The surgical management of the pars tensa retraction pocket in the child — results following simple excision and ventilation tube insertion

Abstract

Retraction pockets of the pars tensa formed due to poor mesotympanic ventilation can result in chronic infection, ossicular damage and even acquired cholesteatoma. A diversity in opinion exists as to the best surgical treatment of an established retraction pocket. This paper presents a consecutive prospective series of 39 ears managed over the last 4 years by means of simple excision and insertion of a middle ear ventilation tube. The retraction pockets were graded according to Sadé’s 1979 classification. There were 23 grade II and sixteen grade III retractions. All 39 pockets were successfully excised. Thirty-four of the perforations healed, with the remaining five failing to heal at the time of analysis. In 13 cases the pockets recurred, but in five of these cases the recurrence is minimal and has required no further surgical intervention. Of the eight remaining significant recurrences, four have undergone a repeat procedure with no further recurrence in three cases. Following initial surgery, 67% of the ears operated upon had either minimal or no recurrence. Following further surgery this figure increased to 75%. The air conduction threshold improved by an average of thirteen decibels in those ears that healed with no recurrence.

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:

• Middle ear ventilation tube insertion [8]

• Tympanotomy, tympanic membrane mobilisation and ventilation tube insertion [9], [10]

• Dissection and reinforcement [6], [7]

• Transcanal excision with middle ear ventilation tube insertion [11], [12], [13]

• 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.