The Tympanic Membrane and Middle

The Scar Solution Natural Scar Removal

Scar Solution By Sean Lowry

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Fig. 2.52 "Chalk" patches. White areas of tympanosclerosis (arrows) are common findings on examination of the drum. They are of little significance in themselves, and the hearing is often normal. A past history of otorrhea in childhood or grommet insertion is usual. Chalk patches do occur with no apparent past otitis media.

Extensive tympanosclerosis with a rigid drum is a sequela of past otitis media, and the ossicles, too, may be fixed or noncontinuous.

Tympanic Membrane Scarring

Fig. 2.53 Scarring of the drum. a A gossamer-thin membrane can be seen to close this previously well-defined central perforation (arrow). At first sight with the auriscope, a central perforation would appear to be the diagnosis; more careful examination with a pneumatic otoscope will show that this thin membrane moves and seals the defect, giving reassurance that the drum is intact.

b Scarring of the drum with retraction onto the round window, promontory, and incus (arrows) is also evidence of past otitis media. It is sometimes difficult to be sure whether this type of drum is intact; a thin layer of epithelium indrawn onto the middle-ear structures may seal the middle ear, and examination with the operating microscope may be necessary to be certain of an intact drum.

Fig. 2.53 Scarring of the drum. a A gossamer-thin membrane can be seen to close this previously well-defined central perforation (arrow). At first sight with the auriscope, a central perforation would appear to be the diagnosis; more careful examination with a pneumatic otoscope will show that this thin membrane moves and seals the defect, giving reassurance that the drum is intact.

b Scarring of the drum with retraction onto the round window, promontory, and incus (arrows) is also evidence of past otitis media. It is sometimes difficult to be sure whether this type of drum is intact; a thin layer of epithelium indrawn onto the middle-ear structures may seal the middle ear, and examination with the operating microscope may be necessary to be certain of an intact drum.

Tympanosclerosis And Grommet Scar

Fig. 2.52 "Chalk" patches. White areas of tympanosclerosis (arrows) are common findings on examination of the drum. They are of little significance in themselves, and the hearing is often normal. A past history of otorrhea in childhood or grommet insertion is usual. Chalk patches do occur with no apparent past otitis media.

Extensive tympanosclerosis with a rigid drum is a sequela of past otitis media, and the ossicles, too, may be fixed or noncontinuous.

Fig. 2.54 Scarred tympanic membrane. A scarred tympanic membrane in which the drum has become atelectatic and indrawn onto the long process of the incus and promontory (arrows).

Fig. 2.55 A retracted tympanic membrane which is thin and indrawn onto the long process of the incus (a), head of the stapes (b), promontary (c), and round window (d). The stapedius tendon is also seen in this panoramic view obtained with a fiberoptic endoscope.

Tympanic Membrane Scarring

Fig. 2.56 Traumatic perforation. A

blow on the ear with the hand is a common cause of traumatic perforation which has an irregular margin (a), and there is fresh blood or a blood clot (b) on the drum.

The defect is frequently slit-shaped (c). Pain and transient vertigo at the time of injury are followed by a tinnitus and hearing loss.

Fig. 2.56 Traumatic perforation. A

blow on the ear with the hand is a common cause of traumatic perforation which has an irregular margin (a), and there is fresh blood or a blood clot (b) on the drum.

The defect is frequently slit-shaped (c). Pain and transient vertigo at the time of injury are followed by a tinnitus and hearing loss.

Central Hearing Loss Hearing Defects Healing Tympanic PerforaitonTympanic Membrane Perforation Healed

Fig. 2.57 Healing perforation.Almost all traumatic perforations heal spontaneously within two months, a thin membrane growing across the defect. Traumatic perforations are usually central, but if the perforation extends to the annulus, healing may not occur. The extremely large traumatic perforations may also fail to close spontaneously.

Taking care to avoid water entering the middle ear and avoiding inflating the middle ear with the Valsalva maneuver are the only precautions the patient need take.

A middle-ear infection with discharge is the commonest complication, usually settling with a course of topical and systemic antibiotics. Blast injuries, barotrauma, foreign bodies or their careless removal, and even over-enthusiastic kissing of the ear may also cause traumatic perforations.

Fig. 2.58 Central perforation. Acute otitis media with pus under pressure in the middle ear may rupture the drum, and although healing usually occurs, a permanent perforation can result. These perforations are usually central. A small perforation may be symptom-free, but episodes of otorrhea with head colds and after swimming are common, along with a conductive hearing loss.

The otorrhea tends to be profuse and mucopurulent, and may be intermittent or persistent. This type of central perforation, when dry, is successfully closed with a fascial graft (myringopalsty).

