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Age range (months)
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37 Pathogenesis ofChronic Otitis Media andtheContinuum: TheBasics, Further andBeyond
351
American Academy of Otolaryngology-Head and Neck
80
60
40
20
0
up to 24 25 to 84 85 to 144
%
50
40
30
20
10
0
up to 24
%
16
Chronic cholesteatomatous otitis
12
media
8
4
0
up to 24
%
12
Chronic non-cholesteatomatous
otitis media
8
4
0
up to 24
Moderate/severe retrac
25 to 84
25 to 84
25 to 84
85 to 144
85 to 144
85 to 144
Eusions
> 145
> 145
> 145
> 145
Surgery selected a subcommittee composed of experts in the
elds of primary care, otolaryngology, infectious diseases,
epidemiology, hearing, speech and language, and advancedpractice nursing to review the OME guideline.
According to the panel recommendations, “conditions of
the tympanic membrane that generally mandate inserting a
tympanostomy tube are posterosuperior retraction pockets,
ossicular erosion, adhesive atelectasis, and retraction pockets that accumulate keratin debris. Ongoing surveillance is
mandatory, because the incidence of structural damage.”
It should be noticed that all the above-mentioned conditions are already under the scope of COM (with an honorable
mention to “retraction pockets that accumulate keratin
debris” which literally represents Schuknecht’s [18]deni-
tion of aural cholesteatoma). The insertion of a ventilation
tube at this moment it is not only late but also not anymore
indicated, since it will never abort neither abbreviate the natural history of the disease.
In accordance with the Continuum theory, OME is the initial step of the process that, when unresolved, may progress
to chronic transformation. Although only a percentage of the
ears with OME will evolve to COM, our attached question is:
once bilateral effusion are reported to be high [29], shouldn’t
Fig. 37.25 Linear correlation between age range and otologic
ndings
the presence of bilateral COM be also very prevalent?
Therefore, we postulate that the presence of COM in one
ear carries a higher risk of coexisting contralateral abnormalities. Based on such reasoning and the limited data avail-
Otitis Media: Beyond
able in the literature [30, 31], we have decided to report the
characteristics of the contralateral ear (CLE) in COM. To
The Contralateral Ear inChronic Otitis Media
emphasize our concepts and trying to build up overlapped
evidences, we carried out three different studies focusing: (1)
It is curious to notice that even after such massive evidences,
the Continuum theory is not so much explored by those who
dedicate their best efforts to study COM pathogenesis and
natural history. Perhaps one of the reasons for such a paradox
is due to the extreme concern of the clinicians in unveiling
the secrets of two groups of conditions: otitis media with
the cellular level—histology (histopathology of 170 human
temporal bones with COM); (2) the anatomy—clinical picture (ME ndings of 500 patients with COM and CT scan
ndings in 75 patients); and (3) the physiology—function
(the quantication of the air–bone gap in the CLE of 463
patients with COM).
effusion (OME) and cholesteatomas. These studies have
effectively shed light on a number of questions related to the
etiopathogenesis, diagnosis, and treatment of these conditions. Notwithstanding, few studies try to establish the right
connections existing between these two extremes that, when
separately analyzed, seem to follow parallel natural histories.
A tacit example of this disconnection is the joint document
published by the American Academies of Otolaryngology,
Pediatrics and Family Practice in May [28].
These guidelines were published for the sole purpose of
informing clinicians of evidence-based methods to identify,
monitor, and manage OME in children aged 2 months
through 12 years. For such, The American Academy of
Pediatrics, American Academy of Family Physicians, and
The Contralateral Ear inCOM:
TheHistopathology
The rst study was designed to determine the prevalence of
CLE changes in HTB from patients with COM [32].
Secondary objectives included verifying whether the presence of cholesteatoma in the more damaged ear was related
to a greater prevalence of CLE changes, and whether there
was an association between the ndings in the more damaged ear and in the CLE.
We studied 85 pairs of HTB under light microscopy
describing all otitis media-related ndings (as pointed out
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S. S. da Costa and M. M. Paparella
before, COM was dened by the presence of irreversible
inammatory alterations in the MEC). The CLE was dened
as the normal or the least affected ear.
