Tympanic Membrane Retraction Pocket : Overview and Advances in Diagnosis and Management

This book reviews current knowledge of the etiopathogenesis, pathophysiology, and molecular biology of tympanic membrane retraction pockets and provides clear guidance on clinical assessment and treatment. A new diagnostic approach based on clinicoradiologic correlations is presented, and the ability of computer tomography to offer objective criteria for improved differentiation between stable and unstable or unsafe retraction pockets is explained. Surgical options are discussed, and on the basis of their own clinical and surgical experiences the authors propose a novel procedure, masto-atticotomy with anterior epitympanotomy (AER surgery), which addresses the causative factors underlying a retraction pocket. This surgery aims to restore adequate aeration routes for the middle ear compartments situated above the tympanic diaphragm; it results in better control of the pathology and in most cases prevents its recurrence. The book will assist otologists and surgeons in ensuring that retraction pockets are effectively diagnosed and treated, avoiding progression to cholesteatoma. Preface 6 Contents 8 1: Introduction 11 References 12 2: Related Anatomy of the Middle Ear Cleft and Eustachian Tube 13 2.1 The Tympanic Membrane 13 2.1.1 Tympanic Membrane Stability 13 2.1.2 Microscopic Structure of the Tympanic Membrane 14 2.1.2.1 The Epidermal Layer 14 2.1.2.2 The Mucosal Layer 14 2.1.2.3 The Lamina Propria 14 2.2 Middle Ear Ventilation Anatomy 15 2.2.1 The Tympanic Diaphragm 15 2.2.2 The Tympanic Isthmus 18 2.2.3 The Anteroinferior Compartment 18 2.2.3.1 The Mesotympanum 18 2.2.3.2 The Lower Unit of the Attic 19 2.2.4 The Posterosuperior Compartment 19 2.2.4.1 The Attic 20 2.2.4.2 The Mastoid Air Cells 22 2.2.4.3 Mastoid Air Cell System Volume 23 2.3 Middle Ear Mucosa 24 2.3.1 The Anteroinferior Compartment 24 2.3.2 The Posterosuperior Compartment 24 2.4 The Fibrocartilaginous Eustachian Tube 27 References 27 3: Middle Ear Pressure Regulation: Physiology and Pathology 29 3.1 Middle Ear Transmucosal Gas Diffusion 29 3.2 Eustachian Tube Function: Middle Ear Macroventilation 30 3.3 Middle Ear Microventilation 30 3.4 The Role of Mastoid in Pressure Regulation 31 3.5 Role of the Tympanic Membrane in Middle Ear Pressure Regulation 32 3.6 Middle Ear Dysventilation 32 3.6.1 Mucosal Dysfunction 33 3.6.1.1 Impact of Inflammation in the Posterosuperior Compartment of the ME: Increased Gas Diffusion 33 3.6.1.2 Impact of Inflammation on the Anteroinferior Compartment of the ME: Mucociliary Clearance Dysfunction 33 3.6.2 Eustachian Tube Dysfunction 34 3.6.3 Middle Ear Dysventilation Syndromes (Fig. 3.3) 35 References 36 4: Tympanic Membrane Retraction Pockets 39 4.1 Prevalence 39 4.2 Etiology and Pathogenesis 40 4.2.1 Pars Tensa Retraction Pocket Formation 40 4.2.1.1 Anatomical Predisposition of ME Structures 41 4.2.2 Pars Flaccida Retraction Pocket Formation 41 4.3 Histopathology of the Retraction Pocket 42 4.4 Molecular Biology of the Retraction Pocket 45 4.5 Fate of Retraction Pockets 47 4.6 Ossicular Erosion in Retraction Pockets 48 4.7 Staging of Retraction Pockets 50 4.8 Clinical Features 52 4.8.1 Clinical Description of the Pocket 52 References 55 5: Role of Computed Tomography Imaging in Retraction Pockets 58 5.1 A Morphologic Assessment of the Retraction Pocket by Computed Tomography 58 5.2 Pneumatization of the Temporal Bone and Aeration of ME Cleft Spaces 60 5.2.1 Pneumatization of the Temporal Bone 60 5.2.2 The Aeration of the Air Cell System of the ME Cleft 60 5.3 Clinico-radiologic Correlations 61 5.3.1 Materials and Methods 62 5.3.2 Results 62 5.3.2.1 The Retraction Pocket Aspects 62 5.3.2.2 Status of Pneumatization 62 Mastoid Pneumatization 62 Anterior Epitympanic Recess (AER) Pneumatization 63 5.3.2.3 Status of Aeration 63 Mastoid Aeration 63 Aeration Status of the AAA Spaces 64 5.3.2.4 Association Between Aeration and Pneumatization Status 65 5.4 Conclusions of Clinico-radiologic Correlations 65 References 66 6: Management of Retraction Pockets 67 6.1 Watchful Observation 67 6.2 Surgical Strategies 68 6.3 Surgical Procedures 68 6.3.1 Myringotomy with Tubes 68 6.3.2 Subannular Ventilation Tubes 69 6.3.3 Tympanoplasty 69 6.3.4 Resection of the RP and Mastoid Obliteration 70 6.3.5 Masto-atticotomy with Anterior Epitympanotomy (AER Surgery) 71 6.3.5.1 Our Clinical Experience According to This Surgical Concept 73 6.3.5.2 Conclusion of Our Clinical Data 74 References 75 7: Atelectasis and Adhesive Otitis Media 78 7.1 Pathogenesis 78 7.1.1 Histopathology of Adhesive Otitis Media 81 7.2 Clinical Manifestations 81 7.3 Complications 84 7.3.1 Ossicular Chain Erosion 84 7.3.2 Cholesteatoma 84 7.4 Imaging 84 7.5 Treatment 84 7.5.1 Preventive Treatment 85 7.5.1.1 Treatment of Eustachian Tube Dysfunction 86 7.5.1.2 Treatment of Atelectasis 86 7.5.2 Treatment of Adhesive Otitis Media 87 References 87 8: Conclusion 90 Index 92 Front Matter....Pages i-ix Introduction....Pages 1-2 Related Anatomy of the Middle Ear Cleft and Eustachian Tube....Pages 3-18 Middle Ear Pressure Regulation: Physiology and Pathology....Pages 19-28 Tympanic Membrane Retraction Pockets....Pages 29-47 Role of Computed Tomography Imaging in Retraction Pockets....Pages 49-57 Management of Retraction Pockets....Pages 59-69 Atelectasis and Adhesive Otitis Media....Pages 71-82 Conclusion....Pages 83-84 Back Matter....Pages 85-87