Atelectasis, Adhesive Otitis Media Keywords: adhesive otitis media, retraction pocket, Sadè classification, ventilation tube Abstract Adhesive otitis media is characterized by retraction of the thin and atrophic tympanic membrane to the medial wall of the middle ear due to the negative middle ear pressure caused by Eustachian tube dysfunction or persistent secretory otitis media. Different grades of atelectasis can be distinguished, based on Sadè classification: Grade I corresponds to a mild retraction, while Grade IV is a complete atelectasis of the tympanic membrane. Treatment depends on the grade of retraction and hearing function. Each grade of atelectasis with the relative management will be discussed in this chapter. Adhesive otitis media is characterized by complete or partial adhesions between the thin retracted and atrophic pars tensa and the medial wall of the middle ear. Necrosis of the long process of the incus or the stapes suprastructure can also occur, with a resultant natural myringostapedopexy. It should be differentiated from atelectasis and from simple drum retraction, in which the tympanic membrane is mobile with the Valsalva or Toynbee maneuvers. Sadè (1979) distinguished five grades of atelectasis ( ▶ Fig. 6.1): Grade I is characterized by a mild retraction of the tympanic membrane; in grade II, the retracted tympanic membrane comes in contact with the incus or the stapes; in Grade III, the tympanic membrane touches the promontory; Grade IV is adhesive otitis media; and, in Grade V, there is a spontaneous perforation of the atelectatic ear drum with otorrhea and polyp formation. Fig. 6.1 Sadè classification of atelectasis (modified) (see text). Nakano (1993) proposed two types of adhesive otitis: type A, in which the retracted and atrophic tympanic membrane adheres completely to the promontory, and, type B, in which retraction and adhesion affect mainly the posterior part of the tympanic membrane, usually without retraction of its anterior half. Histologically, the tympanic membrane is atrophic due to thinning or even absence of the lamina propria. It can be hypothesized that the negative middle ear pressure caused by Eustachian tube dysfunction or persistent secretory otitis media leads to atrophy of the elastic fiber of the pars tensa. An occasional episode of acute suppurative otitis media might form adhesions between the mucosa of the promontory and the retracted tympanic membrane. The figures in this chapter present different grades of atelectasis and types of adhesive otitis media ( ▶ Fig. 6.2, ▶ Fig. 6.3, ▶ Fig. 6.4, ▶ Fig. 6.5, ▶ Fig. 6.6, ▶ Fig. 6.7, ▶ Fig. 6.8, ▶ Fig. 6.9, ▶ Fig. 6.10, ▶ Fig. 6.11, ▶ Fig. 6.12, ▶ Fig. 6.13, ▶ Fig. 6.14, ▶ Fig. 6.15, ▶ Fig. 6.16, ▶ Fig. 6.17, ▶ Fig. 6.18, ▶ Fig. 6.19, ▶ Fig. 6.20, ▶ Fig. 6.21, ▶ Fig. 6.22, ▶ Fig. 6.23, ▶ Fig. 6.24, ▶ Fig. 6.25, ▶ Fig. 6.26, ▶ Fig. 6.27, ▶ Fig. 6.28, ▶ Fig. 6.29, ▶ Fig. 6.30, ▶ Fig. 6.31, ▶ Fig. 6.32, ▶ Fig. 6.33, ▶ Fig. 6.34, ▶ Fig. 6.35, ▶ Fig. 6.36, ▶ Fig. 6.37, ▶ Fig. 6.38). Fig. 6.2 Right ear. Sadè Grade I atelectasis. The tympanic membrane is retracted but does not come into contact with the middle ear structures. A mild retraction of the pars flaccida, through which the head of the malleus is visible, is also noted. The base of the retraction pocket is under control, with no sign of cholesteatoma. It is also possible in this case to assume that the drum is mobile on Valsalva or Toynbee maneuvers. This patient presented with very mild conductive hearing loss and a normal tympanogram (type A) (see ▶ Fig. 6.3 and ▶ Fig. 6.4). Fig. 6.3 Audiogram of the same case. Mild conductive hearing loss. Fig. 6.4 Tympanogram of the same case. Normal or type A. Fig. 6.5 Right ear. Grade I atelectasis. This case could represent an evolution of that in ▶ Fig. 6.2. There is a deeper retraction pocket with erosion of the scutum. Even if it is a self-cleaning retraction pocket and the base seems under control, it is better to perform a CT scan to exclude an epitympanic cholesteatoma or strictly follow-up the patient with proper otoscopic evaluations. The hearing function is the same as in ▶ Fig. 6.3. Fig. 6.6 Left ear. Another case of Grade I atelectasis. There is an erosion of the long process of the incus, resulting in mild conductive hearing loss (within 20 dB). A myringosclerosis of the anterior quadrants of the tympanic membrane is also visible. Considering the hearing function and the absence of other symptoms, the patient could be just followed up with otoscopic examinations. In case of worsening of hearing function, ossiculoplasty with autologous remodeled incus and a posterior reinforcement of the tympanic membrane with tragal cartilage should be considered. Fig. 6.7 Right ear. Grade I atelectasis with the malleus slightly medialized. An epitympanic retraction pocket is also seen. A yellowish middle ear effusion can be appreciated. Pure tone audiogram revealed a 40-dB conductive hearing loss ( ▶ Fig. 6.8), whereas the tympanogram was type B, i.e., typical of middle ear effusion ( ▶ Fig. 6.9). In this case, the insertion of a ventilation tube is indicated to avoid further retraction of the tympanic membrane, to aerate the middle ear, and to improve hearing. Fig. 6.8 Audiogram of the same case, showing a 40-dB conductive hearing loss. Fig. 6.9 Type B tympanogram of the same case, typical of middle ear effusion. Fig. 6.10 Right ear. Grade I atelectasis. The tympanic membrane is markedly thinned due to partial resorption of the lamina propria. The incus is seen in transparency. Pure tone audiogram is normal ( ▶ Fig. 6.11), whereas the tympanogram has a very high compliance ( ▶ Fig. 6.12). As the tympanic membrane is mobile with the Valsalva maneuver, insertion of a ventilation tube is not indicated. Fig. 6.11 Audiogram of the same case.
6 Atelectasis, Adhesive Otitis Media
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