Audiogram Of Otitis Media

Adhesive Otitis Media Audiogram
Figure 6.23 Audiogram of the same case showing conductive hearing loss.

Figure 6.24 Left ear. Meso- and epitympanic retraction pockets that adhere to the head of the malleus, the partially eroded long process of the incus, and the incudostapedial joint. A ventilation tube has been inserted in the anterior quadrant to avoid further retraction that might lead to cholesteatoma.

Figure 6.26 Right ear. Large mesotympanic retraction pocket that caused erosion of the incus and stapes suprastructure. The second portion of the facial nerve passing superior to the oval window, the promontory, and the round window can all be seen in transparency. In cases with good social hearing and no otorrhea, surgery is not indicated.

Sade Grade Atelectasis Ear

Figure 6.25 Right ear. Grade IV atelectasis. All of the middle ear structures can be seen in transparency. Starting from the malleus and moving in a clockwise direction, we can distinguish the tubal opening, the hypotympanum, the promontory, the round window, the stapedius tendon, and the incudo-stapedial joint.

Figure 6.25 Right ear. Grade IV atelectasis. All of the middle ear structures can be seen in transparency. Starting from the malleus and moving in a clockwise direction, we can distinguish the tubal opening, the hypotympanum, the promontory, the round window, the stapedius tendon, and the incudo-stapedial joint.

Figure 6.26 Right ear. Large mesotympanic retraction pocket that caused erosion of the incus and stapes suprastructure. The second portion of the facial nerve passing superior to the oval window, the promontory, and the round window can all be seen in transparency. In cases with good social hearing and no otorrhea, surgery is not indicated.

Tympanic Membrane Promontory

Figure 6.27 Right ear. Posterior retraction pocket. The tympanic membrane adheres to the promontory, the round window, the partially eroded long process of the incus, the head of the stapes, and the stapedius tendon. The processus cochleariformis is clearly visible between the malleus and the long process of the incus. Middle ear effusion can be observed anterior to the malleus and in the region of the oval window. In this case, ventilation tube insertion is indicated in an attempt to prevent further erosion of the ossicular chain and the formation of mesotympanic cholesteatoma.

Figure 6.27 Right ear. Posterior retraction pocket. The tympanic membrane adheres to the promontory, the round window, the partially eroded long process of the incus, the head of the stapes, and the stapedius tendon. The processus cochleariformis is clearly visible between the malleus and the long process of the incus. Middle ear effusion can be observed anterior to the malleus and in the region of the oval window. In this case, ventilation tube insertion is indicated in an attempt to prevent further erosion of the ossicular chain and the formation of mesotympanic cholesteatoma.

Summary

In grade I, II, and III atelectasis, a long-term ventilation tube is usually inserted to prevent further retraction of the tympanic membrane. However, in cases with marked conductive hearing loss that denotes erosion of the incus or the superstructure of the stapes, ossiculoplasty is performed after extraction and sculpturing of the eroded incus or using a homologous incus. A large disk of tragal cartilage is used to reinforce the tympanic membrane. Indications for surgery in adhesive otitis media include cases with tympanic membrane perforation (grade V according to Sade 1979), with or without polypi, granulation or otorrhea, those cases with a large infected retraction pocket causing frequent otorrhea, or those with conductive hearing loss due to ossicular chain erosion. In all these cases a tym-panoplasty is performed using a postauricular incision. A disk of tragal cartilage is used with the peri-chondrium adherent to its lateral surface. If the handle of the malleus is present, it is incorporated into the cartilaginous disk after creating a triangular defect for its accommodation. This technique has the advantage of preventing retraction and adhesions between the tympanic membrane and the promontory. At the same time, it enables repair of the tympanic membrane perforation with the tragal perichondri-um.

