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C. Kayaalp et al.
Fig. 40.5 A 73-year-old female had a history of bilateral chronic otitis
media. Histopathologic analysis showed tympanosclerosis, especially
around the incus
Fig. 40.6 This was a 50-year-old patient with metastatic breast carcinoma. Histopathologic evaluation showed retraction pocket with the
erosion of incus and carcinoma involvement of the petrous apex
Fig. 40.7 This patient had a history of bilateral mixed-type hearing
loss due to chronic otitis media with new bone formation, ossicular erosion, brocystic changes, and tympanic membrane retraction
Granulation tissue is the most common pathology encountered in chronic ears. It consists of vascularized connective
tissue with a component of acute inammatory exudation.
Fig. 40.8 Chronic otitis media with cholesteatoma caused erosion of
incus and stapes ending up with conductive hearing loss
The most common sites for granulation tissue are the epitympanum, mesotympanum, round window niche, and mastoid antrum [18, 19]. During the formation of granulation
tissue, the mucous membrane is thickened by edema, submucosal brosis, and inltration with chronic inammatory
cells. Later, mucosal edema may progress to the formation of
polyps [20]. With maturation, granulation tissue becomes
more brous and less cellular with increased collagen and
reticular formation [18]. This pathologic growth may lead to
adhesion, xation, and/or resorption of the ossicles in the
middle ear [20]. Furthermore, this activity, if unchecked,
may lead to serious complications, such as inammation of
the inner ear [21].
Cholesteatoma (Fig.40.9a, b) may cause erosion of the
ossicular chain by several mechanisms including the pressure exerted by the cholesteatoma mass, osteoclastic activities, or enzymatic activities. Even after a radical cleaning of
cholesteatoma during surgery, residual cholesteatoma can
occur in 7–50% of cases [22, 23]. Residual cholesteatoma
can be found in inaccessible areas such as around the arch of
the stapes, the sinus tympani, oval window area, retrolabyrinthine, and the perifacial regions [24]. Therefore, the
removal of all accessible mastoid air cells and the pathologic
tissue hidden in the inaccessible areas are necessary for reliable eradication of cholesteatoma. It has also noted that
many innocent-looking mucosal changes at a considerable
distance from cholesteatoma can contain squamous epithelium [25].
Tympanosclerosis is observed as a submucosal whitish
onion-like lamellar deposit in the middle ear. It usually is a
consequence of chronic otitis media and starts with collagen
deposition or brosis in the subepithelial extracellular matrix
of the middle ear or tympanic membrane. Then, it is followed by fusion of collagen bers into a homogenous mass
and later the deposition of extracellular calcium and phosphate crystals appear [26]. Usually, no suppuration is seen
with tympanosclerosis. Because tympanosclerosis will
diminish the perfusion of the mucosa and ossicles, it will
eventually cause devitalized bone. This might be the under-
40 Ossicular Pathology inChronic Otitis Media
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393
a b
Fig. 40.9 (a) This was a 94-year-old male patient with a hx of total deafness at the age of 12 years. A cholesteatoma was found in the middle ear
eroding the ossicles. (b) High magnication showed macrophages
lying pathogenesis of failure of revision surgeries in cases
with residual hearing loss due to tympanosclerosis. Otoscopic
examination shows white plaques in the tympanic membrane
and nodular appearance within submucosa of the middle ear.
If tympanosclerosis is localized in the tympanic membrane, it may not affect the hearing. If the ossicular chain is
involved, it will cause air–bone gap and may require ossicular reconstruction [27]. If the stapes is involved, a staged surgery including rst myringoplasty and reconstruction of
malleo-incudal xation before releasing the xation of stapes will be performed. If the xation is observed at the stapedial muscle level, stapes movement may be provided by just
cutting the stapedial tendon. Rarely, the head of the malleus
may be xed in the attic due to tympanosclerosis or calcication process (Fig.40.5).
