FIG 2 - uploaded by Christianne Veugen
Content may be subject to copyright.
The adjusted Sade classification used in this study as described in the Methods section. 1: Sade I: mild retraction in the posterosuperior quadrant of the right tympanic membrane. 2: Sade II: retraction in the posterosuperior quadrant of the pars tensa in which the right tympanic membrane touches the incus, with a slight retraction in the pars flaccida. 3: Sade III: retraction in the posterosuperior quadrant of the pars tensa in which the left tympanic membrane touches the incus and the promontory, with a slight retraction in pars flaccida and tympanosclerosis of the anterior edge of the pars tensa. 4: Sade III: subtotal atelectasis of the posterosuperior quadrant of the right tympanic membrane in which the incus and the promontory are clearly visible.
Source publication
Introduction:
Tympanic membrane retraction (TMR) is a relatively common otologic finding. Currently, there is no consensus on the optimal treatment of TMR. Some ENT-surgeons advocate surgical correction while others opt for a watchful-waiting policy. Our aim was to investigate the natural course of retraction pockets in the posterosuperior quadran...
Context in source publication
Citations
... An inactive mucosal COM implied either dry central perforation or pars tensa retraction without cul-de-sac (pocket) (Sadé stages I-IV; for generalized pars tensa retraction), with/without mucosal edema, hyperemia, granulations, or glue determined at surgery, but not with frank (mucoid/mucopurulent) discharge [11][12][13] . These disease states corresponded to COM without cholesteatoma 2,5 . ...
Objective: Pure tone audiometry (PTA) guides surgical decision-making
in chronic otitis media (COM), and PTA values depend upon the type and
extent of COM.
Methods: Our cross-sectional study included patients with COM with/
without cholesteatoma who were scheduled for surgery. Findings on
examination of the middle ear under the microscope and at surgery which
could explain the hearing loss were corroborated with preoperative PTA
through appropriate statistical methods.
Results: The study included 114 patients (mean age: 31.07 years; range:
7-57). Following preoperative PTA, 50% of patients had moderate hearing
loss and ~73% had air-bone gap (ABG) <35 dB. Conductive hearing loss
affected 109 patients (97.61%); five had mixed hearing loss. At surgery, 27
patients (23.68%) had ossicular discontinuity, with the incus being the most
affected. Twenty-one patients in this group had ABG ≥35 dB. Perforations
involving the anterior and posterior halves of the pars tensa, and subtotal
perforations, demonstrated the maximum mean hearing loss [45.39±8.29
dB HL (p=0.075), 51.08±12.51 dB HL (p=0.26), respectively]. The mean pure
tone average in the intact ossicles group was 43.62±8.07 dB HL and that in
the absent/eroded ossicles group was 58.15±11.05 dB HL (p<0.0001); the
mean ABG was 27.89±4.77 dB and 38.88±6.47 dB, respectively (p<0.0001).
Conclusions: Hearing loss was significantly associated with the size but
not the site of the central perforation. With ossicular discontinuity, hearing
loss and ABG deteriorated significantly. The findings re-establish the
relationship between preoperative PTA and the middle ear status which
should help surgeons plan surgery and counsel patients regarding hearing
outcomes
... Even for retraction pockets of the pars tensa and independently from the grade, no vascularization was ever apparent in the retracted areas (Fig. 2b) [16]. When the tympanic membrane is completely bound to the middle ear structures, such as the promontory or ossicular chain by fibrous adhesions, it is called adhesive otitis media (AdOM) [17]. ...
Purpose
Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation.
Methods
Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard.
Results
NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice.
Conclusions
NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.
... The prevalence of TMRs in the military is not described in literature. In the majority of cases TMRs remain stable, and spontaneous recovery occurs in approximately 30% of mild TMR cases (Sade grade I) [4][5][6]. However, if TMRs are more severe, it can lead to conductive hearing loss, tympanic membrane perforations, erosion of the ossicular chain, higher rate of external otitis due to failure of the normal 'cleaning' of the tympanic membrane outer edges and formation of cholesteatoma. ...
... The wait-and-see policy is a conservative management policy in which patients with TMRs are followed-up at the otolaryngology clinic without invasive surgery or ventilation tube placement. The wait-and-see policy was used in three studies (Table 3) [5,6,31] (n = 207). In 76-96% of TMRs remain stable or improved during follow-up, complete remission rates vary between 0 and 38% [5,6,31]. ...
... The wait-and-see policy was used in three studies (Table 3) [5,6,31] (n = 207). In 76-96% of TMRs remain stable or improved during follow-up, complete remission rates vary between 0 and 38% [5,6,31]. One study found that no adult ears had complete remission, while 31% of children's ears did improve [31]. ...
Importance
Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances.
Objective
To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction.
Evidence review
The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development.
Findings
In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs.
Conclusions and relevance
This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).
