International Journal of Pediatric Otorhinolaryngology
The surgical management of the pars tensa retraction pocket in the child — results following simple excision and ventilation tube insertion
Introduction
A recognised complication of poor middle ear ventilation combined with chronic otitis media is the pars tensa retraction pocket [1]. Development of such a retraction pocket may be caused by, or result in, episodes of suppuration and thus ossicular damage. Furthermore, retraction pockets can play an important role in the pathogenesis of acquired cholesteatoma [2], [3].
Several different classification systems have been advocated to describe the pars tensa pathology [4], [5], [6], [7]. We have chosen that of Sadé to grade the varying degrees of retraction. Grade I represents simple retraction of the tympanic membrane, grade II retraction onto the incudo-stapedial head (with or without incudo-stapedial joint erosion), grade III retraction without adhesion to the promontory and grade IV adhesion to the promontory. Whilst most otologists would agree on the treatment of grades I and IV disease, there is ongoing debate as to the most appropriate management of grades II and III. Surgical treatments recommended include:
- 1.
Middle ear ventilation tube insertion [8]
- 2.
Tympanotomy, tympanic membrane mobilisation and ventilation tube insertion [9], [10]
- 3.
Dissection and reinforcement [6], [7]
- 4.
Transcanal excision with middle ear ventilation tube insertion [11], [12], [13]
- 5.
Excision and reinforcement tympanoplasty [14], [15]
The diversity in opinion attests to the fact that no single treatment has been proven to be superior to any other.
This paper presents a consecutive series of 39 ears with retractions of grades II and III managed by means of simple excision of the pars tensa pocket and insertion of a middle ear ventilation tube. The tube is inserted in order to allow spontaneous repair of the surgically created perforation in the presence of a normal middle ear pressure.
Section snippets
Materials and methods
Thirty one children presenting with Grades II and III pars tensa retraction pockets in the last 4 years were included in this prospective study. Eight of the children had bilateral retraction pockets. A detailed pre-operative history was taken including symptomatology, predisposing factors and previous management. Ears were examined both with the pneumatic otoscope and the operating microscope. The site and grade of retraction pocket were recorded on the basis of the visual findings. In
Results
Retraction pockets were excised in 31 children. Bilateral disease was present in eight children thus making a total of 39 ears undergoing pocket excision and ventilation tube insertion. The average age at operation in the 17 boys and 14 girls was 7 years (range 3–13 years). Follow-up ranged from 1 to 52 months with a mean of 27 months.
The presenting symptoms were hearing loss in 29 children and recurrent episodes of acute otitis media in 23 children. There were 23 grade II and 16 grade III
Discussion
Retraction pockets of the pars tensa can be progressive and if not treated may result in incudo-stapedial joint erosion and cholesteatoma. The primary aim of management therefore is the establishment of a safe dry ear in which the hearing can be maintained or restored to the normal level.
Treatment in the first instance should be preventive. Tos, Stangerup, and Larsen [16] have shown that chronic serous otitis media can lead to a high incidence of atelectasis and retraction of the pars tensa.
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Cited by (17)
Retraction pockets of pars tensa in pediatric patients: Clinical evolution and treatment
2010, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Surgical techniques and material reinforcing the tympanic membrane (myringoplasty) have been widely studied. Removal of retraction pockets and adjacent atrophic areas often leads to large perforations which, in our view, are unlikely to undergo spontaneous healing, although this has been reported [17,18]. The cartilage of the tragus or the concha with or without the perichondrium [6,9,19], is considered by many to provide the best tissue for obtaining a suitable and long-lasting TM consistency.
Atelectasis of the middle ear in pediatric patients: Safety of surgical intervention
2009, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Atelectasis of the middle ear due to atrophy and retraction of the tympanic membrane is a common and frustrating problem in pediatric otolaryngology. However, there is no consensus as to the best treatment strategy [1–11]. There are several options, varying from watchful waiting, via surgical intervention in the form of ventilation tube insertion, to simple excision and ventilation tube insertion, myringoplasty and tympanoplasty (with or without cartilage support and palisades), or cortical mastoidectomy in an attempt to improve middle ear ventilation.
The extraordinary healing properties of the pediatric tympanic membrane: A study of atelectasis in the pediatric ear
2008, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Temporalis fascia, conchal and tragal perichondrium and both conchal and tragal cartilage [8–12] have all been described. Blaney et al. [4] described a simple excision of pediatric retraction pockets with a healing rate of 87%. In 1992, Sharp and Robinson [6] similarly described simple excision of retraction pockets though his reported rate of healing was only 65%, for a mixed group of patients.
A review of retraction pockets: Past, present and future management
2007, Journal of Laryngology and OtologyMastoidectomy in surgical procedures to treat retraction pockets: a single-center experience and review of the literature
2023, European Archives of Oto-Rhino-LaryngologyManagement of tympanic membrane retractions: a systematic review
2022, European Archives of Oto-Rhino-Laryngology