Rensink, Michael J. MD
Dr. Rensink is a member of ENT Associates of San Diego, and has been a practicing ENT specialist for more than 35 years.
Sandra, a 52-year-old woman, came to the office complaining about decreased hearing in her right ear, with a stuffy, plugged-up sensation in both ears. Her hearing tests indicated moderate conductive hearing loss in the right ear (Figure 1) and mild conductive hearing loss in the left ear. (Figure 2.)
Tympanograms were flat, acoustic reflexes were absent, and the relative physical volume values were 1.3 and 1.1 CCs in the right and left ear, respectively. She denied tinnitus and vertigo, and reported having this condition for a considerable amount of time.
The hearing problem in her right ear, however, worsened over the past couple of months. She is unable to use the telephone with her right ear. Sandra also denied having any recent upper respiratory or ear infections, and is in otherwise good health.
Figure. Michael J. R...Image Tools
What is your diagnosis?
By Michael J. Rensink, MD
The air in the middle ear is depleted and a partial vacuum is created when the Eustachian tubes malfunction due to upper respiratory congestion. The eardrum is retracted by the difference in air pressure in the outer and middle ear. The eardrum collides as the condition worsens, first with the ossicles, then with the medial wall, or promontory, of the middle ear. The promontory is a rounded protrusion formed by the basal turn of the cochlea. Figures 1 and 3 show Sandra's right ear in a condition of severe retraction called atelectasis.
Patients who have severely retracted tympanic membranes (TMs), such as in this case, need to be managed by an otolaryngologist. The treatment may be as simple as politzerization (inflating the middle ear by applying pressure to the ear through the nose, similar to a Valsalva maneuver), or it may require the insertion of a ventilation tube to restore the normal aeration to the middle ear. Treatment may fail completely, and the problem may progress and create a natural mastoid cavity, depending on the underlying pathophysiology. Chronic pressure in the middle ear over a period of years may erode bony tissue, forming a cavity.
The eardrum, as seen through an otoscope, has a long process, or arm, of the malleus that is sandwiched between the outer and inner layers of the eardrum. The position of the arm is an important landmark, and may help us differentiate a normal versus retracted TM.
Professionals should be able to recognize the three parts of the malleus: the head and lateral process, the long process, and the umbo at the end of the process.
Much of the head of the malleus can be seen through the eardrum in the upper-central zone if the eardrum is healthy and translucent. The lateral process of the malleus appears as a white ball in the top-center area of the eardrum. The manubrium, the long process of the malleus, extends from the lateral process to the midpoint in the eardrum. The umbo has a small white tip located near the middle of the eardrum.
In a healthy ear, the orientation of the manubrium is almost vertical. Think about the hands on a clock. The position of the manubrium is situated around 7 p.m. in a healthy right ear and at 5 p.m. for a healthy left ear. An ear with a dysfunctional Eustachian tube shows the eardrum and manubrium pulled inward. This alters the angle of the manubrium, near 8 p.m. for the retracted position in the right ear and about 5 p.m. for the retracted position in the normal left ear.
Figure 1 shows Sandra's right ear the first time she was seen in the office. Figure 3 is the same ear eight months later. Compare the two figures and notice the buildup of middle ear fluid in Figure 2 as well as the bubbles in the fluid in Figure 3. More than half of the total surface area of Sandra's right TM is in contact with the medial wall.
When I evaluated the right ear using pneumotoscopic massage, no tissue movement was observed in the central zone of the eardrum, the area that includes the long arm of the malleus. The lack of TM and ossicular movement created a 35 to 45 conductive hearing loss in the right ear.
Figure 2 is a photograph of Sandra's left ear, and shows the early stages of atelectasis: the eardrum has retracted, and is touching the incudostapedial joint. This point is a white oval in the upper right part of this photograph. The chronological progression of atelectasis can be observed by comparing Figures 1 and 2 with Figure 3. The condition in the right ear is advanced, and the condition in the left ear is early stage.
Chronic congestion and loss of Eustachian tube function destroys the health of the middle ear by robbing the space of air. Initially, the TM is retracted, and the ear feels stuffy. The TM makes contact with the incudostapedial joint as the retraction continues. The TM wraps around the ossicles and collides with the medial wall of the middle ear as the ear continues to deteriorate, which results in substantial hearing loss. If this is not corrected, the ear can continue to deteriorate with the loss of the bony tissues, structures, and hearing. Continuous effective medical treatment is essential for preservation of ear health and hearing.
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© 2012 Lippincott Williams & Wilkins, Inc.