Describe adhesive otitis media, retraction pockets and tympanosclerosis.

Retraction Pockets and Atelectasis

• Retraction is inward displacement of the tympanic membrane from persistent negative middle ear pressure.
• atelectasis is generalised collapse of the drum onto the promontory, and adhesive otitis media is the end stage in which the drum becomes adherent to the promontory and ossicles.
• The sequence is a continuum: Eustachian dysfunction → negative pressure → retraction → loss of the fibrous middle layer with thinning → atelectasis → adhesion; and, where a pocket cannot self-cleanse, cholesteatoma
• SADE classified pars tensa retraction in four grades, and the grading guides management: I, mild retraction; II, retraction onto the incus or stapes; III, onto the promontory but not adherent (atelectasis); IV, adherent to the promontory (adhesive otitis media)

Tympanosclerosis

• Tympanosclerosis is hyaline degeneration with calcification of the collagen of the tympanic membrane and middle ear, occurring as a healing response to long-standing or repeated inflammation
• It follows chronic otitis media, recurrent acute otitis media, long-standing effusion, and grommet insertion, in which it is common at the site of the tube
• Pathologically the fibrous middle layer degenerates into hyaline material which then calcifies and may ossify. It is not infective and not progressive once the inflammation has settled
• Two forms, with very different significance:
• Myringosclerosis — confined to the tympanic membrane, appearing as chalky-white, horseshoe or crescent-shaped plaques. It is of NO functional significance and needs no treatment
• Tympanosclerosis of the middle ear — deposits around the ossicles, the oval window and the stapes footplate, causing ossicular fixation and a significant conductive hearing loss.
• The distinction matters because only the second requires treatment, and white plaques on the drum are frequently over-interpreted
• Tympanometry shows a shallow (type As) trace with reduced compliance.
• Differential — it must be told apart from otosclerosis.
• Management — myringosclerosis needs nothing; for middle ear disease, surgical removal of plaques with ossiculoplasty or stapes surgery, though results are unpredictable and RE-fixation is common.
• Ask whether you can see the bottom of the pocket; a pocket that cannot be fully seen has stopped cleansing itself
• Attic retraction is more dangerous than pars tensa.
• Use cartilage rather than fascia when repairing a retraction.
• A hearing aid is often better than surgery in adhesive otitis media, where results are poor and re-adhesion usual