It can be concluded that there is no single treatment for the atelectatic ear. The milder the degree of atelectasis, the more conservative the treatment is. It should be noted, however, that in the long term conservative treatment (e.g., ventilation tube) was not found to modify further evolution of atelectasis. As atelectasis results from eustachian tube dysfunction, the ideal solution would be correction of this defect. At present, there is no acceptable "functional" surgery for the eustachian tube. Individual treatment should be administered according to the consequences of this dysfunction in each case. Such a strategy, however, requires a high mental elasticity and versatile surgical techniques.

7 Non-Cholesteatomatous Chronic Otitis Media

The difference between acute and chronic otitis media is not the duration of the disease but rather the anatomo-pathological characteristics. Untreated acute otitis media persisting for months is still a process that tends essentially to return to normality. On the other hand, a chronic otitis, even if the ear stops discharging, has anatomopathological sequelae of clinical importance.

The most commonly encountered forms are active chronic suppurative otitis media characterized by otor-rhea and inactive chronic suppurative otitis media in which the ear is dry. Naturally, the active form may become quiescent either spontaneously or following treatment. The ear becomes dry and the condition is designated inactive. A dry perforation, however, may be infected, leading to ear discharge. In this latter case, the mucosa may be hyperplastic and thick due to interstitial edema, fibrosis, or cellular infiltration. In some cases, polypi are formed which may be large enough to occupy the external auditory canal. In other cases, persistence of suppuration can lead to ulceration of the mucosa, formation of granulation tissue, and even bone resorption. The anatomical sequelae of chronic otitis media vary. They may be in the form of a simple central tympanic membrane perforation, erosion of the ossicular chain, or formation of tympanosclerosis. Both the active and inactive forms cause functional alterations such as conductive or mixed hearing loss (very rarely sensorineural). The absence of squamous epithelium in the middle ear has led to the designation of this form as a "safe type" of otitis media. This is to distinguish it from cholesteatoma, which is considered "unsafe" due to the potential complications that may arise from the presence of keratinized squamous epithelium in the middle ear.

• General Characteristics of Tympanic Membrane Perforations

Tympanic membrane perforations are usually present at the pars tensa. Pars flaccida perforations are generally associated with epitympanic cholesteatoma.

If a tympanic membrane perforation does not heal spontaneously, the epithelial and mucosal layers creep and meet along the borders of the perforation. This pathological communication between the middle and external ear can be considered a true "air fistula." In the presence of a tympanic membrane perforation, the patient is subject to recurrent infections and ear discharge.

Whenever tympanic membrane perforations are diagnosed, the following three considerations must be fulfilled: 1) At the level of the perforation the site, size, and state of the remainder of the tympanic membrane around the perforation should be determined. 2) At the level of the middle ear, the state of the mucosa, the condition of the ossicular chain (if possible), and the presence or absence of epithelialization should be evaluated. 3) The otoscopic examination has to be complemented with the pure tone audiometry to have a better understanding of the ossicular chain (possible erosion of the incus, fixity of the chain).

Pars tensa perforations can be either central or marginal. Marginal perforations lie at the periphery of the tympanic membrane with absence of the fibrous annulus. Marginal perforations are considered "unsafe" because the skin of the external auditory canal, in the absence of the annulus, can easily advance towards the middle ear, giving rise to cholesteatoma.

Otoscopic examination can often define the junction between the skin and mucosa at the borders of the tympanic membrane perforation. At this junction the squamous epithelium has a "velvety" appearance. The presence of a red de-epithelialized ring along the perforation rim indicates the evagination of the mucosa towards the external surface of the tympanic membrane residue. However, invagination of the skin towards the inner surface of the tympanic membrane residue is more difficult to diagnose. This inward skin migration is favored by the atrophy of the mucosa which occurs as a result of the perforation. At the time of myringoplasty, freshening of the edge of the perforation not only favors the attachment of the graft but also greatly reduces the risk of leaving entrapped skin on the undersurface of the drum, which may lead to iatrogenic cholesteatoma.

Conductive hearing loss caused by tympanic membrane perforation has two main causes: 1) Reduction of the tympanic membrane surface area on which the acoustic pressure exerts its action. 2) Reduction of the vibratory movements of the cochlear fluids because sound reaches both windows at nearly the same time without the dampening and phase-changing effect of the intact tympanic membrane.

