Department of Otolaryngology, Head and Neck Surgery

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Unit Four: Middle Ear Disease Diagnosis

Middle ear diseases are usually seen in the changes of the tympanic membrane, or through the transparent tympanic membrane. The commonest conditions are shown here.

Bullous Myringitis

This is a 6 year old female who came to the clinic with severe right ear pain. She had a cold and fever one week ago and still has nasal congestion. Her parents state that she has had no ear drainage.

Upon examination of the left ear reveals a fluid filled blister anterior to the malleus. Only the back part of the blister can be seen easily. The anterior canal wall blocks visibility to the rest of the TM. The rest of the TM is erythematous and edematous and has lost the usual landmarks.

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Information: Bullous myringitis is considered by many primarily a viral inflammation of the tympanic membrane that accompanies colds and influenza. It usually does not cause injury to the middle ear or the ossicles. Signs and symptoms include otalgia, blockage, fullness, severe pain with movement of the eardrum, hemorrhagic (herpetic) blebs on lateral surface of the tympanic membrane and adjacent canal. The tympanic membrane may have a purplish hue. Raised water blisters may develop on the tympanic membrane. However, David Fairbanks,M.D. in Antimicrobial Therapy in Otolaryngology - Head and Neck Surgery defines acute bullous myringitis in the absence of prior TM perforation or cholesteotoma as a varient of acute otitis media. It is caused by the same organisms (Streptococcus pneumoniae, Hemophilus influenzae,and Moraxella catarrhalis) and treated with the same agents.

Acute otitis media

This is a 30 year old male who presented to the office with severe left ear pain, hearing loss, and fever for the past 24 hours. Three days ago he began to have symptoms of a "head cold".

Notice the redness of the tympanic membrane from the hypervascularity. This is common in the early stages of acute otitis media.

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Information: Acute otitis media is the rapid onset of an inflammatory process in the mucosa of the middle ear space associated with local or systemic signs. The infection results in a bulging tympanic membrane, swelling, and redness due to a bacteria or virus that has migrated from the nasopharynx, through the Eustachian tube, to the middle ear. The Eustachian tube becomes increasingly blocked by inflammation and fluid accumulates under pressure.

Without treatment, this bacterial infection progresses through four stages.

  1. The first stage is mucosal hyperemia. Occlusion of the Eustachian tube by inflammation initially causes a negative pressure in the middle ear cavity. A sense of fullness is felt along with a hearing loss. The tympanic membrane is hyperemic along the handle of the malleus, the pars flaccida, and around the periphery. Fever and otalgia may be apparent but neither is severe.
  2. The second stage is exudation. Serum, fibrin, red cells, and polymorphonuclear leukocytes escape into mucous secreted by goblet cells. This exudate fills the middle ear cavity under pressure. The tympanic membrane becomes very thickened and bulging, resulting in a conductive hearing loss, pain, and otalgia. A fever occurs. Landmarks are difficult to view. In children, the mastoid area may be tender and swollen.
  3. The third stage is suppuration; also referred to as acute suppurative otitis media. At this point, the TM spontaneously ruptures and a pyogenic bacterial exudative infection is present in the middle ear mucosa. Signs and symptoms include conductive hearing loss, pain, purulent discharge, fever, thickness of the middle ear mucosa, mastoid tenderness, and possibly abscess.
  4. The fourth stage is either of resolution, or coalescence and complications. About 95% of treated cases resolve spontaneously without coalescence making acute otitis media a self-limiting disease process. In the remaining 5% of the population, pus under pressure in the mastoid causes resorption of the bony mastoid air-cell partitions leading to coalescence (the smaller air cells coalesce into larger irregular cavities filled with mucosa, granulations, and pus under pressure). There is erosion of bone in all directions creating an abscess inside and/or outside the mastoid bone. Mucopurulent discharge, fluctuating in amount, continues. Recurring pain and mastoid tenderness accompany low-grade fever and leukocytosis when the discharge is under pressure. Radiography shows decalcification and destruction of cell partitions. Conductive hearing loss is noted. Other signs and symptoms may include sagging of the posterosuperior bony meatal wall, periosteal thickening and deep mastoid tenderness.

Complications may include acute mastoiditis, petrositis, labyrinthitis, facial nerve paralysis, conductive/sensorineural hearing loss, and lateral sinus thrombosis. Complications beyond the tympanic membrane and mastoid air cells include a subperiosteal mastoid abscess, an extradural abscess, a brain abscess, leptomeningitis, and sigmoid sinus thrombophlebitis. The bone in acute coalescent mastoiditis is soft due to decalcification and osteoclasis, yet still living. New bone can form when the pus under pressure is relieved.