... This watchful waiting policy is associated with good clinical outcomes (e.g. hearing outcomes) in patients with mild retractions (Bayoumy et al., 2021). Another strategy, especially for more severe retractions and adhesive otitis media, is to excise the tympanic membrane retraction, leaving behind a perforation which heals spontaneously in more than 90% of cases (Borgstein et al., 2008a). ...
The interest for telemedicine has increased since the COVID-19 pandemic because of the risk of infection. Recently, commercial companies started selling digital USB-otoscopes (DUO) that can be connected to a mobile phone. These DUOs are inexpensive (costing approximately $6e35 each) and make it possible to visualize the whole tympanic membrane. Here, we illustrate the case of a patient who had operative correction of a tympanic membrane retraction, and who self-monitored the tympanic membrane in the course of time. Additionally, we discuss the use of DUOs in otolaryngology telemedicine practice. The use of simple digital USB otoscopes provides a promising method to assess and monitor the tympanic membrane remotely. However, more research is needed to establish the role of DUOs in telemedicine.
... This watchful waiting policy is associated with good clinical outcomes (e.g. hearing outcomes) in patients with mild retractions (Bayoumy et al., 2021). Another strategy, especially for more severe retractions and adhesive otitis media, is to excise the tympanic membrane retraction, leaving behind a perforation which heals spontaneously in more than 90% of cases (Borgstein et al., 2008a). ...
The interest for telemedicine has increased since the COVID-19 pandemic because of the risk of infection. Recently, commercial companies started selling digital USB-otoscopes (DUO) that can be connected to a mobile phone. These DUOs are inexpensive (costing approximately $6–35 each) and make it possible to visualize the whole tympanic membrane. Here, we illustrate the case of a patient who had operative correction of a tympanic membrane retraction, and who self-monitored the tympanic membrane in the course of time. Additionally, we discussed the use of DUOs in otolaryngology telemedicine practice. The use of simple digital USB otoscopes provides a promising method to assess and monitor the tympanic membrane remotely. However, more research is needed to establish the role of DUOs in telemedicine.
Objective:
Review the effectiveness of surgical and non-surgical management strategies for isolated pars flaccida and combined pars tensa and flaccida tympanic membrane retractions in preventing progression or recurrence, improving hearing and preventing development of cholesteatoma.
Design:
Narrative review.
Setting:
ENT and otology services worldwide.
Participants:
Patients with non-cholesteatoma tympanic membrane retractions.
Main ouctome measure:
Changes in retraction (progression or resolution, or development of a known sequela such as perforation).
Results:
Eight full text papers are included: three randomised controlled trials and five case series or cohort studies of more than five patients (a total of 238 ears). Data exists for the use of conservative management, ventilation tubes, laser tympanoplasty, cartilage and fascia tympanoplasty, lateral attic reconstruction as well as mastoid procedures.
Conclusion:
Few high-quality studies on the management of isolated and combined pars flaccida retractions exist. For isolated pars flaccida retractions deemed to require surgical intervention, this review suggests that lateral attic reconstruction and cartilage tympanoplasty carries least risk of recurrence.
Purpose:
Progressive adherent pars tensa occasionally induces ossicular erosion. Specifically, stapes discontinuity adversely affects postoperative hearing. However, this irretrievable sequela is challenging to prove preoperatively, partly because perimatrix inflammation on the pars tensa can obscure the visibility of the ossicles or the partial volume effect of computed tomography (CT) imaging can hamper detailed ossicular visualization. Therefore, there is no consensus regarding the ideal timing for switching from a wait-and-see approach to a surgical one. Herein, we aimed to explore the potential predictors of stapes superstructure destruction in adherent pars tensa.
Methods:
This retrospective cohort study enrolled consecutive patients who underwent primary tympanoplasty for adherent pars tensa categorized as grade IV on Sadé's grading scale between April 2016 and September 2021. The impact of features on otoscopy and CT and air-bone gap (ABG) on stapes superstructure destruction was assessed using uni- and multivariable logistic regression analyses.
Results:
Sixty-four ears were included. Multivariate analysis revealed the presence of debris on the adherent pars tensa (odds ratio [OR] [95% confidence interval {CI}]): 4.799 [1.063-21.668], p = 0.0415), presence of soft-tissue density occupying the oval window (OR [95% CI]: 13.876 [3.084-62.437], p = 0.0006), and a ≥ 20-dB preoperative ABG at 3 kHz (OR [95% CI]: 7.595 [1.596-36.132], p = 0.0108) as independent predictors for stapes superstructure destruction.
Conclusion:
High preoperative awareness of the possibility of destruction of the stapes superstructure would enable the surgeon to make a timely decision to provide surgical intervention before progression to severe stapes destruction, thereby maintaining long-term satisfactory hearing.
Eustachian tube dysfunction (ETD) is a common middle ear disorder in children that can have a significant impact on the quality of life. This review aims to provide an updated understanding of ETD and its clinical management. We will discuss the pathophysiology and diagnosis of ETD, as well as the medical and surgical treatment of ETD. We will also review studies of both adults and children with ETD, although special attention will be paid to children with ETD.