If the ossicles are intact but the tympanic membrane is
perforated, the intensity of hearing loss will be linearly proportional to the size of perforation [28]. If the ossicular disruption is combined with a perforated tympanic membrane,
the hearing loss may be around 35–40 dB. However, the
ossicular disruption under an intact tympanic membrane will
reect the sound back to the external ear canal with ending
up a maximal conductive hearing loss of 55–60dB.If ossicular resorption is associated with a retracted tympanic membrane that attaches to the stapedial supra-structure, relatively
a better hearing is observed due to the uninterrupted conductivity of the sound to the inner ear [29].
References
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and future clinical applications in otology. Curr Opin Otolaryngol
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17. Rosowski JJ, Nakajima HH, Hamade MA, Mahfoud L, Merchant
GR, Halpin CF, Merchant SN.Ear-canal reectance, umbo velocity, and tympanometry in normal-hearing adults. Ear Hearing.
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media. Ann Otol Rhinol Laryngol. 1978;87:749–60.
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cholesteatoma. Otolaryngol Clin North Am. 1989;22:1029–40.
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Am. 2006;39(6):1177 89.
28. Mehta RP, Rosowski JJ, Voss SE, O’Neil E, Merchant
SN.Determinants of hearing loss in perforations of the tympanic
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29. Paparella MM, Jung TK.Experience with tympanoplasty for atelectatic ears. Laryngoscope. 1981;91:1472–7.
Tympanic Membrane Retractions:
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Pathophysiology, Classification,
andManagement
InesangelaCanali, LetíciaPetersenSchmidtRosito,
andCarolineCatherineLacerdaElias
41
Tympanic membrane (TM) retractions are dened as a medialization of its position toward the promontory. Anatomically,
they can be pars accida (PF) or pars tensa (PT) of TM and
may be sectoral or diffuse. By denition, retractions that
have a diameter of the outer opening smaller than that of the
inner part are known as retraction pockets, having less selfcleaning capacity. Atelectasis refers to a diffuse medialization of the TM, while adhesive otitis media occurs when the
TM is adhered to the promontory [1].
Histologically, TM is formed by an outer layer of keratinized squamous epithelial tissue, an inner layer of cuboidal
mucosal epithelium, and a middle layer (lamina propria)
formed by brous connective tissue. The posterosuperior
portion of the PT has a thinner lamina propria and also an
increase in vascular supply, which makes it more susceptible
to rupture of its collagen bers during inammatory processes, thus making it more likely to retract. The same occurs
in FP, for having a thinner lamina propria and lack of the
brocartilaginous ring in the Rivinus notch [2].
I. Canali (*)
Department of Otolaryngology, Pontical Catholic University,
Porto Alegre, Rio Grande do Sul, Brazil
Federal University of Rio Grande do Sul,
Porto Alegre, Rio Grande do Sul, Brazil
L. P. S. Rosito
Federal University of Rio Grande do Sul,
Porto Alegre, Rio Grande do Sul, Brazil
Department of Otolaryngology—Head and Neck Surgery, Porto
Alegre Clinica’s Hospital, Porto Alegre, Rio Grande do Sul, Brazil
C. C. L. Elias
Federal University of Rio Grande do Sul,
Porto Alegre, Rio Grande do Sul, Brazil
Department of Otolaryngology, Hospital Nossa Senhora da
Conceição, de Porto Alegre (GHC),
Porto Alegre, Rio Grande do Sul, Brazil
Pathogenesis ofTympanic Membrane
Retractions
The TM has a natural elasticity that allows its shape and
position to vary according to the pressure variations of the
middle ear (OM) with the environment. A healthy TM is
capable of equalizing certain pressure variations, however,
when the pressure gradient exceeds the capacity of this
equalization, a positive or negative pressure is installed. In
normal situations, this pressure variation is corrected by
active or passive opening of the eustachian tube. Sustained
negative pressures make the TM elastic bers lose elasticity
and thickness and retract more easily [1].
Classically, there are three described mechanisms that
regulate OM pressure: (a) equalization of OM and environmental pressures through the eustachian tube; (b) gas
exchange through the mucosa of the OM; and (c) pressure
control mechanism of the ventilated spaces of the mastoid.
