getting a shot, this is the basic positioning. Don’t let the child face forward, make sure they are turned to the side.

Ear Exam PositionDHS Comforting Restraint for Immunizations 2001

Tip 2) Specula: Our ED has just two size specula – 2.75mm “pediatric” and 4.25mm “adult”. If the child is 1yo or more, start with the larger specula. You can always go down in size if it’s too big or you need to push through or around wax. Don’t be afraid to push the speculum in a bit – it is tapered so you are unlikely to reach the tympanic membrane with the tip.

Tip 3) Otoscope: Grasp the helix of the ear and pull posteriorly and slightly outwards. Brace the fingers of your otoscope hand against the patient’s cheek so you can move with the child if he moves. Angle the speculum anteriorly as you enter – a common pitfall of trainees is seeing only the canal because the TM is angled more anteriorly in a young child. The best visual I could find of this positioning is a screen grab from the video below:

Ear Exam Position 2

Regarding the video, to examine the patient’s left ear, I prefer to keep the otoscope in my right hand and bring my left hand up and over the ear to pull on the helix, rather than switch hands