Our results showed that cholesteatoma was the main
pathology in 22.4% of the more damaged ears. The overall
prevalence of CLE with alterations was incredibly high
(91.8%). We next stratied the CLE changes as slight or signicant (with effusion being the mildest form, followed by
moderate and severe retractions and TM perforations, the
presence of granulation tissue, and cholesteatoma) and still
77.6% were considered to be signicant. The chief ndings
were tissue granulation (81%), effusion (58%), and tympanic
membrane retractions (35%) (Fig.37.26).
Of the 19 donors who had cholesteatoma in the more
damaged ear, 7 (36.84%) also exhibited this pathology in the
CLE.Granulation tissue was diffuse in 39 (45.9%) samples
and focal in 30 (35.3%). Tympanic membrane retractions in
the CLE were more prevalent in the pars tensa (43.33%),
with nine (30%) ears presenting retraction in the pars accida and in both regions for eight (26.67%) cases. Twelve
(70.59%) of the retractions in the pars accida were moderate to severe, as were 11 (52.39%) of the retractions in the
pars tensa.
Of the tympanic membrane perforations observed in the
CLE, two (66.67%) were central. All were located in the posterior quadrants of the pars tensa. Of the eight HTB donors
presenting perforation in the more damaged ear, two also
showed this change in the CLE, showing a bilateral prevalence of 25% (Fig.37.27).
There was a direct and moderately strong correlation
between the extent of granulation tissue in the more dam-
aged ear and the CLE. A strong correlation was observed
between the extent of cholesteatoma in the more damaged
ear and in the CLE.
The Contralateral Ear inCOM: TheClinical
Study
Our second study aimed to study the CLE of patients with
clinical diagnosis of chronic otitis media. For such, 500 consecutive patients were included. We dened COM as chronic
inammation of the middle ear and/or mastoid associated
with a permanent perforation or retraction of the tympanic
membrane with or without otorrhea. Cholesteatoma was
dened as a perforated or retracted TM with keratin retention, with or without granulation and recurrent inammation.
There was no age restriction. Patients with previous otologic
surgery other than ventilation tubes were excluded.
All patients with COM were further categorized as associated or not to cholesteatoma (CCOM and NCCOM groups,
respectively). The CLE was dened as the asymptomatic ear
or, in cases with bilateral symptoms, the ear with clearly less
symptoms based on hearing loss, otorrhea, and overall
discomfort.
Otoendoscopy of CLE was reviewed, and the ears were
classied as normal or abnormal. All ears were classied by
their dominant pathologic ndings if more than one nding
was present; and these were dened as effusion, retraction,
perforation, cholesteatoma, or presence of otitis-derived
sequelae (tympanosclerosis). The TM retraction was classied according to a modied Sadé and Berco classication
a
Fig. 37.26 (a) Histological section of the right ear with TM retraction, bone erosion, and granulation tissue and tympanosclerosis in the middle
ear cleft. (b) The contralateral temporal bone with exactly the same prole (hematoxylin-eosin; magnication, X10)
b
a b
37 Pathogenesis ofChronic Otitis Media andtheContinuum: TheBasics, Further andBeyond
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353
Fig. 37.27 (a) Histological section of the most affected ear. There is
granulation tissue lling the round window niche and central TM perforation. (b) Histological section of the contralateral ear. Central TM per-
Table 37.1 Data about the CLE of each patient were recorded in the
specic protocols
Location Degree Denition
Pars
tensa
Pars
accida
Mixed Mild/
Modied from Sadé (1979)
Mild (PT1) Extended to the external third of the
middle ear
Moderate
(PT2)
Severe (PT3) Extended into the inner third of the
Mild (PF1) Minimal medial displacement of the
Moderate
(PF2)
Severe (PF3) Medial displacement with adherence and
moderate
(M1)
Moderate/
severe (M2)
Extended into the middle third of the
middle ear
middle ear or abutted the promontory
and/or the medial wall
tympanic membrane
Medial dislocation of the tympanic
membrane with adherence to the malleus
bony erosion
Description above
Description above
(2006) as from the pars tensa or pars accida. The retractions
were then further graded as mild, moderate, or severe,
according to the criteria shown in Table37.1.