Auditory Tube
When pathological conditions are installed, determining permanent occlusion of the auditory tube (AT), the negative
pressure, in a vicious cycle, will tend to progressively
increase, causing TM retraction [3]. In addition, there may
be cavity transudation of intravascular uid to the interstitial
space and from there to the lumen of OM [4]. Sustaining this
negative pressure can also lead to histopathological changes
in the epithelium and subepithelium of the auditory cleft,
leading to the occurrence of TM retractions and atelectasis
which, in the absence of restraining factors, could evolve and
culminate in the formation of cholesteatomas. This sequence
of events is known as the continuum theory, proposed by
Paparella and collaborators to explain the pathogenesis of
chronic otitis media [5].
Although the term tube dysfunction is usually used in
cases of AT obstruction, it also encompasses situations in
which it is pathologically open (patent tube) [3]. Studies have
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. V. Goycoolea et al. (eds.), Textbook of Otitis Media, https://doi.org/10.1007/978-3-031-40949-3_41
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shown that patent AT can also result in changes in OM.Some
patients who present this alteration develop the habit of sniffing constantly and repeatedly (sniffers) to alleviate the
uncomfortable symptoms presented [6]. This maneuver,
despite providing temporary comfort from symptoms, as it
tends to close the tube, can lead the patient to overcorrect,
creating conditions similar to the functional obstruction of
AT.Thus, this habit results in a high negative pressure in the
OM, which can lead to the occurrence of TM retraction and
its possible subsequent pathological evolution [7].
Gas exchange Through theMiddle ear Mucosa
The gas exchange that takes place between the tympanic cavity and the mastoid with the mucosal microcirculation is
another important factor in the regulation of pressure in
OM.The direction of gaseous diffusion is implicated in differences in the partial pressure of gaseous components in the
auditory cleft. Inammatory processes that inuence mucosal thickness and blood ow in the tympanic cavity have a
direct effect on the rate of diffusion. In general, when the
mucosa is healthy, there is an equal gas exchange rate so that
oxygen and nitrogen are absorbed in the same way that carbon dioxide is expelled. However, the thicker and more vascularized the mucosa, the greater the rate of gas diffusion [4].
It is believed that when the AT remains occluded, a negative pressure would set in, with a predominance of carbon
dioxide over oxygen and causing thickening of the OM
mucosa, vasodilation with serous transudation, and mucosal
metaplasia in the tympanic cavity, with an increase in the
number of glandular structures, ultimately resulting in an
accumulation of uid in the ME in an attempt to equalize the
pressure difference. Thus, the accumulation of uid in the
tympanic cavity would be the last way to regulate the pressure [8]. According to Bunne etal. [9], this hypothesis has
been questioned for several reasons. Among them is the fact
that it is based on the assumption that gas is continuously
absorbed by the mucosa of the OM, but studies have shown
that transmucosal gas transport is bidirectional, and that the
pressure in the tympanic cavity can be maintained equal to
that of the environment, or even be positive, without tubal
opening in healthy ears. Thus, these ndings support the
hypothesis that gas exchange is an important mechanism for
pressure regulation in OM, while AT serves as an escape
valve for excessively positive pressures and also to equalize
excessively negative pressures [8, 9].
Middle Ear Complex: Mastoid andMiddle Ear
Ventilation Pathways
The pneumatization of the mastoid, which starts in the thirtythird week of gestation and continues until 8–9 years of age,
could also inuence pressure maintenance in OM.This pressure depends not only on a functioning AT but also on the gas
exchange existing in the auditory cleft mucosa, which, in
turn, is related to the degree of pneumatization of the mastoid. A well-pneumatized mastoid would have greater capacity to compensate for pressure changes than an eburnean
mastoid [10].
In addition to AT, other anatomical factors would play an
important role in the ventilation of middle ear (ME) spaces
and in the pathogenesis of retractions, especially those
located in the epitympanum.
The anatomy of the OM and the mastoid and their airways
have been described since the end of the 19th century. Proctor
in 1964 and after Palva and Johnson were the rst to describe
the airways of the tympanic cavity and their implications for
OM diseases [11–13]. In recent decades, the use of endoscopes in ear surgeries has made it easier for surgeons to
explore anatomical spaces that were not so well visualized
with the use of a microscope alone.
