Description
Case I
Case II
Case III


Description 

One can describe a retraction pocket as a condition where part of the tympanic membrane is drawn towards the middle ear space and lies deeper than a healthy part. Pockets may be formed in any part of the tympanic membrane, but typically are located in epitympanum. Epitympanum is the weakest part of the tympanic membrane, and therefore collapses most often in chronic otitis media, where long-lasting negative pressure in the middle ear plays an important role. Retraction pockets can be divided into controlled and uncontrolled and the difference stems from the possibility of assessing its interior. There are many grading schemes to describe the retraction pockets, one of them is Charachon’s scheme: controlled and movable, controlled and immovable, uncontrolled and immovable. Usually controlled pockets do not require surgery but uncontrolled, which will develop in cholesteatoma should be operated.


Case I

Picture below: this is a picture of the otitis media with effusion and retraction pockets of pars tensa and epitympanum. 13-year-old child, left ear. The tympanic membrane is pulled in the inferior, posterior quadrants and creates small retraction pocket in epitympanum. All these pockets are controlled. The tympanic cavity is filled with a serous yellowish fluid. The lateral process of the malleus is protruding, handle is well visible, you can also notice hypervascularity. The mobility of the tympanic membrane was restricted in otoscopy. This is the image of intermediate,  uncomplicated otitis media with effusion (fig. 1 and 2a).

Symptoms included aural fullness, plugged ear and hearing loss. But often in early stages chronic OME is asymptomatic. Even in late stages with destruction of the tympanic membrane, where the atrophic tympanic membrane lies directly on the incudostapedial joint, hearing may be normal. Such otitis media with effusion in children is often associated with chronic, untreated adenoid and tonsills hypertrophy, upper respiratory tract infections and is very common in children affected with cleft palate.

Retraction pockets
Fig. 1 OME with retraction pockets
Retraction pockets - scheme
Fig. 1a OME with retraction pockets – scheme
  1. lateral processs of malleus
  2. handle of malleus
  3. retraction pocket in inferior quadrants
  4. small, controlled epitympanic retraction pocket
  5. incudostapedial joint
  6. small retraction pocket in posterior quadrant
  • Because it was an early stage of the OME, retraction pockets were controlled, I adopted a stretegy of watchful waiting.
  • Non pharmacological methods including autoinflation with nasal balloons were used during weeks of observation.
  • Nasal sprays with steroids were used but only for two weeks during upper respiratory tract infection with nasal obstruction.
  • There were no signs of allergy so antihistamines and decongestants were not used – they can increase the viscosity of fluid in middle ear.
  • Surgery was not necessary in this case, effusion resolved spontaneously, retraction pockets got better.

Case II

Pictures below show the eardrums with retraction pockets in the same child. Fig. 2 and 2a – right ear with epitympanic controlled retraction pocket, which did not require surgery. Fig. 3 and 3a – left ear with uncontrolled pocket, which was operated on. 15-year-old child. On the photo 2 you can see the whole area of epitympanum, the tympanic membrane is pulled and resting on the the neck of the malleus. You can not see the skin or accumulation of cholesteatoma. The the photo 3 you can see the uncontrolled retraction pocket in epitympanum: eardrum is strongly retracted one can not determine the exact position of its banks, the destruction of the lateral wall of the attic is larger and the epithelium begins to grow into the back, forming the initial stage of cholesteatoma.

Symptoms included recurrent upper respiratory infections, plugged ear, periodically appearing effusion, and mild degree hearing loss. Probably allergy was the cause, after exclusion of adenoid hypertrophy and other causes.

Controlled epitympanic retraction pocket
Fig. 2 Controlled epitympanic retraction pocket
Controlled epitympanic retraction pocket - scheme
Fig. 2a Controlled epitympanic retraction pocket – scheme
  1. controlled epitympanic retraction pocket
  2. lateral processs of malleus
  3. anterosuperior quadrant
  4. handle of malleus
  5. posterosuperior quadrant

Case III

The same child, opposite ear. Uncontrolled retraction pocket. 

Uncontrolled epitympanic retraction pocket
Fig. 3 Uncontrolled epitympanic retraction pocket
Uncontrolled epitympanic retraction pocket - scheme
Fig. 3a Uncontrolled epitympanic retraction pocket – scheme
  1. lateral processs of malleus
  2. handle of malleus
  3. anterosuperior quadrant
  4. big and uncontrolled epitympanic retraction pocket
  5. posterosuperior quadrant.
  • Because there was evident destruction of the tympanic membrane, uncontrolled pocket with accumulation of epithelim, we made the decision of surgical treatment.
  • Range of surgical intervention: epitympanotomy with removing of the retraction pocket, myringoplasty with tragus perichondrium.
  • Sometimes a condition like this requires antromastoidectomy and posterior tympanotomy if removal of the epithelium is impossible from anterior tympanotomy approach.
  • In this case non pharmacological methods e.g. nasal balloons were ineffective.
  • Nasal sprays with steroids were used ocassionally during upper respiratory tract infection with nasal obstruction.