Overall, only 24.8% of the patients presented with a completely normal CLE. In the 75.2% with abnormalities, the
most frequent ndings were TM retraction (38.2%), TM perforations (26.2%), cholesteatoma (5.2%), tympanosclerosis
(3.6%), and effusion in the middle ear (2.0%). A total of 302
patients (60.4%) presented with NCCOM in the most
affected ear, and of this group, 30.1% presented with a normal CLE.In the 69.9% with abnormalities, the most frequent
foration (diagonal arrow) and thickening of the middle ear mucosa
(vertical arrow) (hematoxylin-eosin; magnication, X10).
Table 37.2 Description of the abnormalities found for NCCOM and
CCOM separated and together
Videotoscopy WITH NCCOM CCOM
Normal 157 119 38
Mild retraction 112 78 34
Moderate retraction 78 41 37
Severe retraction 32 10 22
Perforation 102 82 20
Cholesteatoma 19 0 19
Total 500 330 170
alterations were TM perforations (30.8%), TM retraction
(30.1%), tympanosclerosis (6.0%), and effusion (3.0%).
Among patients with CCOM, 16.7% presented with a normal CLE. The most frequent abnormalities in this group
were TM retraction (50.1%), TM perforation (19.3%), cholesteatoma (13.3%), and effusion in the middle ear (0.6%).
Table 37.2 describes the abnormalities found for NCCOM
and CCOM separately and together.
Although all listed abnormalities were undisputable,
some of them were mild and possibly not as clinically relevant. Therefore, an effort was made to focus on the more
marked levels of disease. For this analysis, we excluded
those CLEs with solely the presence of mild retractions,
serous effusion, and otitis-derived sequelae (tympanosclerosis); and we still found a total of 55.8% of CLEs with abnormalities; 43.0% in the NCCOM group and 68.6% of CLE in
the CCOM group (Table37.3). The difference between the
two groups was statistically signicant (P<0.0001).
When we looked only for the presence of retractions on
the CLE, we found in the NCCOM group mild retractions in
17.9% of the CLE, moderate retractions in 8.6%, and severe
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Table 37.3 Description of the major ndings in the CLE (horizontal axis) of patients with COM (NCCOM and CCOM, vertical axis) after
excluding normal, mild TM retractions, tympanosclerosis, and effusion in the CLE
Videotoscopy Moderate retraction Severe retraction Perforation Cholesteatoma Total
Perforation 26 (20.0%) 11 (8.5%) 93 (71.5%) 0 (0.0%) 130 (100%)
Cholesteatoma 23 (16.9%) 49 (36.0%) 38 (27.9%) 26 (19.2%) 136 (100%)
Total 49 (18.4%) 60 (22.2%) 131 (49.7%) 26 (9.7%) 266 (100%)
Fisher’s exact test; P<0.0001
S. S. da Costa and M. M. Paparella
retractions in 3.6%. Interestingly, in the CCOM group, those
with cholesteatoma in the most affected ear displayed severe
retractions in 24.7% of the CLE, mild retractions in 14.1%,
and moderate retractions in 11.2%.
Our results support the conclusion that patients with
chronic otitis media in one ear have a high chance of presenting some degree of pathology in the contralateral side. We
believe that our ndings suggest that chronic otitis media
should ideally be approached not as a static pathological
incident affecting one ear but rather as an ongoing process
which may affect both ears.
The Contralateral Ear inCOM: TheFunctional
Study
Our rst two studies were able to clearly demonstrate that
there is a high prevalence of bilateral COM or, at least, a
considerable slice of the population with COM in the main
ear that also exhibits gross abnormalities in the CLE.Whether
these pathological ndings actually may affect the physiology of the tympanossicular system was the predominant
question of our third study.
It is well known that COM (even at early stages) may
compromise the effectiveness of the vibratory pattern of the
TM and/or ossicular chain. As a consequence, a variable
degree of conductive hearing loss is almost omnipresent in
these patients. The pathogenesis of the hearing loss is related
to a combination of many factors which include partial or
total loss of vibratory surface of the TM, ossicular chain erosion or xation.
In order to bring our primary hypothesis to the functional
level, we carried out a prospective cross-sectional study of
463 patients with COM to analyze the hearing status of the
CLE focusing on the presence of an air–bone gap as an indicator of tympanossicular damage.
We employed the same denitions of COM and the same
parameters to determine the main and the CLE as in the clinical study discussed in the sections above. The patients were
divided into four categories according to the clinical diagnosis in the main ear: NCCOM (n=324); pars accida CCOM
(n=60); pars tensa CCOM (n=72); open CCOM (n=7).