A series of mucous folds, ligaments, and part of the ossicles make up the so-called tympanic diaphragm, practically
separating the mesotympanum from the epitympanum and
the mastoid. Two narrow passages cross this diaphragm: the
anterior and the posterior tympanic isthmus. The anterior
isthmus is more consistent, lying medially to the body of the
incus, passing between the stapes and the tendon of the tensor tympani muscle. When the medial incudal fold is present,
a small posterior isthmus appears between this fold and the
posterior tympanic wall [12, 14, 15]. Figure41.1 shows the
two main ventilation pathways to the epitympanum, as mentioned above.
Right ear: A, posterior view; B, anterior view. A schematic drawing representing the two independent aeration
routes of the epitympanum. The major aeration route (red
arrow) passing through the isthmus for the large upper unit
(epitympanic compartments, antrum, and mastoid cells); the
second independent aeration route (yellow arrow) for the
smaller lower unit (Prussak’s space) passing through the posterior pouch between the tympanum and the posterior malleolar ligamental fold. PES, posterior epitympanic space;
AES, anterior epitympanic space; in, incus; Hma, malleus
head; imlf, incudomalleolar lateral fold; mlf, malleolar lateral fold; is, tympanic isthmus; st, stapes; cp, cochleariform
process; et, eustachian tube; pml, posterior malleolar ligament; aml, anterior malleolar ligament; tf, tensor fold; PS,
protympanic space; tt, tensor tympani; Prs, Prussak space;
hm, malleus handle; ps, posterior spine.
Eustachian tube is the direct ventilation route to the mesotympanum and hypotympanum, while the epitympanic
region receives ventilation from the tube through the tympanic isthmus which, in normal ears, are physiologically
open [16, 17].
The obstruction of the tympanic isthmus, however, is
observed in several OM pathologies such as TM retractions
ab
41 Tympanic Membrane Retractions: Pathophysiology, Classication, andManagement
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397
Fig. 41.1 Anatomy of middle ear folds and the two main ventilation routes [19]. Right ear: (a) posterior view; (b) anterior view
and cholesteatomas. Marchioni et al. described in their
endoscopic studies the presence of anatomical blocks in the
ventilation pathways. These blocks could cause poor sectorial (epitympanic) ventilation of the OM, which they called
the “selective epitympanic dysventilation syndrome”[18].
microfoci are created, adhesions between the inner layer of
the TM and the mucoperiosteum of the ossicles and OM are
formed, being the precursors of the perimatrix of a future
cholesteatoma, regardless of the reestablishment of OM
ventilation [21].
This syndrome is characterized by the presence of normal
eustachian tube function, complete epitympanic diaphragm,
and total isthmus block [19]. Thus, these individuals have
normal aeration of the mesotympanum and hypotympanum,
Inammationand Formation
ofRetractions—Histopathology
while the attic and mastoid have poor ventilation and, consequently, a negative pressure is installed and perpetuated,
which can trigger the evolution to a retraction bag or attic
cholesteatoma. They also observed that, even in the absence
of isthmus blocks, if the Prussak space does not have enough
airways for the adjacent spaces and the OM mucosa presents an inammatory process, negative pressures can also
set in [20]. It is believed that once these hypoventilation
Inammatory processes, such as acute otitis media or the
presence of persistent effusion in OM, through inammatory
mediators and cytokines, can structurally affect the mucosal
histology of OM and TM [1]. The main histological features
observed in the more advanced stages of retraction pockets
are usually: loss of the collagen brous double layer in the
lamina propria, increased keratinization, chronic subepithe-
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I. Canali et al.
lial inammation, increased cell proliferation, and structural
changes in the basal layer [22]. These ndings may favor a
loss in TM elasticity and plasticity, making it more vulnerable to the effect of negative pressures [23]. However, histopathologically, no differences were observed in the degree of
inammation between the different degrees of retraction
[22]. The increasing occurrence of these histological signs in
relation to the clinical progression of retractions corroborates the fact that retraction pockets are a progressive disease, and possibly a precursor of cholesteatoma [23].
