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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
118
A
AP
3 History andExamination ofEar
Fig. 3.33 Normal
tympanic membrane. (a,
b) Normal tympanic
membrane; (c) labelled
diagram of tympanic
membrane; and (d) four
quadrants of tympanic
membrane
a b
c
A
Left ear
Right ear
Pars flaccida
Posterior malleolar fold
Anterior malleolar fold
Long process
of incus
Handle of
malleus
Umbo
Pars tensa
Annulus
Cone of light
Fig. 3.34 Bulge
tympanic membrane
d
Left ear
3.2 Examination ofEar
Table 3.51 Grades of retraction of pars tensa
Grade 1—Minimal retraction of TM with prominence of handle of malleolus and annulus, absence of cone of light,
prominent lateral process, sickle-shaped malleolar fold
Grade 2—TM retracted and attached to long process of incus
Grade 3—TM retracted and attached to promontory but it is mobile. The mobility of TM can be checked on
otoscopy by pneumatic bulb
Grade 4—TM adhered to promontory and is not mobile. It is also termed as atelectatic tympanic membrane and
later may lead to adhesive otitis media
119
Fig. 3.35 Sade’s
classication of pars
tensa retraction. (a)
Grade 1; (b) Grade 2;
(c) Grade 3; and (d)
Grade 4
Fig. 3.36 Signs of
adhesive otitis media
a
c
b
d
120
de
Table 3.52 Retraction of pars accida
Grade 0—No retraction
Grade 1—Minimal retraction of pars accida
Grade 2—PF is retracted and touched to neck of malleus with obliteration of Prussak’s space
Grade 3—Partial erosion of outer attic wall (scutum)
Grade 4—Total erosion of outer attic wall (scutum)
3 History andExamination ofEar
ab
a
b
c
de
c
Fig. 3.37 Pars accida retraction. (b) Toss classication of pars accida retraction: (a) no retraction; (b) Grade 1; (c)
Grade 2; (d) Grade 3; and (e) Grade 4
3.2 Examination ofEar
121
Fig. 3.38 Tympanosclerosis in pars tensa (white arrow)
Fig. 3.39 Glue ear or serous otitis media
Fig. 3.41 Red colour TM
– Appearance of tympanic membrane
Normal—The tympanic membrane
is thin (~0.1 mm thick), oval,
funnel- shaped and semitransparent.
It marks the transition from ectoderm to endoderm and separates the
tympanic cavity from the external
acoustic meatus.
Thinned TM—It becomes transparent; middle structure can be
visualized.
Thick/thickened TM—This is due
to SOM, tympanosclerosis.
– Other ndings
Granulation over TM—Granular
myringitis—Wolf etal. suggested a
staging system for granular myringitis in which Grade 1 is focal deepithelialization with focal
granulation tissue, Grade 2 is focal
polypoid formation that bleeds with
removal and purulent discharge,
Grade 3 is diffuse tympanic membrane involvement, while Grade 4 is
the disease extending to involve the
canal (Fig.3.42).
Blebs/Bulla over TM—This is
dened as uid-lled space between
epithelial and brous layers of
TM. Bulla over TM is caused by
bullous myringitis.
Fig. 3.40 Blue tympanic membrane (haemotympanum)
122
Fig. 3.42 Granulation over tympanic membrane
– Perforation of tympanic mem-
brane—There are various types or
perforations present in tympanic membrane, which are classied according
to site, size, shape and numbers.
Perforation of pars tensa
Perforation in anterior part of tympanic
membrane
Anterior perforation
Anterosuperior perforation
Anteroinferior perforation
Perforation in posterior part of tym-
panic membrane
Posterior perforation
Posterosuperior perforation
Posteroinferior perforation
Perforation in central part of tympanic
membrane (central perforation)
Small central
Medium central
Large central
Perforation present/involving margin of
TM (marginal perforation)
Posterior marginal
Posterosuperior
Total perforation
3 History andExamination ofEar
Classication of perforation according
to size
Small (pin hole)
Medium
Large
Subtotal perforation
Near-total perforation
Total perforation
Perforation according to numbers
Single
Double
Multiple
Other perforation
Healed perforation
Perforation in pars accida
Anterior part
Central part
Posterior part
Whole pars accida
Perforation in pars tensa—The
perforations in tympanic membrane
have been classied depending on
site, size and numbers of
perforation.
Site of perforation
Perforation in anterior part of tympanic membrane
Anterior perforation—If perforation involved both the quadrants of
anterior part of tympanic membrane,
it would be termed as anterior perforation (Fig.3.43a).
Anteroinferior—If perforation
limited to anteroinferior quadrant of
tympanic membrane (Fig.3.43b).
Anterosuperior perforation—If
perforation limited to anterosuperior quadrats of TM, which is anterior to handle of malleus and the
superior level of umbo (Fig.3.43c).
