Description
Case I
Case II
Case III


Description

Tympanosclerosis is a middle ear disorder that involves fibrosis and deposition of calcium salt deposits within the middle ear and especially the eardrum. As a result, the mobility of the eardrum may be limited. Sometimes tympanosclerosis also spreads on the ossicles and tympanic cavity internal walls causing the progressive loss of hearing. In children, this process is rarely so advanced and is restricted primarily to the tympanic membrane. The process of formation of deposits of tympanosclerosis is associated with chronic inflammation of the middle ear, but etiology is not fully understood. It may be also associated with insertion of a larger tympanostomy tubes or repeated procedures of tympanic cavity drainages.


Case I

The photo below shows the tympanic membrane with deposits of tympanosclerosis, left ear, 7 – year old child. There are whitish patches on the tympanic membrane that form kind of hard layer, which mobility is restricted, in particular in the posterior quadrant but also in the rest of the tympanic membrane at its edges (fig. 1).

The symptoms were associated with the presence of chronic otitis media with effusion for which the child had suffered for several years. The presence of tympanosklerosis of such limited range does not cause hearing loss. The differential diagnosis should take into account the presence of congenital cholesteatoma as an whitish mass behind an intact eardrum. Sometimes the differentiation is very difficult but in this case is evident.

Tympanosclerosis
Fig. 1 Tympanosclerosis
  • In this case treatment was not required, because the hearing remained normal. The presence of deposits of tympanosclerosis which are limited only to the part of the tympanic membrane does not cause significant hearing loss and other symptoms.
  • The child should be periodically monitored with a photographic documentation in order to assess progression. One should also perform basic audiometric testing.
  • If tympanosclerosis spreads causing hearing loss, surgical treatment should be considered.
  • The surgeon removes deposits of tympanosclerosis, sometimes with a part of the tympanic membrane, performs myringoplasty with tragal perichondrium or temporal muscle fascia and ossiculoplasty with ossicular chain mobilization.
  • In general: surgical treatment of tympanosclerosis is complicated and difficult.

Case II

The photo shows the central perforation and the tympanosclerosis of the tympanic membrane, 10-year-old child, left ear. Perforation covers anterior and inferior quadrants of the tympanic membrane, from umbo nearly reaching the annulus. The perforation is dry, safe, ear without discharge. Tympanosclerosis in the form of large, white, well limited plate is located in posterior quadrant but also can be seen in anterior quadrant (fig 2).

The emergence of these changes was associated in this case with chronic otitis media with effusion for which the child had suffered several years and also with repeated procedures of tympanic cavity drainages. After falling out of the grommet the perforation remained. This perforation did not heal spontaneously partially because of the presence of tympanosclerosis and poor vascularization. The child reported no problems, no hearing loss, there was also no discharge  from the ear.

Tympanosclerosis with perforation of the tympanic membrane
Fig. 2 Tympanosclerosis with perforation of the tympanic membrane
  • Persistent perforation of the tympanic membrane should be treated surgically.
  • Range of surgical intervention: myringoplasty with removing of the tympanosclerosis and tragal perichondrium.
  • During the operation the surgeon opens the middle ear after external auditory canal skin incision. Then the tympanosclerosis is gently removed from the inner surface of the tympanic membrane. A patch of tragal perichondrium or temporal muscle fascia is harvested and perforation is closed. The graft should extend under the margins of the perforation (the remnants of the tympanic membrane). This technique is called “underlay”.
  • Due to the presence of tympanosclerosis and poorer blood supply of the rest of the tympanic membrane, sometimes perforation is not closing.
  • In such cases a re-operation must be done, but using the tragal cartilage (stronger, thicker material).