All patients were submitted to PTA, determining air
conduction thresholds (AC) at 250, 500, 1000, 2000, 3000,
4000, 6000, and 8000 Hz; bone conduction thresholds
(BC); and air–bone gaps (ABG) at 500, 1000, 2000, 3000,
and 4000Hz frequencies. The ABG was calculated using
the difference between AC and BC thresholds. For BC
thresholds, a bone conduction transmitter placed on the
mastoid bone was used. Even for AC and BC, Narrow Band
masking noise was applied when needed. In young children, which could arise problems to measure reliable
thresholds, playful conditioning (play-conditioned audiometry with supra-aural earphone) was performed. When necessary, the PTA could be concluded after two sessions in
order to conrm its results.
The mean ABG variable represented the arithmetic mean
of the gaps at the same frequencies. Taking into consideration the magnitude of the mean ABG, it was created three
new subcategories: ABG (0–14 dBHL); ABG (15–29 dBHL);
and ABG ( ≥30dBHL). The mean ABG was further subdivided according to the tested frequencies: low frequencies
(500 and 1000 Hz), and high (2000, 3000, and 4000 Hz).
We have compared with the Kruskal–Wallis test the mean
ABG and the mean ABG for low and high frequencies in the
CLE among the four groups and no differences were found
(P=0.567).
In the other hand when we analyzed all CLE for the
occurrence of ABG of any magnitude, we found that they
were present in almost 30% of the ears (135 CLE or 29.10%
with ABG greater than 14 dBHL). There were no statistically
signicant differences (P = 0.940) when we compared
through the chi-square test the prevalence of the ABG among
the four studied groups (30.3% NCCOM; 22.4% pars acida
cholesteatomas; 29.4% pars tensa cholesteatomas; 34.4%
open cholesteatomas)
The conclusions of the functional study are closely related
to the histological and clinical ones, i.e., at least one-third of
the CLE of patients with COM have a major interference in
the tympanossicular system possibly related to inammatory
conditions.
The Contralateral Ear inCOM: TheRadiologic
Study
Previous studies indicate a bilateral tendency of chronic otitis media, and they clearly showed that the contralateral ear
can provide the potential pathogenesis in the most affected
ear.
37 Pathogenesis ofChronic Otitis Media andtheContinuum: TheBasics, Further andBeyond
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The CT scan is an excellent test to evaluate the structures of the temporal bone and the changes resulting from
otitis media. In the fourth study of our group, Silva etal
(2013) evaluated Temporal Bone Computed Tomography
of 75 patients with chronic otitis media. All the exams
were requested as part of our preoperative workup, and the
main ear in this study was the one booked for surgery.
Only the most severe cases of COM are referred for CT
examination. Among these are patients with persistent
granulation tissue refractory to ofce treatment, conductive hearing loss above 30 dB or associated with sensorineural hearing loss, suspected complications, and presence
of cholesteatomas. Thus, the study population was a convenience sample of patients with COM, ve years old or
more. A neuroradiologist blinded to clinical information
and diagnosis evaluated CT scans. Images were evaluated
based on a 38-question protocol focusing on the structures
considered to be the most important in the radiological
analysis of the temporal bone. Only indisputable ndings
Fig. 37.29 CT scan—coronal incidence—radiological ndings in the
main and contralateral ear in a patient with COM
secondary to COM in the CLE were accounted for: middle
ear opacication, epitympanum opacication, gross erosion of the lateral wall of the attic, and mastoid sclerosis or
opacication (Figs. 37.28 and 37.29). The results also
showed a high prevalence of abnormalities in the CLE
(54.7%).
Within the tympanic cavity, the prevalence of some degree
of inammation was 28%, 20%, 18%, and 25% in the meso-
mastoid, tegmen erosion, or stula of the lateral semicircular
canal.
Once again, the high prevalence of radiographic ndings
in the contralateral ears of patients with COM point to the
same direction than the clinical, histopathological, and functional studies or the tendency of the disease to affect both
ears.
tympanum, hypotympanum, protympanum, and epitympanum, respectively. Posterior recesses were lled by soft
tissue density material in 24% of facial recesses and sinus
tympani. Similar ndings were observed in the mastoid:
The Contralateral Ear inCOM: Tympanic
Membrane Perforations Study
65.3% well-pneumatized mastoids; 6.7% diploic, and 28%
sclerotic. Out of these, 6.7% were patients with signs of
some form of complication, such as cortical erosion of the
TM perforations are the trademark of NCCOM.Their size
and location are of paramount importance when surgery is
planned and are also key determinants for graft-taking rates.