Classication
The rst and best known classication of TM retractions was
proposed by Sadé and Berco, in 1976 [24]. Since then, several authors have described its variations [25]. Most of these
classications encompass the following criteria: topography,
presence of ossicular chain erosion, self-cleaning property,
and TM mobility.
As for the location of the retractions, they are classied
separately by PF and PT, and the latter can be subdivided
into localized (retraction pocket) or diffuse TM (atelectasis)
retractions. No existing classication in the literature encompasses PF and PT at the same time.
Regarding the depth of the retraction pocket, the bottom
of the pocket often cannot be seen by otoscopy or otomicroscopy. More recently, with the use of endoscopes in otological
examination (videotoscopy), we have been able to have a
clearer view, especially in the analysis of the posterosuperior
and attic quadrants. The importance of visualizing the bottom of the pocket is due to the fact that the presence of epithelial accumulation, due to the loss of self-cleaning capacity,
leads us to the presence of a cholesteatoma, and its management is distinct from retraction [1].
Another criterion to be analyzed is the presence of bone
erosion, which may be from the long branch of the incus and
stapes suprastructure, when there is involvement of the posterosuperior quadrant and the scutum (attic lateral wall) and/
or the malleus head and incus body, when there is attical
involvement. These erosions commonly cause a conductive
hearing loss, even if clinically insignicant, as demonstrated
in previous studies by our research group [26].
Pars Flaccida Retractions
The three most used classication systems for PF are
described in Table41.1:
Initially, Sadé etal. proposed three stages for the retractions, in which the graduation increases, being able to be dry
or humid and with the bone limits of the attic intact or not
[24]. Later, Tos etal. published a new classication also tak-
Table 41.1 Staging of pars accida retraction pockets [25]
Stage Sadé T Charachon
1 Micro-metula:
retraction is very
small and noticed
only if looked for
II Metula: an obvious,
easily observed RP,
resting on the
malleus neck. Often,
some of the scutum
around it is missing
III Macro-metula: large
RP with erosion of
the scutum and
visible head of
malleus
IV NA There is a denite
NA, not applicable; RP retraction pocket
Pars accida is
dimpled and is more
retracted than
normal
The retraction
pocket is adherent to
the malleus head
The retraction
pocket may be
hidden. There may
also be associated
erosion of the outer
attic wall (scutum)
erosion of the outer
attic wall. The
fundus cannot he
clearly seen
Mobile
retraction
pocket
Fixed, fundus is
visible
regardless of
the atticotomy
size
Fixed, fundus is
not visible,
regardless of
the atticotomy
size
NA
ing into account the adherence of the TM to the malleus head
[27]. Characon etal., on the other hand, considered the presence of TM adherence and the visualization of the bottom of
the pocket (Table41.1) [28].
Localized Pars Tensa Retractions (Retraction
Pocket)
Sadé and collaborators classied these retractions into three
categories, according to the visibility of the stock market and
its self-cleaning capacity [29]. Charachon and collaborators
proposed the classication for PT applying the same mobility criteria of MT that were applied to PF [28]. In 1998,
Gersdorff etal. proposed a classication similar to that of
Charachon, but with modications granted by the use of the
endoscope, the last two stages culminating in the presence of
cholesteatoma [30]. These classications are described in
Table41.2.
Generalized Pars Tensa Retractions
(Atelectasis)
Sadé and Berco proposed stages for grading atelectasis,
according to the medial extent of PT retraction (Fig.41.2)
[24]. This classication served as a model for future classications and modications by several authors (Table41.3).