Chronic otitis media exists when there is a permanent perforation in the tympanic membrane with or without a permanent change in the middle ear. The extent of mucopurulent inflammation in the middle ear is variable. Signs and symptoms include ossicular bone loss, perforation, retraction, opacities, and granulation tissue including polyps. The tympanic membrane perforation may allow an ingrowth of squamous epithelium. Although drainage may be more or less continuous, active infection is marked by hyperemic, thickened mucosa with mucopurulent discharge.

Serous Otitis Acute and Chronic

This is a 66 year old male who presented to the clinic with fullness and plugging in his right ear for one month. He had been given Augmentin for a previous acute otitis. His past medical history is significant for cleft palate surgery as a child and frequent ear infections. He also had myringotomy tubes placed three years ago.

Notice the yellow serous fluid behind the ear drum. It is particularly visible at the 7 and 9 o'clock positions. There is some retraction at the 9 and 12 o'clock position. Occasionally, air bubbles or an air-fluid level can be seen, although it is not demonstrated in this patient.

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Audiogram information:This audiogram shows a conductive hearing loss in the right ear. The nerve has normal hearing, demonstrated by the bone line (black arrows) near 0 dB. The air line (red circles) is at 45dB - 30 dB. The fluid in the middle ear is preventing the tympanic membrane and ossicles from vibrating normally. Tympanogram Information:The tympanogram shows a flattened line because the fluid is preventing tympanic membrane mobility.

Information: Serous otitis media (SOM) - acute is an ear condition due to the accumulation of a thin, watery transudate in the middle ear. Eustachian tube dysfunction is the primary cause. Respiratory infections and allergies are predisposing factors. Serous otitis is commonly found in children younger than six years of age with a history of otitis media. Patients with an early first episode of otitis, low birth weight, bottle feeding, and daycare in their history are more prone to this disease as well. In adults, barotrauma from flying or scuba diving can cause serous otitis.
Adults with palatal problems and nasopharyngeal lesions or tumors may present with serous otitis as their first complaint. Patients undergoing radiation therapy to the head and hyperbaric oxygen therapy frequently have middle ear fluid.Signs and symptoms include impaired hearing, a bubbling sensation, an ear infection with a bulging tympanic membrane, and pain. Hearing may vary in different positions as the fluid repositions in the middle ear cavity.

Serous otitis media - chronic is the long term accumulation of non-purulent middle ear fluid behind the eardrum. Serous otitis lasting longer then three months, affects up to 5-10% of children. SOM is common in those with syndromic conditions, such asTreacher-Collins and Trisomy 21 and abnormalities such as cleft palate and immotile cilia syndrome.
Signs and symptoms include mild otagia, stuffiness, autophony, hearing loss, and a discolored tympanic membrane with diminished mobility. Complications may include cholesteotoma,and ossicular destruction.


The patient is a 5 year old male presenting at the clinic for a routine school physical. His history is positive for myringotomy and tubes at the age of two. He has no hearing loss.

Notice the whitish irregular area at the 2-4 o'clock positions in the left ear. This demonstrates tympanosclerosis in the fibrous layer of the tympanic membrane.

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Information: Tympanosclerosis is collagen in the pars tensa of the tympanic membrane typically found in patients with a previous history of recurrent otitis media. Tympanosclerosis appears as smooth, white, slightly raised areas of dense tissue. It usually occurs in the area of a healed perforation or extruded tube after recovery from otitis media. Hearing loss is not usually noted unless a major portion of the TM is involved. Tympanosclerosis is usually asymptomatic. In rare cases tympanosclerosis may involve the ossicles and cause fixation with a resultant conductive hearing loss.

Aural Polyp

This 52 year old gentleman had a long history of serous otitis and had a myringotomy tube. After a year the patient came to the clinic with complaints of left ear fullness and hearing loss. The tube became plugged and was removed.

Upon examination of the left ear, the perforation can be seen in the center of the tympanic membrane. There is pink granulation tissue seen through the perforation. The rest of the TM is thickened and opaque from chronic infection.
The lower picture shows an anterior canal polyp secondary to a foreign body reaction.

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Information: An aural polyp is granulation tissue with a stalk that extends from the middle ear through a perforation in the tympanic membrane. It is usually associated with a cholesteatoma or a retained ventilation tube. In suppurative otitis media a polyp is a sign of consolidation and chronicity. This chronic process is difficult to heal without surgery.

Polyps may occur singly or in multiples and are quite variable in size. They may occlude the ear canal and protrude from the meatus. The consistency may vary from very soft to firm. They may appear erythematous or pale.

There are two types of polyps: mucous membrane and granulation. Both are inflammatory in origin, consisting of a mixture of polymorphonuclear leukocytes, plasma cells, mast cells, giant cells and fibroblasts containing numerous new blood vessels.