Despite the plethora of new technologies available, the
dimensions and location of tympanic membrane (TM) perforations and tympanosclerosis plaques have been subjectively
estimated in terms of how they affected the geometry of the
four quadrants, since there is a lack of a specic tools that
could provide such information.
A careful evaluation of the different aspects of the middle
ear environment, especially the integrity of its lateral wall
(the TM) and the limitations inherent to the unaided human
visual judgment of measurement-related aspects, has pointed
to the need of developing an alternative method to more precisely quantify these ndings.
This led to the creation of the Cyclops Auris Project,
which aimed at the development of quantitative computational methods to assess the spatial relationships between
affected tympanic areas and surrounding tissue through the
Fig. 37.28 CT scan—axial incidence—radiological ndings in the
main and contralateral ear in a patient with COM
analysis of stored digital video-otoendoscopy.
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S. S. da Costa and M. M. Paparella
The Cyclops Auris system was developed specically as a
standalone software tool to be used in the clinical routine for
the quantitative analysis of the extension of TM pathologies,
implementing a set of mathematical and image processing
methods customized for this specic purpose. The software
wizard provides a user-friendly and semi-automated solution, where the medical end user has only to intervene where
medical judgment is required, such as in the ne-tuning of
the determination of the boundaries of the anatomical structures, being all mechanical error-prone tasks performed
automatically by the software. The Cyclops Auris also allows
the quadrant-wise measurement of the perforated relative
area, which was shown to have clinical implications. Finally,
Cyclops Auris’ features that allow the direct feeding of a
database with the measurement results or the export of data
in statistical programs friendly formats allow the easy performing of retrospective and prospective studies. A complete
description of this tool is beyond the scope of this chapter,
but its methodology involves ve steps and is summarized in
Fig.37.30.
After validated (2009), the Cyclops Auris was tested on
our examination collection encompassing 950 patients with
chronic otitis media, without any previous clinical or surgi-
cal treatment for whom examinations were acquired bilaterally, totaling 19,000 video-otoscopic recordings. Seven
hundred patients were classied as presenting NCCOM, and
166 (16.57%) of them were selected for having bilateral dry
TM perforations as the sole alteration. The size and location
of these perforations were calculated with the help of the
software.
When the Spearman coefcient was applied on the sizes
of the major perforation, called principal ear (PE) and the
minor perforation, called contralateral ear (CE) of the 166
patients presenting a bilateral pathology, there was found a
strong correlation (rS=0 .79; P<0.0001). When the perforation position of both ears of these patients were compared
with the Wilcoxon test (P<0.0001), there was also found a
high concordance (P<0.0001).
In a group of patients, the similarity of the size and location of the perforations were so impressive that they could be
considered almost as mirror images (Figs.37.31 and 37.32).
The conclusions of this study again showed that the prevalence of NCCOM is high. Furthermore, in those cases
where bilateral perforations were documented, their size and
quadrant distribution were strongly correlated. In short, the
ndings of all the studies briey presented above point to the
Fig. 37.30 Cyclops Auris: ve-step methodology. 1: Opening the le and describing the boundaries of the TM. 2: Selecting the perforation area.
3: Fine-tuning the perforation area. 4: Adjusting the quadrants. 5: Making the measurements
37 Pathogenesis ofChronic Otitis Media andtheContinuum: TheBasics, Further andBeyond
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357
a
b
c d
Fig. 37.31 Video-otoscopy and analysis of bilateral perforations. It is easy to notice the resemblance, both in image and the measured parameters.
(a) Video-otoscopy right ear. (b) Measures in the right ear. (c) Video-otoscopy left ear. (d) Measures in the left ear
same direction overlapping evidences that the bilateral
chronic otitis media is much more than a coincidence.
microbiology to the ultra-structure; from physiology to
molecular biology; and from the pathogenesis to technological breakthroughs. Essentially, the degree of scientic development from 1955 to 2010 highly exceeds the veried
The Contralateral Ear inCOM: Discussion
andPractical Implications
between 1853 (when the simple mastoidecotomy was completely described) and 1955 (when the last objective—hearing restoration—was rst proposed).