The site of the perforation cannot be correlated to a particular audiometric pattern. However, it is generally observed that hearing loss occurs more in the low frequencies and that for perforations of the same size, hearing loss occurs more in posterior perforations than in anterior ones.

The majority of posttraumatic and postotitic perforations heal spontaneously. When large portions of the tympanic membrane are lost or when chronic or recurrent infections occur, the perforation may become permanent. In these cases, the tympanic membrane must be repaired (myringoplasty) to restore the normal physiology of the ear.

Posterior Perforations

Tympanic Membrane Atrophy

Figure 7.1 Left ear. The tympanic membrane is very thin due to atrophy of the fibrous layer. A posterosuperior marginal perforation is seen. This perforation is risky because the skin of the external auditory canal can easily advance into the middle ear, forming a cholesteatoma. In this case, a myringo-plasty using an endomeatal approach is indicated.

Cholesteatoma Marginal Posterior

Figure 7.2 Right ear. Marginal posterosuperior perforation through which the intact incudostapedial joint, the stapedius tendon, and the pyramidal process can be seen.

Figure 7.1 Left ear. The tympanic membrane is very thin due to atrophy of the fibrous layer. A posterosuperior marginal perforation is seen. This perforation is risky because the skin of the external auditory canal can easily advance into the middle ear, forming a cholesteatoma. In this case, a myringo-plasty using an endomeatal approach is indicated.

Figure 7.2 Right ear. Marginal posterosuperior perforation through which the intact incudostapedial joint, the stapedius tendon, and the pyramidal process can be seen.

Audiogram Perforated Membrane

Figure 7.3 Left ear. Perforation of the posterosuperior quadrant of the tympanic membrane. Visualized through the perforation are the incudostapedial joint, the stapes, the stapedius tendon, the pyramidal process, the promontory, and the round window. The residue of the tympanic membrane is very thin due to absence of the fibrous layer. Tympanosclerosis can be seen in the marginal part of the drum residue. From the surgical point of view, posterior perforations are the easiest to repair especially when partial reconstruction of the tympanic membrane is all that is required. When the residue of the tympanic membrane is transformed into a rigid tympanosclerotic

Detachment Ear Membrane

Figure 7.4 Right ear. Large perforation of the posterior quadrants. Normal middle ear mucosa. The incudostapedial joint is intact. The oval window with the annular ligament surrounding the footplate can be seen. The pyramidal eminence, the stapedius tendon, the round window, and Jacobson's nerve running on the promontory are also visible. The remaining anterior quadrants of the tympanic membrane are tympanosclerotic and rigid, blocking the mobility of the malleus.

Figure 7.3 Left ear. Perforation of the posterosuperior quadrant of the tympanic membrane. Visualized through the perforation are the incudostapedial joint, the stapes, the stapedius tendon, the pyramidal process, the promontory, and the round window. The residue of the tympanic membrane is very thin due to absence of the fibrous layer. Tympanosclerosis can be seen in the marginal part of the drum residue. From the surgical point of view, posterior perforations are the easiest to repair especially when partial reconstruction of the tympanic membrane is all that is required. When the residue of the tympanic membrane is transformed into a rigid tympanosclerotic plaque, it is advisable to remove it, conserving the epidermal layer to be laid over the graft.

Figure 7.4 Right ear. Large perforation of the posterior quadrants. Normal middle ear mucosa. The incudostapedial joint is intact. The oval window with the annular ligament surrounding the footplate can be seen. The pyramidal eminence, the stapedius tendon, the round window, and Jacobson's nerve running on the promontory are also visible. The remaining anterior quadrants of the tympanic membrane are tympanosclerotic and rigid, blocking the mobility of the malleus.

