Tympanic Membrane Perforation

Antral Membrane Perforation

Figure 7.27 Right ear. Large tympanic membrane perforation. The anterior drum residue shows tympanosclerosis. The ossicular chain is difficult to identify because of the presence of epidermization at this level. The round window is visible. A staged tympanoplasty is also indicated in this case.

Otitis Perforation

Figure 7.28 Right ear. Granulomatous otitis media. A roundish mass fills the middle ear. Serous otorrhea is present.

Figure 7.27 Right ear. Large tympanic membrane perforation. The anterior drum residue shows tympanosclerosis. The ossicular chain is difficult to identify because of the presence of epidermization at this level. The round window is visible. A staged tympanoplasty is also indicated in this case.

Figure 7.28 Right ear. Granulomatous otitis media. A roundish mass fills the middle ear. Serous otorrhea is present.

Otitis Media Serous Adults

Figure 7.29 Right ear. Small perforation of the inferior quadrants of the tympanic membrane with eversion of the mucosa onto the outer layer of the membrane. Tympanosclerosis, both antero- and posteromalleolar, can be noted.

Mucosal Disease Ear

Figure 7.30 Right ear. Case similar to that in Figure 7.29. The mucosa has replaced the epithelial layer. Ear discharge is also present. During myringoplasty, curettage of the everted mucosa is necessary until the fibrous layer of the tympanic membrane is reached.

Figure 7.29 Right ear. Small perforation of the inferior quadrants of the tympanic membrane with eversion of the mucosa onto the outer layer of the membrane. Tympanosclerosis, both antero- and posteromalleolar, can be noted.

Figure 7.30 Right ear. Case similar to that in Figure 7.29. The mucosa has replaced the epithelial layer. Ear discharge is also present. During myringoplasty, curettage of the everted mucosa is necessary until the fibrous layer of the tympanic membrane is reached.

Left Tympanic Marginal Perforation

Figure 7.31 Left ear. Perforation of the anterior quadrants. Skin envelopes the handle of the malleus. During myringoplasty, curettage of the skin is necessary before reconstruction.

Bulging Tympanic Membrane

Figure 7.32 Right ear. Posterior perforation. The residues of the tympanic membrane appear whitish and bulging. During surgery, the middle ear was occupied by granulomatous tissue that proved to be tuberculosis (TB) on histopathological examination. This patient had a past history of pulmonary TB. Tuberculous otitis media should be suspected in cases of pulmonary TB presenting with otorrhea.

Figure 7.31 Left ear. Perforation of the anterior quadrants. Skin envelopes the handle of the malleus. During myringoplasty, curettage of the skin is necessary before reconstruction.

Figure 7.32 Right ear. Posterior perforation. The residues of the tympanic membrane appear whitish and bulging. During surgery, the middle ear was occupied by granulomatous tissue that proved to be tuberculosis (TB) on histopathological examination. This patient had a past history of pulmonary TB. Tuberculous otitis media should be suspected in cases of pulmonary TB presenting with otorrhea.

• Tympanosclerosis

Tympanosclerosis is characterized by fibroblastic invasion of the submucosal spaces of the middle ear followed by thickening, hyalinization, and fusion of collagen fibers into a homogenous mass with calcium deposits and phosphate crystals. Though the patho-genesis is not yet clear, it seems that chronic otitis media is a predisposing factor. Two distinct forms are recognized:

Tympanosclerosis with Intact tympanic membrane. This is characterized by calcareous plaques (chalk patches) in the fibrous layer of the tympanic membrane. The antero- and posteromalleolar regions are usually involved. The periannular region of the inferior quadrants is also affected, forming a horseshoe pattern. The pars tensa is rigid, thick, and loses its elasticity, assuming a whitish aspect. Atrophic and thinned areas can also occur. Infrequently, in very advanced cases, the tympanosclerotic plaques occupy all the middle ear spaces, attic, and aditus and completely block the ossicular chain. The tympanic membrane in these cases is very thick or even replaced by the plaques.

Tympanosclerosis associated with tympanic membrane perforation. The perforation is frequently central or subtotal and the annulus, infiltrated by calcium deposits, is well visualized. Frequently, submucous nodular deposits are encountered in the middle ear. Ossicular fixation or erosion due to devitalization as a result of loss of blood supply can also occur. The middle ear mucosa is very thin with reduced vascularity. In some cases, tympanosclerotic plaques are seen extruding from the mucosa to present as white middle ear masses.