A close analysis of the history of the procedures designed to
treat COM and its complications clearly show that otological
surgery gradually evolved during this last century with at
least three different phases: preservation of life (the 1853
simple mastoidectomy by Schwartz); anatomical conservation (the 1910 Bondy operation), and hearing improvement
(the 1955 tympanoplasty by Wullstein and Zollner).
Interestingly, these three phases bring us to current concepts
which can be perfectly summarized under the contemporary
objectives of chronic ear surgery: elimination of infection,
preservation of the normal anatomical contours of the ear
and, whenever possible, restoration of hearing function.
In fact, the last objective of COM surgery was set more
than 50 years ago! During the same period, there were major
advances in the understanding of a variety of ear pathologies.
These advances were spread over a variety of elds: from
After all these years, the body of knowledge that has
emerged coped with the accumulated experience mandates
an important question: Is it possible to come up with a fourth
objective in COM surgery? Our answer to that question is
YES, IT IS: to interfere and abort the natural history of the
disease. The basic precondition for doing so is the correct
understanding of the pathogenesis of the condition. In other
words, to identify which direction the process will take from
the precipitating etiology to the establishment of irreversible
tissue pathology or an outburst of a dangerous
complication.
The body of studies denes a roughly standard natural
history allowing us to forecast and possibly anticipate unfavorable end points, since COM follows what we call a “predictable script.” Some interventions along the process are
traditional and include:
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S. S. da Costa and M. M. Paparella
a
b
d
c
Fig. 37.32 Video-otoscopy and analysis of bilateral perforations. (a) Video-otoscopy right ear. (b) Measures in the right ear. (c) Video-otoscopy
left ear. (d) Measures in the left ear
1. Identifying and controlling risk factors
2. Clinical treatment during early phases
3. Close and careful follow-up
4. Management of diseases in the neighborhood
and targeting the correct timing of intervention implies a
very challenging decision, since there is a lack of evidencebased information to support choosing one or other approach.
When the clinician is confronted to this borderline situation
what should be his next step? Holding back and waiting for
With this concept in mind, we advance the discussion to a
new level by considering a more vigorous and active intervention in the oligosymptomatic early steps of the disease.
The main dilemma is to appropriately decide between a
passive or contemplative attitude or to undertake an early
intervention to thwart progressive disease, despite the fact
that an intervention is not devoid of intrinsic morbidity!
Should one wait for a dry symptomless retraction pocket to
become a draining cholesteatoma which then needs major
surgery? Or, would a less invasive approach to an earlier
stage have been better? Of course, the answers would be
simple if we could ensure that this transition would be inevitable! Choosing the best option between these two extremes
an evidence-based solution or venturing into a yet to be
proven new alternative technique?
When we take into consideration a patient that comes to
our attention hoping to be cured, waiting for the evidences
may become too late or no more appropriate. In the other
hand, choosing a new technique in the hope of aborting the
process may be ineffective and aggressive. The main difculty when getting to this crossroad is the natural history of
the disease itself since it moves freely between different
stages, going through phases that are not necessarily unidirectional. Thus, as the active disease relapses for long periods, the silent sequel may emerge in acute outbursts, at times,
very close to complications.
ab
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359
In real-life practice, it is frequently impossible to determine the boundaries between subtypes of otitis media since
the limits are thin if not overlapped.
We believe the importance of considering the CLE in conjunction with the most affected side in COM cannot be overemphasized. Regardless of the presence of cholesteatoma,
the astute analysis of both ears may shed some light into
three key aspects of the disease process: where did it come
from? (etiology) what is the current condition (established
pathology) and, more importantly, how fast and in which
direction the disease is marching toward (natural history).
The answer to these questions will illuminate and improve
the true understanding of the pathogenesis of COM by helping the treatment and the counseling of patients and
relatives.
When we take into account the CLE, we can understand
the dynamic pathologic process right before our eyes. There
are many patients displaying similarity on both sides, at
times one step ahead or behind the other.
For example, it is not rare to nd a patient with a posterosuperior cholesteatoma in one ear and a severe retraction of
the pars tensa in the other, or with a classical pars acida
cholesteatoma in one ear and a deep attic retraction pocket,
but still cholesteatoma free in the other (Fig.37.33a, b).
