Middle Ear Atelectasis

Definition
● A condition of retraction and atrophy of the tympanic
membrane in chronic otitis media with effusion.
● It is generally accepted that dysfunction of the eustachian
tube ventilating the middle ear leads to chronic negative
pressures, tympanic membrane atrophy, and retraction.
● Retraction of the tympanic membrane (TM) is defined by the
abnormal position of the TM medial to the plane of the anulus
and malleus.
Pathogenesis

The three main mechanisms that regulate middle ear pressure are:
1. Gas diffusion through the middle ear mucosa
2. Pressure buffer of the mastoid air cell system
3. Gas exchange through the eustachian tube
Four stages of middle ear atelectasis.
● Grade I. Mild tympanic
membrane retraction: TM is
medial to the plane made by
the anulus and malleus.
● All or a portion of the drum is
retracted, but does not touch
any middle ear structures.
● All aspects of the drum are
visible.
● Grade II. Moderate
retraction: TM contacts
the incus.
● The drum is retracted
and draped over the
incus or stapes. The
drum is not touching the
promontory.
● All aspects of the drum
are visible.
● Grade III. Severe
retraction: TM
contacts the
promontory but
remains mobile.
● The same as grade
two, but the drum is
now touching the
promontory.
● All aspects of the
drum are visible.
● Grade IV. Retraction
cholesteatoma: TM
adheres to
promontory.
● The same as grade
three, but the drum is
now retracted around
a corner.
● All aspects of the
drum are not visible.
Treatment of Middle ear atelectasis
 Treatment of Middle ear atelectasis
●Grade one or two retractions are often managed medically by encouraging the patient to insufflate
the middle ear space by attempting to blow through a pinched nose.
If the patient has difficulty accomplishing this task, nasal steroid spray is recommended.
●Grade three retractions are managed generally with Valsalva and nasal steroids; usually, if the drum
fails to improve, a pressure equalization tube is recommended.
During routine follow-up, if the drum has progressed to a grade three with medical management, or has
adhesive characteristics, then a cartilage tympanoplasty is often recommended
●Grade four retractions are managed by performing a cartilage tympanoplasty and a mastoidectomy
for cholesteatoma, as needed.
Typically, unless the retraction pocket extends into the antrum and mastoid, a mastoidectomy is not
performed
 Surgery for atelectasis
The goals of surgery for atelectasis are the restoration of an aerated middle ear and preserved or
restored conductive hearing. This is accomplished by addressing the following:

1. Removal of all keratinizing epithelium invading the middle ear.

2. Removal of infectious foci.
3. Removing anatomic obstructions that may favor infection or failure of ventilation.
4. Placement of a long-term ventilation tube.
5. Cartilage graft for reinforced TM strength.
Technique Surgical Approach
1. Graft Harvest
2. Tympanomeatal Flap
3. Canalplasty and Atticotomy
4. Middle Ear Evaluation
5. Ventilation Tube
6. Grafting
Postoperative Care
● Follow-up is extremely important in the atelectatic ear.
● Good anatomic and functional results 6 months, 1 or even 2 years after
surgery
● The cartilage graft can migrate and epithelium can retract around it.
● Long-term recurrence has been observed and requires vigilant clinical
follow-up
Summary
● Many options are available to manage a patient who has atelectatic ears
● Establishing normal middle ear ventilation and aeration is the
cornerstone to successful control of these ears.
● Often, medical management with nasal steroids and decongestants is all
that is needed
● If recurrent infections have weakened the tympanic membrane
progressively, or the middle ear environment is so severe that medical
management does not correct the problem, then surgical correction is
often necessary.
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