• Tympanosclerosis Associated with Perforation

White Spots Tympanic Membrane
Figure 7.33 Right ear. Tympanosclerosis associated with perforation. The tympanic membrane residues and the middle ear (promontory and hypotympanum) show the characteristic plaques. The malleus is blocked by tympanosclerosis.
Tympanic Membrane Bulging
Figure 7.35 Right ear. Perforations of the inferior quadrants with tympanosclerosis involving the residues of the tympanic membrane and the middle ear.
Tympanic Membrane
Figure 7.34 Right ear. Tympanosclerosis with perforation. A large tympanosclerotic plaque is noted in the anterior residue of the tympanic membrane. The middle ear is also involved. The promontory, oval window, stapes footplate, and round window can be appreciated.
Tympanosclerosis

Figure 7.36 Right ear. Tympanosclerosis with perforation. The tympanosclerotic process involves the anterior residues of the tympanic membrane and the mucosa of the promontory reaching to the posterior mesotympanum. At this level, ossification of the stapedius tendon is seen. The tympanic segment of the fallopian canal is covered by a sclerotic plaque. The long process of the incus is eroded.

Figure 7.36 Right ear. Tympanosclerosis with perforation. The tympanosclerotic process involves the anterior residues of the tympanic membrane and the mucosa of the promontory reaching to the posterior mesotympanum. At this level, ossification of the stapedius tendon is seen. The tympanic segment of the fallopian canal is covered by a sclerotic plaque. The long process of the incus is eroded.

Tympanosclerosis with Intact Tympanic Membrane

Tympanic Membrane Tympanosclerotic
Figure 7.37 Left ear. Tympanosclerosis and intact drum. The majority of the tympanic membrane is thinned due to atrophy of the fibrous layer. Two tympanosclerotic plaques are present near the anterior and posterior margins.
Quadrants Ear Drum
Figure 7.38 Left ear. The intact tympanic membrane shows tympanosclerotic plaques lying both anterior and posterior to the malleus that alternate with areas of atrophy (in the inferior quadrants).
Intact Tympanic Membrane
Figure 7.39 Left ear. Tympanosclerosis with intact drum. A large plaque is visible in the posterior quadrants of the tympanic membrane. The anterior quadrants are thinned and atrophic, allowing visualization of the tubal orifice.

Summary

Chronic otitis media associated with tympanosclero-sis represents a more complex anatomopathological entity. In cases with intact tympanic membrane, surgery is indicated in the presence of a significant air-bone gap, signifying ossicular chain affection. Should erosion or fixation of the ossicles be found, ossiculoplasty is performed. Fixation of the stapes is an indication for stapedotomy. In cases associated with tympanic membrane perforation, it is often possible to perform a single-stage reconstruction in which myringoplasty is performed with or without ossiculoplasty. A fixed stapes, however, is an indication for staging where myringoplas-ty is performed first, followed by a second-stage stapedotomy after a few months. In all suspected cases, the patient should be informed preoperatively of the possibility of staging surgery. In a small percentage of cases of chronic otitis media with tympanosclerosis, a good postoperative functional level can deteriorate with time due to refixation of the ossicular chain with consequent air-bone gap. In such cases, after achieving closure of the tympanic membrane, a hearing aid is recommended.

8 Chronic Suppurative Otitis Media with Cholesteatoma

Cholesteatoma is an epidermal inclusion cyst localized in the middle ear, whose capsule and matrix is formed from stratified squamous epithelium. The desquamating debris includes pearly white lamellae of keratin that accumulate concentrically, forming the cholestea-tomatous mass.

The term cholesteatoma is actually a misnomer. It is derived from the Greek "cole" or bile, "steatos" or fat, and "oma" or tumor. There is no relation between cholesteatoma and bile or fat. The suffix "oma" (tumor), however, is more appropriate because cholesteatoma can be considered an epidermal inclusion cyst.

Cholesteatoma can be divided into congenital (middle ear or petrous bone) and acquired (middle ear or petrous bone). Congenital cholesteatoma is derived from entrapped ectodermal cellular debris during embryonic development. When it involves the middle ear, it appears as a whitish retrotympanic mass that may be localized either anterior or posterior to the malleus (see Chapter 9). When it involves the petrous part of the temporal bone, it is termed congenital petrous bone cholesteatoma and in the majority of cases it is localized in the petrous apex (see Chapter 10). In this chapter we will deal exclusively with cholesteatoma involving the middle ear. Petrous bone cholesteatoma is dealt with in a later chapter.

Acquired cholesteatoma of the middle ear can be caused by invasion of the skin of the external auditory canal into the middle ear through a marginal perforation. It can also originate from a epitympanic retraction pocket that becomes so deep that keratin debris can no longer be expelled, leading to their accumulation and subsequent cholesteatoma formation. Such retraction pockets can remain asymptomatic until they become infected, resulting in otorrhea and hearing loss. In other cases, the only symptom might be progressive hearing loss due to erosion of the ossicular chain by the developing cholesteatoma.