Mucous membrane polyps originate from folds in the mucous membrane that protrude and are covered by the same epithelial layer as the middle ear. Granulation polyps are not usually covered by epithelium and often signify a cholesteatoma. Granulation polyps may also occur adjacent to a tympanostomy tube.

Retraction Pocket

A 50 year old female presents to the clinic with complaints of decreased hearing and fullness for 2 months in her right ear. She has no acute symptoms. She had a tympanic membrane perforation five years ago.

The tympanic membrane has a posterior retraction at the 9 o'clock position. The retraction is transparent because this is the site of the previous perforation which healed without a fibrous layer. A superior retraction pocket can be seen at the 12 o'clock position in the pars flaccida. The TM has no fibrous layer in that area and frequently becomes retracted by chronic negative middle ear pressure. There is also a middle ear effusion making the TM appear dull and opaque.

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Information: A retraction pocket occurs when an area of the tympanic membrane is pulled into the middle ear space by chronic negative pressure. A superior retraction pocket occurs when the pars flaccida is retracted into the attic. A posterior retraction pocket occurs when the posterior part of the TM is retracted possibly draping over the incus and stapes. The pocket is caused by Eustachian tube dysfunction creating a negative pressure in the middle ear cavity. The physical orientation of the pocket in the tympanic membrane often prevents the epithelium from sloughing properly,allowing keratin debris to accumulate, forming a cholesteatoma.

Adhesive Otitis

History: This is a 75 year old female who complains of severe hearing loss in her left ear. She has a life long history of recurrent ear infections and several operations to repair her ear drum (tympanoplasties).

Examination: Notice the severe retraction of the tympanic membrane. It has moved so far medially that ii lies on the inner wall of the middle ear space. Any ossicles present are highly visible because the TM drapes around them. The midportion of the middle ear bony wall - the promontory - appears white.

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Information: Adhesive otitis is the end stage of serous otitis. It develops over an extended period of time in the presence of chronic serous otitis media. Atrophy of the tympanic membrane occurs causing it to drape over and adhere to the incus and stapes, obliterating the middle ear space.


History: This is a 40 year old male who had a history of many infections as a child. His only complaint now is left ear hearing loss and fullness. He has had no ear surgery.

Examination: The cholesteotoma is seen filling the entire middle ear space. It can be seen through the transparent TM and makes it appear white. The landmarks of the TM can be seen, but there is a slight bulging

The second picture shows a cholesteotoma that has formed in a perforation or retraction pocket through the TM and is growing outward from the ear drum. The patient has a history of chronic otitis media; the cholesteatoma presents as the whitish area at the 12 o'clock position. This is a common area to find a cholesteatoma that develops from a superior retraction pocket. When the outer squamous debris is suctioned away, the resultant perforation or retraction pocket with retained debris is seen in the middle ear space.

On pictures below, notice the cholesteatoma growing in the pars flaccida of the TM^ Click on the arrow to view the video

Information: A cholesteatoma is a keratin accumulation in concentric onion-like layers containing crystals of cholesterol. It is caused by squamous epithelium growing in an enclosed space. The expanding mass of desquamated epitheliium destroys surrounding bone. Cholesteatomas may develop in retractions of the tympanic membrane or from squamous metaplasia in the middle ear due to longstanding infection. The characteristic feature is the presence of white keratin debris in the middle ear. A cholesteotoma typically causes erosion of the ossicles and may damage the semicircular canals and facial nerve, resulting in hearing loss, dizziness and facial paralysis

Cholesteatomas require surgery, usually a mastoidectomy and possible reconstruction of the ossicular chain.


This is 37 year old female who had been on a 4 day vacation. She returned home yesterday by plane. On descent she felt severe pressure and pain in her ear.

Upon examination of the ear, erythematous vessels can be seen parallel to the malleus. This represents hypervascularity secondary to the pressure changes that occurred when the patient was unable to equalize the pressure in her middle ear space.
The lower picture shows a similar patient with a hemotympanum (blood filled middle ear).

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Information:The Eustachian tube is normally closed. It opens with positive pressure in the nasopharynx or by palatal muscle contraction. It acts as a flutter valve and remains closed unless it is opened voluntarily or by reflex. While climbing in an airplane, the external pressure decreases, causing the volume of the air in the middle ear to expand. This relative increase in middle ear pressure will passively open the Eustachian tube, relieving the pressure difference. During descent, middle ear volume decreases, creating a relatively negative middle ear pressure. This pressure opposes the opening of the Eustachian tube and can lead to an irreversible negative pressure, resulting in pain, dizziness, TM rupture, middle ear hemorrhage (hemotympanum) or effusion and hearing loss.

The hemotympanum seen above gives a purple color to the TM. The middle ear space is filled with blood that usually resolves spontaneously. Tympanometry would show a "flat" tympanogram. Decongestants may be prescribed to aid in the resolution.

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