Tympanosclerosis

Tympanosclerosis is hyalinisation and calcification of collagen in the tympanic membrane and middle ear mucosa, forming white plaques. It is the result of repeated or chronic middle ear inflammation and may fix the ossicles.

It is found in about 10% of patients who have had tympanostomy tubes, and in up to a third of those with chronic otitis media. Most plaques in the drum (myringosclerosis) cause no hearing loss. Ossicular fixation is rare but causes conductive loss.

Pathophysiology.

Chronic inflammation and trauma lead to fibroblast activation and hyaline degeneration of collagen, followed by deposition of calcium and phosphate crystals. Plaques form in the submucosa of the middle ear and in the fibrous layer of the drum.

Most patients have no symptoms, with chalky white plaques found on examination. Conductive hearing loss occurs when plaques fix the stapes, malleus or incus. Other findings relate to the cause, such as a perforation or past tube insertion.

Red flags.

• Sensorineural loss.
• Vertigo or facial weakness.
• Discharge from a perforation.

Otoscopy shows white or cream, chalky plaques in the drum (myringosclerosis). Audiometry shows a normal pattern or a flat conductive loss, and tympanometry shows reduced compliance or a normal curve. CT of the temporal bone shows calcified plaques in the middle ear and ossicular fixation. Diagnosis of ossicular fixation is confirmed at surgery.

Differential diagnosis.

• Otosclerosis.
• Congenital ossicular fixation.
• Adhesive otitis media.
• Cholesteatoma.
• Healed perforation with atrophic scar.

No drug treats established plaques. Observe asymptomatic myringosclerosis. Offer a hearing aid for conductive loss, or surgery (removal of plaques, mobilisation, and ossiculoplasty or stapedotomy) for ossicular fixation, accepting a high rate of recurrence and a risk of inner ear damage. Keep the ear dry when a perforation is present, and treat infections early.

Monitoring. Audiometry every 12 months or when symptoms change.

Referral and escalation. ENT and audiology.

Special groups. Children with past tube insertion need hearing review until school age.