Perforations in posterior part of
tympanic membrane
Posterior perforation—if a perforation present behind the handle of
3.2 Examination ofEar
123
a
Left ear
P
A
A
b c
P
A
P
Fig. 3.43 Anterior perforation of pars tensa. (a) Anterior perforation; (b) anteroinferior perforation; and (c) anterosu-
perior perforation
malleus in the posterior half of tympanic membrane involving both
posterior quadrants (Fig.3.44b).
Posterosuperior perforation—This
perforation presents in posterosuperior quadrat of TM which lies behind
the handle of malleus and above the
level of umbo and below the posterior malleolar fold (Fig.3.44a). This
perforation is included in unsafe type
of perforation and presents with disproportionate hearing loss.
Posteroinferior perforation—This
perforation presents in the posteroinferior quadrat of TM which lies
below the level of umbo and posterior to line dividing the TM into anterior and posterior half (Fig.3.44c).
Perforation involving the central
part of tympanic membrane (central perforation)—Perforations
which involve all quadrants of tympanic membrane are known as central perforation. These are divided
into (Fig.3.45):
Small central—It is present around
the umbo and involves less than
25% of all quadrants (Fig.3.45a).
Medium central—It is present
around the umbo and involves less
than 50% almost half part of all
quadrats of pars tensa (Fig.3.45b).
Large central—It is present around
the umbo and involves more the
50% or half of all the quadrants
(Fig.3.45c).
Perforations involving the margin
of TM (marginal perforation)—
when a perforation involves the
margins of TM.This type of perforation of TM is included in unsafe
perforation.
124
PAPA
a b c
Right ear
3 History andExamination ofEar
A
Fig. 3.44 Perforations in posterior half of pars tensa. (a) Posterosuperior perforation; (b) posterior perforation; and (c)
posteroinferior perforation
Posterior marginal—If a perforation in posterior part of tympanic
membrane involves the annulus and
posterior margin. This is termed as
posterior marginal perforation
(Fig.3.46a).
Total perforation—It is dened as
perforation that involves whole of
pars tensa with no remnant of TM
(Fig.3.46b).
Size of perforation—Classication
of perforation according to size
(Fig. 3.47)
Small—If perforation involves less
than 25% of pars tensa, it is called
small perforation. It may present in
either one quadrant of tympanic membrane or in central part (Fig.3.47a).
Medium—If perforation involves
25–50% of pars tensa, it is called as
P
medium perforation. It may involve
the either two quadrants of tympanic membrane or less than half of
all quadrants of tympanic membrane if it presents in central part of
tympanic membrane (Fig.3.47b).
Large—If perforation involves more
than 50% of pars tensa, it is called
large perforation. This perforation is
usually present in central part of tympanic membrane (Fig.3.47c).
Subtotal perforation—If perforation involves all quadrants of pars
tensa with remnants all around
towards the margins and handle of
malleus. This peroration of
tympanic membrane has horseshoe/
kidney-shaped (Fig.3.47d).
Near-total perforation—This is
larger than subtotal perforation in
PAPA
3.2 Examination ofEar
125
a
b
c
Right ear
A
P
Fig. 3.45 Central perforations. (a) Small central; (b) medium central; and (c) large central perforation
Fig. 3.46 (a, b)
Marginal perforations of
a b
pars tensa
P
A
P
A
126
a
3 History andExamination ofEar
b
c
A
d
P
A
e
P
A
P
f
P
A
P
A
P
A
Fig. 3.47 Perforations of pars tensa. (a) Small perforation; (b) medium; (c) large perforation; (d) subtotal perforation;
(e) near-total perforation; and (f) total perforation
3.2 Examination ofEar
Fig. 3.48 Double
perforations in tympanic
membrane. (a) Double
perforations; and (b) one
perforation in PS and
another in pars accida
127
a
b
A
which most of tympanic membrane
is absent but few remnants are present all around (Fig.3.47e).
Total perforation—It involves all
of pars tensa; only tympanic annulus is present (Fig.3.47f).
Number of perforation—classi-
cation of perforation according to
numbers (Fig.3.48)
Single perforation—This is commonest ndings in CSOM and
trauma.
Double perforation—Two perforation in pars tensa of TM is caused
by either the tuberculosis of ear or
trauma. One perforation present in
pars tensa and another in pars accida are caused by dual pathology
(Fig.3.48a, b).
Multiple perforation—More than
two perforations present in pars
tensa are sign of tuberculosis of ear.
Margins of perforation
Smooth margin—Smooth margins
are present in CSOM
P
A
Fig. 3.49 Oedematous TM
Irregular margin—traumatic
perforation
Sharp margins—CSOM (mucosal
type)
Rounded margins—CSOM with
epithelial ingrowth
Oedema of TM
It is a sign of acute infection, allergy
and tuberculosis (Fig.3.49).
Perforation in pars accida—if
perforation presents superior part of
P