Other complications with central perforations are rare, so they are described as "safe" perforations. A central perforation may persist after an episode of acute otitis media and otorrhea in childhood. Myringoplasty is usually delayed in children since closure by puberty is common. If, however, the upper respiratory tract is free of infection, and the perforation is the site of recurrent infections with impaired hearing, these are indications to proceed with myringoplasty in childhood.

Attic Marginal Perforation

Fig. 2.60 A posterior marginal perforation of the eardrum, taken with the fiberoptic camera, showing the round window and head of the stapes. A thin fibrous connection can be seen (arrow) which connects to the necrotic long process of the incus. This type of ossicular discontinuity is a common cause of conductive hearing loss following otitis media (with or without a perforation). Ossicular reconstruction surgery will restore the hearing.

Fig. 2.59 Marginal perforation. A perforation may reach the annulus posteriorly and is called marginal. The middle-ear structures are frequently seen through the perforation.

The well-defined margin of the round window is particularly obvious, and the promontory, incudostapedial joint, and stapedius are also apparent.

Fig. 2.59 Marginal perforation. A perforation may reach the annulus posteriorly and is called marginal. The middle-ear structures are frequently seen through the perforation.

The well-defined margin of the round window is particularly obvious, and the promontory, incudostapedial joint, and stapedius are also apparent.

Marginal Tympanic Membrane Perforation

Fig. 2.60 A posterior marginal perforation of the eardrum, taken with the fiberoptic camera, showing the round window and head of the stapes. A thin fibrous connection can be seen (arrow) which connects to the necrotic long process of the incus. This type of ossicular discontinuity is a common cause of conductive hearing loss following otitis media (with or without a perforation). Ossicular reconstruction surgery will restore the hearing.

Fig. 2.61 Squamous epithelium on the incus. The marginal perforation may enable squamous epithelium to migrate into the middle ear. In this ear, white squamous epithelium has formed on the incus. Marginal perforations, therefore, are described as "unsafe" since there is a risk of cholesteatoma (see Fig. 2.63).

The Tympanic Membrane and Middle Ear 77

Fig. 2.62 Attic perforation. Debris adherent to the pars flaccida of the drum (arrow) suggests an underlying attic perforation. Perforations of the pars flaccida (attic perforations) are invariably associated with cholesteatoma formation.

Fig. 2.63 Cholesteatoma. The debris, when removed, exposes a white mass of epithelium characteristic of a cholesteatoma (arrow). Cholesteatoma is not a neoplasm; it is simply squamous epithelium in the middle ear.

If ignored, it increases in size, becomes infected, and is associated with a scanty, fetid otorrhea. It may erode bone, leading to serious complications. Extension to involve the dura with intracranial infection may occur, and the facial nerve and labyrinth too may be eroded. The extent of the cholesteatoma determines the danger: A small attic pocket of epithelium is relatively harmless, and can be removed with suction, but an extensive mass of epithelium is dangerous and needs exploration and removal via a mastoidectomy approach.

A chronic discharging ear is not painful, and persistent pain and headache, or severe vertigo, strongly suggest an intracranial complication or labyrinth.

Delayed Intracranial Complications

Fig. 2.64 Cholesteatoma.

Cholesteatoma erodes the bony wall of the deep meatus so that a pocket containing white debris forms in the posterior-superior aspect of the drum (arrow).

The complete etiology of the cholesteatoma is not understood. Migration of epithelium into the middle ear via an attic or posterior marginal perforation certainly accounts for most cholesteatomas. However, cholesteatoma may occur behind an intact drum, and may form with central perforations. Eustachian tube dysfunction with a negative pressure in the middle ear, if long-standing, leads to a chronic middle-ear effusion (chronic otitis media with effusion) and a retracted drum. The pars flaccida retracts and may give the opportunity for a pocket of cholesteatoma to develop. In this picture of cholesteatoma, the remainder of the drum is a golden color and fluid is present in the middle ear. This longstanding effusion may have been responsible for this cholesteotoma formation.

Tympanic Membrane Color

Fig. 2.65 A cholesteatoma of 2 cm diameter removed at mastoidectomy presents the typical well-defined mass of white epithelium. The bone erosion that this mass causes shows on mastoid radiographs and computed tomography (CT) or magnetic resonance imaging (MRI) scans.

Fig. 2.65 A cholesteatoma of 2 cm diameter removed at mastoidectomy presents the typical well-defined mass of white epithelium. The bone erosion that this mass causes shows on mastoid radiographs and computed tomography (CT) or magnetic resonance imaging (MRI) scans.

Tympanic Membrane Erosion

Fig. 2.66 Aural granulation. In the same way that epithelium may migrate through a perforation into the middle ear, mucous membrane may extrude outwards to the meatus. Middle-ear mucous membrane extruding through a perforation (arrow) becomes infected and presents with a discharging ear. An aural granulation is seen in the deep meatus. Granulation may also form on the drum of the margin of the perforation, and rarely granulation tissue forms on an intact drum in otitis externa (granular myringitis) (see Fig. 2.45).