Figure 7.5 Right ear. Presence of chronic otitis media. Dry perforation of the posterior quadrants of the tympanic membrane through which the head of the stapes and the round window are visible. The long process of the incus is necrosed. The middle ear mucosa is normal. The tympanic membrane residue shows tympanosclerosis with alternating areas of calcification and areas of thinned membrane due to atrophy of the fibrous layer. The operation, performed through a postauricular incision, will also include the reconstruction of the ossicular chain using the autologous incus.

Anterior Posterior Perforation Left Ear
Figure 7.6 Left ear. Posterior nonmarginal perforation. The incudostapedial joint, the promontory, and the round window are all discernible.

Figure 7.5 Right ear. Presence of chronic otitis media. Dry perforation of the posterior quadrants of the tympanic membrane through which the head of the stapes and the round window are visible. The long process of the incus is necrosed. The middle ear mucosa is normal. The tympanic membrane residue shows tympanosclerosis with alternating areas of calcification and areas of thinned membrane due to atrophy of the fibrous layer. The operation, performed through a postauricular incision, will also include the reconstruction of the ossicular chain using the autologous incus.

Otitis Media Tympanic Membrane

Figure 7.7 Right ear. Presence of simple chronic otitis media; a posteroinferior drum perforation. The middle ear mucosa is normal. The round window and Jacobson's nerve running on the promontory are seen. The incus can also be appreciated posterior to a retromalleolar tympanosderotic plaque. The tympanic membrane residue shows areas of atrophy alternating with areas of tympanosclerosis.

Figure 7.8 Left ear. Perforation of the posterior quadrants of the tympanic membrane. The skin advances along the pos-terosuperior border of the perforation towards the incudo-stapedial joint. The middle ear mucosa appears hypertrophic. Mucoid discharge is also present. A tympanosderotic plaque can be seen in the residue of the tympanic membrane.

Marginal Perforation Tympanic
Figure 7.9 Right ear. Marked posterior marginal perforation through which the skin penetrates into the middle ear. The ossicular chain is not identifiable.

Anterior Perforations

Anterior Cartilaginous Perforations

Figure 7.11 Right ear. Anterior perforation in a patient with anterior and posterior humps of the external auditory canal as well as exostosis of the superior canal wall. In this case, canalplasty should be performed at the same time as my-ringoplasty.

Figure 7.10 Left ear. Anterior perforation of the tympanic membrane through which the tubal orifice is visible. A white mass is present behind the anterosuperior margin of the perforation. This mass can be either a cholesteatoma or a tym-panosclerotic plaque. The consistency of the mass can be tested using an instrument under the microscope; the cholesteatoma is soft and will break, whereas tympanosclero-sis is generally hard.

Figure 7.11 Right ear. Anterior perforation in a patient with anterior and posterior humps of the external auditory canal as well as exostosis of the superior canal wall. In this case, canalplasty should be performed at the same time as my-ringoplasty.

Tympanic Membrane Normal

Figure 7.12 Left ear. Dry anteroinferior perforation. The middle ear mucosa is normal. The tympanic membrane residue shows tympanosclerosis, giving it a white aspect. The tubal orifice can be seen from the anterior margin of the perforation.

Figure 7.13 Right ear. Anteroinferior perforation. The posterior and anterior residues of the tympanic membrane show tympanosclerosis. The anteroinferior residue of the drum is de-epithelialized. The tubal orifice is also visible.

Figure 7.12 Left ear. Dry anteroinferior perforation. The middle ear mucosa is normal. The tympanic membrane residue shows tympanosclerosis, giving it a white aspect. The tubal orifice can be seen from the anterior margin of the perforation.

Figure 7.13 Right ear. Anteroinferior perforation. The posterior and anterior residues of the tympanic membrane show tympanosclerosis. The anteroinferior residue of the drum is de-epithelialized. The tubal orifice is also visible.

Anteroinferior Perforation
Figure 7.14 Right ear. Anteroinferior perforation. Two tym-panosclerotic plaques are appreciated: one anteromalleolar and the other retromalleolar. The middle ear mucosa is normal. The hypotympanic air cells are seen through the perforation.

