FIGURE 118.1 The external meatus is opened by pulling the auricle in the posterior-superior direction and placing traction on the skin immediately in front of the tragus The TM should be evaluated for its appearance; part of the middle ear contents can usually be seen if the eardrum is translucent ( Fig 118.2 ) (see also Fig 58.2 ) Mobility should be evaluated with the pneumatic otoscope rather than visualization alone, as this can increase the accuracy of diagnosing middle ear pathology Pneumatic otoscopy is performed by applying positive and negative pressure to the TM, with the pneumatic otoscope fitted snugly into the ear canal The pressure applied to the ear can be varied by squeezing a rubber bulb (see Chapter 130 Procedures , section on Pneumatic Otoscopic Examination) Middle ear effusion is more likely to be present if the TM fails to move with this technique The ear of a neonate requires special attention to perform an adequate otologic examination The ear canal itself is narrow and collapsible Often, only the otoscopic speculum can be inserted, as positive pressure from the pneumatic bulb is used to distend the canal ahead of the advancing speculum The canal may be filled with vernix caseosa, which must be removed or irrigated out of the canal to permit visualization of the TM The neonate’s TM lies at a more oblique angle to