Because it is not always easy to establish a clear distinction between epitympanic or posterosuperior retraction pockets and cholesteatoma, we prefer to follow up these patients with otomicroscopy and endoscopy. In cases in which the retraction pocket becomes deep, giving rise to a cholesteatoma, a tym-panoplasty is indicated. Because of the early stage of the disease, surgery can be done in a single stage.

Fetid otorrhea and hearing loss are the main complaints in cholesteatoma. In addition, complicated cases can manifest with vertigo and/or facial nerve paralysis. Vertigo occurs as a result of labyrinthine fistula, which is most commonly located in the lateral semicircular canal. Facial paralysis can be caused by pressure of the cholesteatoma sac or neuritis.

In rare cases, the cholesteatoma can invade the labyrinth, cochlea, posterior and middle fossa durae, the internal auditory canal, and the petrous apex, forming a petrous bone cholesteatoma (see Chapter 10).

Treatment of cholesteatoma is exclusively surgical. Early this century, radical mastoidectomy, a destructive procedure for the middle ear, was performed with the only goal being eradication of infection to save the ear.

In the early 1950s, the concept of tympanoplasty was introduced. Tympanoplasty was aimed at eradication of infection as well as reconstruction of the tym-pano-ossicular system. Today, two types of tym-panoplasty are employed: closed tympanoplasty in which the posterior canal wall is preserved, and open tympanoplasty in which the posterior canal wall is drilled. Both techniques, when performed appropriately and with the proper indications, can produce excellent results in terms of eradication of cholesteatoma and restoration of hearing. In children, the closed technique is preferred, performed in two stages, in the majority of cases due to their highly cellular mastoids and in an attempt to preserve the anatomy of the ear as much as possible. In adults, particularly in epitympanic cholesteatoma with marked erosion of the scutum, in cases with sclerotic mastoids, or when middle ear atelectasis is present, an open tym-panoplasty is performed (see also Chapter 13).

Epitympanic Retraction Pocket

Retraction Pocket

Figure 8.1 Right ear. Early epitympanic retraction pocket. The tympanic membrane shows grade I atelectasis. Middle ear effusion with characteristic yellowish coloration of the drum is seen. In the anterosuperior quadrant, the tubal orifice is visible in transparency, whereas the long process of the incus is evident in the posterosuperior quadrant. In the area of the cone of light, an atrophic part of the tympanic membrane due to a previous myringotomy can be appreciated.

Figure 8.1 Right ear. Early epitympanic retraction pocket. The tympanic membrane shows grade I atelectasis. Middle ear effusion with characteristic yellowish coloration of the drum is seen. In the anterosuperior quadrant, the tubal orifice is visible in transparency, whereas the long process of the incus is evident in the posterosuperior quadrant. In the area of the cone of light, an atrophic part of the tympanic membrane due to a previous myringotomy can be appreciated.

Otoscopic Cone Light
Figure 8.2 Right ear. Epitympanic retraction pocket with the onset of tympanosclerosis of the pars tensa of the tympanic membrane.
Retraction Pocket
Figure 8.3 Right ear, similar case. The anterior quadrants of the pars tensa are retracted and thickened.

Figure 8.4 Right ear. A large controllable epitympanic retraction pocket with erosion of the scutum. The head of the malleus is seen. Middle ear effusion gives the tympanic membrane the characteristic yellowish coloration. To prevent progression of the retraction pocket and the formation of adhesions, myringotomy, ventilation tube insertion, and regular follow-up are indicated. These cases frequently represent the

Retracted Normal Tympanic Membrane

transition from a simple retraction pocket to an initial attic cholesteatoma. The distinction between the two is sometimes difficult. In suspected cases, a high-resolution computed tomography (CT) scan (bone window) is beneficial for better evaluation of the extension of the retraction pocket. In cases where the condition remains stable with regular follow-up and where hearing is normal, no surgery is required. If the pocket extends deeper, giving rise to a frank cholesteatoma, surgery is indicated. If hearing is normal, an open tympanoplasty (modified Bondy technique) is performed in a single stage.

Epitympanic Cholesteatoma

Tympanoplasty Technique

Figure 8.5 Right ear. Epitympanic erosion with cholesteato-ma. The patient complained of fetid otorrhea and attacks of bloody ear discharge of several years' duration. Inflammatory tissue is seen surrounding the area of epitympanic erosion. As preoperative hearing was nearly normal (see audiogram, Fig. 8.6), a single-stage open tympanoplasty in the form of a modified dBHL

Figure 8.5 Right ear. Epitympanic erosion with cholesteato-ma. The patient complained of fetid otorrhea and attacks of bloody ear discharge of several years' duration. Inflammatory tissue is seen surrounding the area of epitympanic erosion. As preoperative hearing was nearly normal (see audiogram, Fig. 8.6), a single-stage open tympanoplasty in the form of a modified

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