If there is a question of middle ear infection, pneumatic otoscopy should be performed. This technique requires the use of a speculum large enough to fit snugly into the external canal to establish a closed air chamber between the canal and the interior of the otoscopic head. A rubber squeeze bulb is attached to the otoscopic head. By squeezing the bulb, the examiner can increase the air pressure in the canal. Pneumatic otoscopy must be performed gently, and the patient should be informed that he or she may experience a blowing noise during the procedure. When the pressure in the otoscopic head is increased by squeezing the bulb, the normal tympanic membrane shows a prompt inward movement. In patients with an obstructed eustachian tube, the tympanic membrane moves sluggishly inward. If fluid is present in the middle ear, a marked decrease or absence of movement is detected. The reduction of movement of the tympanic membrane increases the probability of middle ear infection by as much as 40%. This simple technique can provide invaluable assistance in the early diagnosis of many middle ear problems.
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