Is any discharge present? Purulent discharge may be related to bacterial infection. Eczema may cause flaking and cracking behind the ears. A bloody discharge may be caused by irritation, injury, a foreign body, or a basilar skull fracture.

Use the otoscope to inspect the external canal and tympanic membrane. A cooperative 2- to 3-year-old child may be either sitting or lying prone on the examination table with the head turned to one side. An uncooperative child can be held upright or prone in a parent's arms. The otoscope should be held as indicated previously. Use the largest speculum possible. Insert the speculum tip to only 1/2 inch (1.2 cm).

Inspect the tympanic membrane. Redness is commonly seen and may be caused by infection, trauma, or even crying. In suppurative otitis media, the drum bulges outward and becomes diffusely erythematous or even opaque yellow, hearing is decreased, and the light reflex may be lost. Is the tympanic membrane perforated? Does the tympanic membrane move with insufflation? An immobile drum is present in suppurative or serous otitis media (see previous discussion and Fig. 11-29).

Palpate the mastoid tip. Is it tender? Tenderness is suggestive of mastoiditis, which may be associated with redness of the mastoid and forward displacement of the pinna, most obvious when the child is viewed from behind.

Are posterior auricular lymph nodes present? These nodes are classically found in children with rubella. They are also found in children with measles, roseola, chickenpox, or inflammations of the scalp.

Check hearing. Hearing is necessary for the normal development of language. As a screening test, occlude one ear, and whisper a number into the child's other ear. Ask the child what number he or she heard. Repeat the test with the other ear. If hearing loss is suspected, or the child has language delay, the child should be scheduled for audiometric testing as soon as possible.

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