Subtotal and Total Perforations

Tympanic Membrane Perforation

Figure 7.15 Right ear. Large tympanic membrane perforation. The tubal orifice, the hypotympanic air cells, the promontory, the round and oval windows, and the intact stapes can be viewed. An onset of necrosis of the incus can be distinguished.

Pictures The Human Ear Stapes

Figure 7.16 Right ear. Perforation of the inferior quadrants of the tympanic membrane. All the tympanic membrane residue shows dense tympanosclerosis. Removal of these sclerotic plaques during myringoplasty assures an adequate vascularity to the graft, and thus a high success rate for the operation.

Figure 7.15 Right ear. Large tympanic membrane perforation. The tubal orifice, the hypotympanic air cells, the promontory, the round and oval windows, and the intact stapes can be viewed. An onset of necrosis of the incus can be distinguished.

Figure 7.16 Right ear. Perforation of the inferior quadrants of the tympanic membrane. All the tympanic membrane residue shows dense tympanosclerosis. Removal of these sclerotic plaques during myringoplasty assures an adequate vascularity to the graft, and thus a high success rate for the operation.

Superior Annulus Tympanic Membrane
Figure 7.17 Right ear. Similar case. The promontory and the round window are visible. A tympanosclerotic plaque that engulfs the ossicular chain is seen at the level of the postero-superior border of the perforation.
Round Window Membrane

Figure 7.18 Left ear. Subtotal perforation. The annulus as well as a fibrous rim are visualized along the inferior border of the perforation. The handle of the malleus is medialized. The tubal orifice, the hypotympanic air cells covered with mucosa, Jacobson's nerve on the promontory, and the long process of the incus are visible. The residue of the tympanic membrane is thickened. In cases in which only a small anterior residue of the tympanic membrane is found, an overlay technique in which the graft is put over the annulus is used, thus preventing detachment of the anterior part of the graft leading to reperf oration.

Figure 7.18 Left ear. Subtotal perforation. The annulus as well as a fibrous rim are visualized along the inferior border of the perforation. The handle of the malleus is medialized. The tubal orifice, the hypotympanic air cells covered with mucosa, Jacobson's nerve on the promontory, and the long process of the incus are visible. The residue of the tympanic membrane is thickened. In cases in which only a small anterior residue of the tympanic membrane is found, an overlay technique in which the graft is put over the annulus is used, thus preventing detachment of the anterior part of the graft leading to reperf oration.

Tympanic Membrane Total Perforation

Figure 7.19 Left ear. Total perforation of the tympanic membrane through which evolving tympanosclerotic plaques are visible. The stapes and the stapedius tendon are visible. The long process of the incus is partially eroded. The handle of the malleus is medialized and adherent to the promontory. The tubal orifice and the hypotympanic air cells are also noted.

Figure 7.19 Left ear. Total perforation of the tympanic membrane through which evolving tympanosclerotic plaques are visible. The stapes and the stapedius tendon are visible. The long process of the incus is partially eroded. The handle of the malleus is medialized and adherent to the promontory. The tubal orifice and the hypotympanic air cells are also noted.

Figure 7.20 Left ear. Subtotal perforation of the tympanic membrane. The middle ear mucosa is normal. The tympanic membrane residue is de-epithelialized. The incudo-stapedial joint, the medialized handle of the malleus, and the hypotympanic air cells are visible.

Posttraumatic Perforations

Hemorrhagic Tympanic MembraneTympanic Membrane Blood
Figure 7.21 Left ear. Posttraumatic perforation of the tympanic membrane in the region of the cone of light. The blood clot over the perforation has not been removed. This clot helps to guide spontaneous healing of the drum.

Figure 7.22 Left ear. Posttraumatic perforation in the pos-terosuperior quadrant. The characteristic radial tear, running in the same direction as the fibers of the tympanic membrane, is apparent. Hemorrhagic points separating the epidermal layer from the fibrous layer are visible. These tiny hemorrhages are typical of posttraumatic perforations. This type of tympanic membrane perforation has a very high incidence of spontaneous healing.

