International Journal of Science and Research (IJSR)

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Clinical Study of Retraction Pockets in Chronic

Suppurative Otitis Media
Srikanth Myla1, Ramesh Elma2
Abstract: A clinical study was undertaken to evaluate the total incidence of retraction pockets in chronic suppurative otitis media
patients admitted in ENT ward of SVS Medical College and Hospital.Clinical study of retraction pockets regarding aetiological factors,
the pathogenesis in the chronic suppurative otitis media patients selected.Thorough evaluation regarding presenting symptoms, signs
associated with retraction pockets in the patients selected.Studyof surgical procedure adopted for treatment of retraction pockets in the
patients selected. Post operative follow-up and success rate of surgical procedures adopted for retraction pockets in the patients selected.

Keywords: Retraction pockets,sinus tympani, facial recess, cholesteatoma, posterior tympanotomy.

1. Introduction
Chronic suppurative otitis media is a persistent disease of
mucoperiosteal lining of middle ear cleft. This disease often
causes severe destruction and irreversible sequelae,
involving the tympanic membrane, ossicles and the temporal
bone. It manifests clinically as discharge and deafness of
variable severity. It can be subdivided into active or inactive
depending on presence or absence of infection and mucosal
or squamous depending on middle ear mucosa or squamous
epithelium of tympanic membrane involvement.
Management of Retraction Pocket can be optimally planned
and realized only in case of having a thorough knowledge on
its pathogenesis, behaviour, localization of the retraction
pocket as well as the anatomic and functional factors and
ossicular chain involvement.
Retraction Pockets are known to be the precursors of
cholesteatoma formation so the retraction pockets in earlier
stages have to be strategically treated. The impairment of
ventilation between the Eustachian tube and the aditus is
very important in the pathogenesis of retraction pocket
formation so, maintaining or re-creating the pathways again
will serve for better success. The surgical plans should be
based on the locations of the retraction pocket in order to
have a better exposition of the retraction pocket and to
remove it completely. It is important to establish the most
efficient way of reaching to the retraction pocket even if it is
located in sinus tympani or anterior epitympanic recess. May
be the endoscopes can serve us for better control in these
cases. One of the most important factors determining for the
type of surgery is the presence of mastoid air cells. The
sclerotic mastoids as being the evidence of impaired
ventilation should force us for creating small cavities in
common with the middle ear and external auditory canal.
But the most important is preserving the mucosa which is
known as the lungs for the middle ear.Retraction pocket
especially for the posterior superior quadrant is commonly
invaded by retraction pockets and/or granulation tissue,
visualization and eradication of the disease from this area is
critical. But also there appear difficulties of accessing to this
area and handling the disease located inside. The
sinustympani is located medial to the facial nerve and this
makes it impossible to access here by using operating
microscopes. During the second half of the twentieth century
the technique posterior tympanotomy has been defined for
Paper ID: NOV152881

access to posterior mesotympanum (Jansen C.1958)69. With

this access the bone between fossa incudis, facial canal and
the chorda tympani is drilled and a window is created
posteriorly to open the middle ear. With this technique the
access to the facial recess is completely possible. The long
process of the incus, incudo-stapedial joint, stapes, stapedial
muscle, the pyramidal process and the round window is
under the view through this window however accessing to
the tympanic sinus will still be limited.

2. Aims & Objectives of the Study

This study was conducted with following objectives: A
study of incidence of total retraction pockets i.e., attic
retraction pockets & posterior superior retraction pockets.
Study of retraction pockets by staging, Study of
visualization of ossicular status by examination under
microscope. Audiological study of hearing loss in posterior
superior retraction pockets.Role of posterior tympanotomy
approach in posterior superior retraction pockets.

3. Materials and Methods

In our department we conducted a prospective study on
combined approach Tympanoplasty with intact canal wall
with posterior tympanotomy approach on 47 patients during
a period from August 2012 August 2013. These patients
presented to our hospital with different Ear symptoms e.g.
ear discharge and hearing loss.
Inclusion Criteria:Only cases in which posterior superior
retraction pocket are present were included in this
study.Differentiation between stages was based on Sade J
(1979) classification. The patients ranged in age from 11 to
50 years.All patients were subjected to full ENT history and
examination.
Exclusion criteria: Paediatric age group - less than 10
years. Patientsage group above 50 years. Clinically unsafe
ears i.e. with cholesteatoma, intracranial complication,
malignant or tubercular ear disease. Incomplete removal of
the tympnomastoid disease, inadequate exposure due to
severely contracted mastoid, extensive canal wall
destruction. When patient cannot come for follow up postoperatively. All patients evaluated by detailed history and
otologic
assessment
and
documentation
through

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International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2014): 5.611
photography were done through otoendoscopy. Audiological
evaluation was done by tuning fork tests and pure tone
audiometry. Pure tone average and bone conduction at 500
Hz, 1 KHz, 2 KHz, 4 KHz and 8 KHz recorded.
Examination under microscope is done for conformation.

Table 4: Showing distribution of retraction pockets

Type of Retraction Pocket
Attic retraction pocket
Posterior superior retraction pocket

Methods
We used combined approach Tympanoplasty with intact
canal wall with posterior tympanotomy approach for all
cases of Grade III & IV posterior superior retraction pockets.
Analysis
Results were analysed for Grade III & IV retraction pockets
for visualization of ossicular status, audiological evaluation
of hearing loss, various pathologies observed, ossicular
integrity, ossicular status in contrast to examination under
microscope, efficacy of disease clearance.

