Retracted Tympanic Membrane

A retracted tympanic membrane is inward displacement of the drum, or part of it, toward the middle ear because of negative middle ear pressure or loss of fibrous support. Deep retraction pockets, especially of the pars flaccida or posterosuperior pars tensa, may progress to cholesteatoma.

It is common in children with Eustachian tube dysfunction, allergic rhinitis and adenoid hypertrophy, and in adults with chronic rhinosinusitis. Severity is graded by the Sade classification: grade 1 mild retraction, grade 2 contact with the incus, grade 3 contact with the promontory, and grade 4 adhesion to the promontory.

Pathophysiology.

Poor Eustachian tube function leads to negative pressure that draws in the thin, atrophic drum. Retraction pockets trap keratin, which may become infected or form cholesteatoma.

Fullness, mild hearing loss, popping and recurrent ear infection. Many patients have no symptoms. Discharge, offensive smell and pain suggest infected keratin.

Red flags.

• Pocket with trapped keratin or discharge.
• Facial weakness or vertigo.
• Sensorineural loss.
• Pocket with a visible bony erosion.

Otoscopy or microscopy shows inward movement and thinning of the drum, with visible ossicles, and a pocket whose base can or cannot be seen. Pneumatic otoscopy assesses mobility. Audiometry and tympanometry (type C or B curve) are done. CT or non-echo-planar diffusion weighted magnetic resonance imaging is used when the base of the pocket cannot be seen. Look at the nose and postnasal space.

Differential diagnosis.

• Otitis media with effusion.
• Adhesive otitis media.
• Cholesteatoma.
• Tympanosclerosis.
• Atelectatic ear after tube extrusion.

Grade 1 to 2 retraction with a visible base is observed every 6 months, and the cause of Eustachian tube dysfunction is treated. Consider a ventilation tube for progressive disease. Surgical reinforcement with cartilage graft is for deep or non-self-cleaning pockets, ossicular erosion or cholesteatoma.

• Mometasone nasal spray 50 micrograms for each spray: 2 sprays into each nostril once daily for 8 to 12 weeks; maximum 200 micrograms daily in each nostril; monitor for nose bleeding and local irritation; children over 3 years 1 spray in each nostril daily.
• Cetirizine (allergic rhinitis): 10 mg orally once daily for the season; maximum 10 mg daily; monitor sedation; reduce to 5 mg daily when creatinine clearance is under 30 mL/min.

Advise gentle nose blowing and avoid smoke exposure. Adenoidectomy is considered in children with enlarged adenoids.

Monitoring. Examination every 3 to 6 months for deep pockets, and yearly for mild disease.

Referral and escalation. ENT for grade 3 or 4 retraction, or any pocket that cannot be fully assessed.

Special groups. Children with cleft palate or Down syndrome need regular review.