Summary

The presence of a tympanic membrane perforation that does not heal spontaneously as in chronic otitis media represents an anatomical and functional defect that needs surgical correction in the majority of cases.

Myringoplasty is indicated in cases with and without otorrhea, with a small or a large air-bone gap, and with no age limit. It is contraindicated when the tympanic membrane perforation is present in the only hearing ear.

Myringoplasty is generally performed using a postauricular incision under local anesthesia-except for children where general anesthesia is used. The tympanic membrane is repaired by an autologous tempo-ralis fascia graft. We prefer the underlay technique in the majority of cases because it gives better results both anatomically and functionally. The overlay technique is used in selected cases when the anterior residue of the tympanic membrane is pathologic or absent. When properly performed, the overlay technique gives optimal results in these cases. Canalplasty is done whenever bony humps of the external canal are present that limit control of the perforation borders. If reperforation occurs after myringoplasty (in about 5% of cases), a revision operation is indicated after a few months. The results of the first and second operations in terms of graft take and reperforation are generally comparable.

• Perforations Complicated or Associated with Other Pathologies

Mesotympanum

Figure 7.23 Right ear. Total perforation. Epidermization is present in the regions of the mesotympanum and the ossicu-lar chain. The round window, hypotympanic air cells with thickened mucosa, Jacobson's nerve running on the promontory, and the tubal orifice are well visualized. This case is an example of chronic otitis media complicated by the presence of skin in the middle ear. Tympanoplasty should be staged. In the first stage, the skin is removed without traumatizing the ossicular chain, and the tympanic membrane is reconstructed.

Figure 7.23 Right ear. Total perforation. Epidermization is present in the regions of the mesotympanum and the ossicu-lar chain. The round window, hypotympanic air cells with thickened mucosa, Jacobson's nerve running on the promontory, and the tubal orifice are well visualized. This case is an example of chronic otitis media complicated by the presence of skin in the middle ear. Tympanoplasty should be staged. In the first stage, the skin is removed without traumatizing the ossicular chain, and the tympanic membrane is reconstructed.

Reconstructed Tympanic Membrane

Figure 7.24 Left ear. Large perforation with diffuse epider-mization of the middle ear associated with purulent otor-rhea. In these cases, even if the ossicular chain proves intact, mastoid exploration should be done. A second stage is performed 1 year after the first operation to check for any skin residues.

In the second stage, the middle ear is checked for any residual skin, and the ossicular chain is reconstructed.

Figure 7.24 Left ear. Large perforation with diffuse epider-mization of the middle ear associated with purulent otor-rhea. In these cases, even if the ossicular chain proves intact, mastoid exploration should be done. A second stage is performed 1 year after the first operation to check for any skin residues.

Chronic Suppurative Otitis Media

Figure 7.26 Right ear. Another example of chronic otitis media complicated with diffuse epidermization of the middle ear. Surgery follows the same rules as for cholesteatoma.

Tympanic Membrane Otitis Media
Figure 7.25 Right ear. Perforation of the inferior quadrants of the tympanic membrane, the residues of which show tympanosclerosis. Epidermization is evident over the promontory. Since epidermization is limited in this case, a single-stage tym-panoplasty can be performed.

Figure 7.26 Right ear. Another example of chronic otitis media complicated with diffuse epidermization of the middle ear. Surgery follows the same rules as for cholesteatoma.

Perforations Complicated or Associated with Other Pathologies

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Responses

  • Pearl
    Can audiograme be done in case of tympanic perforation?
    7 years ago
  • scudamor sackville
    Can small perforation of TM with cone of light present?
    6 years ago
  • GLORIA
    How to describe ear canals and tympanic membranes on a audiogram?
    6 years ago
  • auli
    What is in each middle ear quadrant?
    5 years ago
  • Primula
    How to identify ottis media on audiogram?
    3 years ago
  • irene
    Is there membrance on round window mice?
    2 years ago

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