Fig. 2.67 Aural polyp. If the growth of granulation tissue is exuberant, a pedunculated polyp develops, which may present at the orifice of the meatus (arrow). Granulations and polyps commonly arise from the tympanic annulus posteriorly, but the originating site may also be the mucous membrane of the promontory, eustachian tube orifice, and antrum and aditus. Careful and thorough removal of polyps and granulation tissue to their site of origin is necessary. If the polyp is associated with cholesteatoma, removal by mastoid approach is required.

Mastoidectomy Danger Structures

Fig. 2.68 Mastoid abscess. A red, acutely tender swelling filling the postauricular sulcus (arrow), and pushing the pinna conspicuously forwards and outwards, is characteristic of a mastoid abscess.

In the past, mastoidectomy was needed for an acute mastoid abscess complicating acute otitis media. This was extremely common in the prean-tibiotic era, and required exenteration of the mastoid air cells (cortical mastoidectomy). The operation is now rarely performed in countries where antibiotics are available.

Fig. 2.68 Mastoid abscess. A red, acutely tender swelling filling the postauricular sulcus (arrow), and pushing the pinna conspicuously forwards and outwards, is characteristic of a mastoid abscess.

In the past, mastoidectomy was needed for an acute mastoid abscess complicating acute otitis media. This was extremely common in the prean-tibiotic era, and required exenteration of the mastoid air cells (cortical mastoidectomy). The operation is now rarely performed in countries where antibiotics are available.

Fig. 2.69 Enlarged meatus after mastoidectomy. A more extensive type of mastoidectomy is, however, still necessary for cholesteatoma which has extended beyond the middle ear. This operation often alters the anatomy of the ear. Examination after operation will show an enlarged meatus. At operation the meatus is enlarged with a meato-plasty to allow access to the mastoid cavity, so that wax can be removed with a Jobson-Horne probe or with suction. This is usually necessary once or twice a year, as the skin of the mastoid cavity does not migrate satisfactorily and therefore wax accumulates. Water entering in the ear following mastoidectomy should be avoided; infection and otorrhea tend to follow. Syringing of a mastoid cavity is also to be avoided, not only because of the possibility of subsequent otorrhea but because irrigation of water over the exposed lateral semicircular canal causes vertigo.

Fig. 2.70 Auriscopeview. With the auriscope, a ridge (containing the facial nerve) can be seen separating the drum anteriorly from the epithelized cavity posteriorly. Failure of the mastoid cavity to epithelize results in an infected cavity with discharge.

(Top arrow: mastoid cavity; middle arrow: facial ridge with the bone overlying the descending portion of the facial nerve; bottom arrow: tympanic membrane.)

Surgical techniques aim to remove cholesteatoma without exteriorizing the mastoid cavity, so that relatively normal anatomy is maintained postoperatively, and hearing is maintained or improved (intact canal wall tympanoplasty), although this operation is not suitable for every case. Although avoiding a mastoid cavity, the intact canal wall tympanoplasty technique tends to conceal a recurrence of cholesteatoma. There are also surgical techniques to obliterate the mastoid cavity with muscle, fascia, or bone grafts.

Inner Ear Infection Auriscope

Fig. 2.70 Auriscopeview. With the auriscope, a ridge (containing the facial nerve) can be seen separating the drum anteriorly from the epithelized cavity posteriorly. Failure of the mastoid cavity to epithelize results in an infected cavity with discharge.

(Top arrow: mastoid cavity; middle arrow: facial ridge with the bone overlying the descending portion of the facial nerve; bottom arrow: tympanic membrane.)

Endaural Post Aural Incision

Fig. 2.71a, b Postaural and endaural incisions. These are two commonly used incisors for access to the middle ear and mastoid. The postaural incision (a) is preferred if extensive mastoid exenteration is planned. The incision lines are delineated here, but in these sites the scars are imperceptible.

Fig. 2.71a, b Postaural and endaural incisions. These are two commonly used incisors for access to the middle ear and mastoid. The postaural incision (a) is preferred if extensive mastoid exenteration is planned. The incision lines are delineated here, but in these sites the scars are imperceptible.

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Responses

  • jeanette
    How attic perforation occur?
    7 years ago
  • Nebay
    What are the dangers of losing ear tympanic membrane?
    7 years ago
  • deborah
    Can tympanic membrane perforation cause hearing loss over time?
    1 year ago
  • albertina
    Can the slope of a tympanic membrane cause hearing loss?
    8 months ago
  • DONTE
    Does scarred tympanic membrane affect valsalva?
    1 month ago

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