Precise and critical analysis of both ears plays a key role
in the prognostic assessment of each case, since the ear
established with COM may predict the likely evolution of the
CLE.An aggressive cholesteatoma on one side with massive
bony destruction and unfavorable evolution should lead us to
more vigilant follow-up care of the CLE.
Another clinical condition in which the analysis of the
CLE can be extremely helpful is the one experienced by
many patients submitted to tympanotomy with bilateral ven-
tilation tubes. On many occasions, one of the tubes is
extruded early and the other remains in situ for prolonged
periods of time. Although it is not our routine to remove ventilation tubes, sometimes we consider removal as a response
to the patient’s anxiety to sum up a routine lifestyle. Analysis
of the CLE is critical in determining whether the remaining
ventilation tube should be removed. If we nd the “extruded”
ear with a satisfactory appearance, we may assume that normal physiology has been restored, encouraging removal of
the remaining tube, since the CLE suggests no trend toward
progression of the disease.
The same holds true for a TM perforation: it is not rare
having patients referred to us for tympanoplasty with smallto medium-sized perforations in one ear and TM retractions
or effusion in the other. The most relevant problem in this
kind of situation is the retraction! The perforation, probably
represents what Ingesltedt once called “a God sent ventilation tube” and should preserved as such! (Fig.37.34a, b).
This situation represents what Costa etal have called the
"crystal ball effect" [31]. In other words, the ears should be
analyzed as an intrinsically related pair and not as an isolated
unit. Frequently, the most affected ear can predict the future
status of the contralateral side. The march toward chronicity
can then be aborted with the most appropriate treatment.
Finally, an interesting observation regarding TM perforations was noted in our clinical study. It was common to nd
ears with wide central or marginal perforations associated
with badly retracted CLE. Often, there were other clinical
ndings such as erosion of the long process of the incus, the
superstructure of the stapes, and horizontal displacement of
the malleus handle. Moreover, some of these cases unveiled
remains of squamous epithelium and keratin lying over the
promontory and/or ossicular chain (Fig.37.35a, b).
Fig. 37.33 (a) Case 559 (right ear): Pars acida cholesteatoma. (b) Case 559 (left ear): CLE with a pars acida moderate retraction
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Fig. 37.34 (a) Case 401:
right ear with a central dry
TM perforation. (b) Case 401:
left ear of the same patient
with a TM retraction grade
3–4
S. S. da Costa and M. M. Paparella
Fig. 37.35 (a) Case 563 (right ear): TM perforation. (b) Case 563 (left ear): CLE with TM perforation, medial displacement of the malleus and
adhesions of the remaining TM to the medial wall of the cleft
This observation gives us some extra insights regarding
the origin of the TM perforations. It has long been postulated
that TM perforations are a consequence of a series of triggering situations including recurrent acute otitis media, acute
necrotizing otitis media, and trauma to the temporal bone,
which in our opinion are rare events (as causes of large denitive TM perforations). Nevertheless, we keep seeing patients
with the condition on a daily basis. In other words, it seems
that the mechanisms traditionally related to the origin of
those perforations (i.e., causes) are identied in a much
smaller proportion on a daily basis than the number of tympanic perforations that is presented to us (i.e., the consequences). Given this paradox, it is possible to conclude that
there must be other mechanisms, which are responsible for
the generation of these alterations, or we are faced with a
bizarre “missing link” as far as chronic otitis media pathogenesis is concerned.
Our studies supply sufcient information in order to reject
missing links, considering additional explanations in the
pathogeneses of tympanic perforations. This way, the transition between acute and chronic cases has been explained predominantly through “explosive” mechanisms, that is, any
sudden inammatory or traumatic events that befall a primarily rigid structure. The rupture of the intratympanic homeostasis will induce a series of histological transformations in
the mucosa layer of the middle ear, which will modify proportionally according to future aggressions. The adoption of
this acute-chronic express or “direct” model of pathogenesis
leaves out a series of situations commonly experienced by the
otolaryngologist. Historically, some of these events (tympanic retractions, atelectasis, and adhesive otitis media) have
been inexplicably set aside this discussion.
The chronic silent otitis media, however, (along with its
long list of clinical and pathological explanations) have been
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