Retraction pockets of pars tensa in pediatric patients: Clinical evolution and treatment

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Abstract

Objective

To assess outcome in pediatric patients after treatment for retraction pockets of pars tensa in relation to retraction grade, site, occurrence of complications, and patient age.

Methods

Outcomes in 45 ears of 37 children medically or surgically treated for retraction pockets were compared to a control group of 40 untreated children over a follow-up period of at least 24 months. Grade I and II retractions were treated with medical therapy or ventilation tube insertion; in III or IV grade retractions, excision and tympanic reinforcement with cartilage grafting and in some cases ossiculoplasty were performed.

Results

Medical treatment or ventilation tube insertion resolved grade I and II retractions in 94% of cases. In grade III or IV retractions the anatomic success rate was 75.8%. Normal hearing (air–bone gap <10 dB) was restored in 31 (68.8%) cases. Surgical failures and complications (recurrence, tympanic membrane perforation, progression to cholesteatoma) were higher in posterior retractions. In the control group, only 35% of retractions healed spontaneously; in the remaining cases the condition progressed to more serious retractions or complications.

Conclusion

A wait and see approach or conservative therapy is indicated only in mild-to-moderate retraction pockets owing to their benign prognosis. Pocket excision and tympanic reinforcement are absolutely indicated in advanced retractions with complications and/or bilateral conductive hearing loss to avert progression to more serious pathologies.

Introduction

Retraction pockets of the tympanic membrane (TM) pars tensa are recognized sequelae to protracted tympanic hypoventilation (tubaric dysfunction) associated with recurrent or chronic otitis media, particularly otitis media with effusion (OME) [1]. This may weaken some areas of the TM, causing it to adhere to the middle ear medial wall or to the ossicular chain and result in fibrosis [2], especially in the posterior quadrants [3].

In children these retraction pockets are considered an insidious disorder because of the initially scarce symptoms and because of the dynamics of the pathology. In fact, it can progress to more severe forms or complications (infection, polyps, perforation) and transform into cholesteatoma in some cases [4], [5]. Because of associated damage to the ossicular chain, retraction pockets often lead to conductive hearing loss and more rarely sensorineural hearing loss secondary to labyrinthine fistulae that may develop in posterior sites [6].

This study reports the outcome in pediatric patients after treatment for retraction pockets of pars tensa assessed according to retraction grade, disease progression, and patient age. In patients eligible for surgery, we also attempted to define the best technique in relation to retraction severity and location.

Section snippets

Materials and methods

In this retrospective study, we reviewed cases of retraction pockets in 45 ears of 37 children (19 boys and 18 girls; age range 5–12 years) treated consecutively from March 2002 to March 2007 at the Ospedali Riuniti University Hospital, Foggia. Only cases with persistent OME (12 cases), severe progression of the disease (wide retractions on the medial wall or progression extending beyond the scutum in 18 cases), recurrent infection and polyps in the pocket (19 cases), perforations (5 cases) and

Results

At final assessment after at least 2 years follow-up, the condition had cleared in 15 cases (94%) of grade I and II retractions, with limited areas of tympanic atrophy in 6 (37.5%) ears, in 3 of which a VT had been inserted. One case of a medically treated retraction progressed to grade III.

In grade III retractions surgical treatment obtained optimal results in 19 (79.1%) cases; myringosclerotic areas were found in only 4 ears, in 2 of which a VT had been inserted. Treatment failure was noted

Discussion

Owing to their potential progression (cholesteatoma, tympanosclerosis) and complications (recurrent infection, TM perforation, ossicular chain damage, etc.) retraction pockets of pars tensa should not be viewed as a minor ear disorder. Current opinion agrees that patients with an apparently stable condition or with good prognosis and normal hearing do not need treatment. Therefore, a watch and wait approach, especially after childhood, is always advisable [7], [8], [9]. In agreement with this

Conflict of interest

The Authors declare that there is no financial or personal relationship with other people or organisations that could inappropriately influence this work.

Funding

No funding sources have contributed to this investigation.

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