In 2000, Dornhoffer etal. proposed a modication in the
Sadé classication, with the last stage being attributed to the
failure to visualize the entire extension of the TM by otomi-
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Table 41.2 Staging of retraction pockets located in the pars tensa [25]
Stage Sadé Charachon Gersdorff
1 Fundus can be
easily seen,
self-cleaning
II Fundus can be
easily seen, not
self-cleaning, but
its debris can be
easily aspirated
in totality
III Large RP tilled
with infected
keratin debris
IV NA NA Stage
V NA NA Cholesteatoma with
NA not applicable; RP retraction pocket
Fig. 41.2 Grades of
tympanic membrane
retractions [24]
Mobile, can be
aspirated by
Valsalva or
politzer even if
adheres to incus
Fixed, visible
fundus with
erosion of incus
Fixed, fundus
not visible but
still
self-cleansing
Mobile can be aspirated
by valsalva or politzer
even if adheres to incus
IIa: Fixed, fundus is
visible by microscope
IIb: Fixed, fundus is
visible by otoendocope
Fixed, fundus not
visible by
otocndoscope
III+accumulation
keratin debris
purulent otorrhea
Table 41.3 Staging of generalized pars tensa retractions[25]
Stage Sadé Domhoffer Erasmus
I TM slightly
retracted
II TM retracted
and touching
the incus or
stapes
III TM touching
the promontory
IV TM adherent to
the promontory
V Perforated TM NA RP with
AM not applicable, TM tympanic membrane
Mild retraction of the
tympanic membrane
Retraction to the incus
or stapes, the so-called
myringo-incudostapedopexy
Involvement down to
the promontory
The full extent or
depth of the retraction
cannot be adequately
visualized by
micro-otoscopy
TM atrophic but
not adherent
TM adherent to the
promontory
TM adherent to the
incus or stapes
Adherent to
ossicles with RP
but without
cholesteatoma
cholesteatoma or
breakthrough
croscopy, as they consider that this is the most effective way
to assess the existence of epithelial accumulation in retraction. They also evaluated the mobility of TM at each stage of
their graduation [31].
Borgstein et al. (2007), proposed a new classication,
which they called “The Erasmus Atelectasis Classication”
due to the need for a more current systematization that takes
into account the assessment of children [32]. While in the
Sadé classication, the retraction of the TM along the headland is a more severe degree than the retraction along the
ossicular chain, in the Erasmus classication, the opposite
occurs.
However, little is discussed about the applicability and
reproducibility of the classications. In 2012, James et al.
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I. Canali et al.
published endoscopically evaluating existing staging systems (Tos for PF and Sadé and Erasmus for PT) [33]. They
also compared the latter two with an analysis they proposed
evaluating multiple variables involved in PT retractions: (0)
normal; (1a) retraction without touching the ME structures;
(1b) touch the headland; (2a) touch the anvil; (2b) retraction
enveloping anvil; (3a) partial erosion of the anvil; (3b) complete erosion of the anvil; (4) bottom of the bag not visualized; (5) accumulation of keratin medial to the anulus
(potentially removable); (6) presence of granulation tissue in
the retraction; and (7) cholesteatoma. They observed that the
interobserver and intraobserver agreements were very weak,
especially for PF and for the Erasmus classication of
PT. The Sadé classication, on the other hand, showed a
moderate inter- and intra-observer correlation and the characterization with the proposed variables showed a more
robust correlation [33].
Each rank, as seen above, prioritizes certain aspects for its
ranks. We observed that in addition to them not being in
agreement with each other, and they tend to systematically
divide the retractions according to the regions of the TM
affected, in PF and PT, and not analyze the TM globally,
none of them takes into account the degree of hearing loss
for their graduations. In addition, the last stages of some
classications represent the presence of cholesteatoma. We
know that the distinction of a severe retraction, starting the
formation of epithelial debris with a cholesteatoma, is often
a challenge.
The concept of staging assumes that each stage is different from the other by the variables described and that each
graduation is a prognostic indicator and must have different
management. However, unlike established staging systems
already established in medicine, such as the TNM classication for malignant tumors, the existing retraction classications in the literature are not clear indicators of prognosis,
much less of management, mainly because there is no unied staging system. In this way, currently the existing clas-
sications serve much more like an instant demonstration of
the retractions at a given moment than as a prognosis or as
denitions of conduct.
In our studies regarding TM retractions, they have been
classied according to the Sadé and Berco classication,
modied by our group. Mild retractions were considered
when there was a medialization of the TM onto the promontory without contact in this, or in the ossicular chain; moderate retractions were considered when there was a contact of
the TM on the ossicular chain or in the promontory or in the
scutum, and severe retractions when there was erosion of the
ossicular chain or bone limits. We believe that the mild
retractions behave like normal ears and so we consider for
study and classication only ears with moderate and severe
retractions.
TM was divided into PF (atticus) and PT (posterior and
anterior quadrant). Each region was analyzed, and the following degrees of severity were noted:
PF: (1) normal or mild retraction, without contact onto the
scutum; (2) contact with the scutum (retraction in the attical
lateral wall without contact with the malleus neck and/or
ossicle heads or erosion); (3) erosion of the scutum (attical
lateral wall); and (4) erosion of the malleus head or incus
body (Fig.41.3)
PT—posterior quadrant (PQ): (1) normal or slight medialization of the TM without contact in the promontory or in
the ossicular chain; (2) contact with the long process of the
incus or with the promontory; (3) erosion of the long process
of the incus; and (4) erosion of the stapes superstructure
(Fig.41.4)
Grade 2 was considered moderate retraction, while Grade
3 and 4 severe for both PF and PT (PQ).
PT—anterior quadrant (AQ): 1, normal; 2, contact with
the promontory (Fig.41.5)
Grade 2 was considered moderate retraction.
The presence or not of adhesions of TM to the ossicular
chain or promontory, analyzed in many classications, how-
Fig. 41.3 Classication of moderate and severe pars acida retractions
41 Tympanic Membrane Retractions: Pathophysiology, Classication, andManagement
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Fig. 41.4 Classication of moderate and severe pars tensa retractions (posterior quadrant)
In a retrospective cohort, 661 ears with moderate and
severe TM retractions were analyzed, corresponding to
24.5% of 2200 patients with COM. When analyzing the
exclusive alterations of each area, it was observed that 64%
of the ears presented retraction in more than one area (PF and
PT) at the same time, while 24.9% presented isolated PF
retraction, 10.6% presented isolated posterior quadrant (PT)
retraction, and only 0.3% presented isolated anterior quadrant retraction. These ndings suggest that, although didactic, the current classications do not describe the retractions
globally and, therefore, are not able to present us with an
accurate clinical diagnosis.
The prevalence of PF isolated retractions observed in our
study can be explained by the pathophysiology of middle ear
ventilation pathways. The blocking of the tympanic diaphragm, due to the retraction itself or due to an inammatory
process, with thickening of the mucosa, can cause poor ventilation in the middle ear, creating the selective epitympanic
dysventilation syndrome, or even global, as the negative
pressure is present and other areas of TM are affected [16,
18]. The PF retraction would therefore be a consequence of
the blockage of the epitympanic diaphragm by a preexisting
Fig. 41.5 Classication of moderate and severe pars tensa retractions
(anterior quadrant)
retraction in the PQ.As the ventilation of the mesotympanum would be more easily restored, either by resolving the
inammatory processes of the middle ear or restoring the
ever, remains a challenge. The lack of standardization in the
technique used for its evaluation, the intra- and interindividual differences in the performance of the Valsalva
maneuver, the difculty of the pediatric population, and the
lack of correlation between the data observed clinically and
those found during surgery after the use of protoxide make
its evaluation extremely difcult and of little use [34]. It
appears that the presence of erosions of the ossicular chain
and the accumulation of epithelial debris in the retraction
(cholesteatoma) are the main indicators of severity
(Fig.41.6).
functioning of the auditory tube, the blockages of the anterior and posterior isthmus, which compartmentalize the epitympanic space, could be more difcult to resolve naturally.
It was observed in the transoperatory that such isthmus is
routinely obliterated in the attic cholesteatomas, either by
brosis or by granulation tissue. Thus, retractions would
occur concurrently in both regions most of the time and
because ventilation in the middle ear has a greater tendency
to spontaneously reestablish, changes in PQ would resolve
more easily, explaining the higher prevalence of retractions
in the PF when seen isolated. The most frequently observed
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