4. Observations
The study was conducted in ENT OPD of SVS Medical
College & Hospital during the period of August 2012August 2013. It is observed an average No. of 80-90 patients
per day visit to our OPD.
Table 1: Showing incidence of CSOM Variety in ENT
OPD.
CSOM Variety
Safe CSOM
Unsafe CSOM

Mastoidectomy and were not included in the study and the

results are tabulated in Table.3

No of Patients (Percentage) (n=6264)

4385 (70%)
1880 (30%)

It is observed that total No. of CSOM cases were 6264 per

year. It is observed out of which safe variety of CSOM were
4385 patients and unsafe CSOM were 1880 patients. The
results in Table.1
Table 2: Showing incidence of unsafe CSOM according to
age group.
Age Group
<10 years
11-20 years
21-30 years
31-40 years
41-50 years
>50 years

No of Unsafe CSOM Patients

(Percentage) (n=1880)
169(9%)
545 (29%)
507 (27%)
358 (19%)
94 (5%)
207 (11%)

Age group below 10 years and above 50 years were

excluded from the study. It is observed that 1504 patients in
the age group of 10-50 years were of unsafe CSOM. The
results are tabulated in Table.2
Table 3: Showing distribution of retraction pockets
&cholesteatoma between age group of 11-50 yrs.
Type of Unsafe CSOM
Definitive cholesteatoma
Retraction pocket

No of patients
(percentage)(n=1504)
664(45%)
840(55%)

It is observed that in 664 were having definitive

cholesteatoma and were treated by modified radical

Paper ID: NOV152881

No. of patients
(percentage) (n=840)
633(75%)
207(25%)

It is observed that in 1504 patients with retraction pockets,

207 patients had posterior superior retraction pocket and 633
patients had attic retraction pocket and the results are
tabulated in table.4
Table 5: Showing distribution of attic retraction by Tos
(1988) staging.
Attic retraction pocket
grade (Tos 1988)
Grade I
Grade II
Grade III
Grade IV

No.patients
(perentage)(n=633)
222(35%)
285(45%)
84(13%)
42(7%)

Table 6: Showing distribution of posterior superior

retraction pockets by Sade (1979) Staging
Posterior superior retraction
pockets (Sade 1979)
Grade I
Grade II
Grade III
Grade IV

No.patients
(perentage)(n=207)
69(35%)
91(44%)
30(15%)
17(8%)

It is observed that in 207 patients with posterior superior

retraction pockets, 160 were in Grade I & II, these were
treated conservatively. 47 patients were having Grade III &
IV; they were treated by posterior tympanotomy approach
and will be our study and the results are tabulated in table.6.
Table 7: Showing incidence of grade III & IV retraction
pockets
Retraction pocket in Grade III & IV
Attic
Posterior superior retraction pocket

No. of patients
(Percentage) (n=177)
126 (73%)
47 (27%)

It is observed that the total No. of patients having Grade III

& IV retraction pockets were 177, out of them 126 patients
(73%) were in attic and 47(27%) were in posterior superior
quadrant of pars tensa. The results were tabulated in table.7
It is observed that the total No. of patients having retraction
pockets were 840. Out of them 633(75%)was having in attic
and 201(25%) were having in posterior superior quadrant of
pars tensa. The results were tabulated in table.4.It is
observed that the total no of patients having attic retraction
were 633. Grading was done by Tos M (1988) classification.
Out of them 222(35%) were Grade I, 285(45%) were Grade
II, 84 (13%) were Grade III and 42(7%) were Grade IV. The
results are tabulated in Table.5.
It is observed that the total No. of patients having posterior
superior retraction pockets were 207. Grading was done by
Sade J (1979) classification. Out of them 69(33%) were
Grade I, 91(44%) were Grade II, 30(15%) were Grade III

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International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2014): 5.611
and 17(8%) were Grade IV. The results are tabulated in
Table.6.

10(59%) patients, fibrous adhesions in 16 (94%) patients.

The results are tabulated in Table.10

Table 8: Showing hearing loss A-B gap in grade III & grade
IV posterior superior retraction pocket.

Table 11: Showing efficacy of posterior tympanotomy in

disease clearance in grade III & IV posterior superior
retraction pockets

Grade

Grade
III
Grade
IV

Hearing loss 2540dB (n=23) No.

of patients
(percentage)
13 (28%)

Hearing loss more

than 40dB (n=24)
No. of patients
(percentage)
17 (36%)

Total No.
Of patients
(percentage)

10 (21%)

7 (15%)

17 (36%)

30 (64%)

It is observed that out of 30 patients with Grade III posterior

superior retraction pocket, 17 (36%) had hearing loss more
than 40dB and 13 (25%) had 25-40dB loss. It is observed
that out of 17 (36%) patients with Grade IV posterior
superior retraction pocket, 7(15%) patients had hearing loss
more than 40dB and 10(21%) had 25-40dB hearing loss. It is
observed that conductive hearing loss of 25-40dB in 49%
and hearing loss of more than 40dB in 51%. The results are
tabulated in table.8
Table 9: showing various pathologies found in middle ear
Pathology

Glue
Cholesteatoma
Granulations
Granulation+Cholesteatoma

Grade III
(n=30)
(Percentage)
14(47%)
3(10%)
24(80%)
3(10%)

Grade IV
(n=17)
(Percentage)
17 (100%)
6(35%)
14(82%)
6(35%)

It is observed that in Grade III, Glue is present in 14 (7%),

cholesteatoma in 3(6%) patients, Granulations in 24 (80%)
patients and granulations with cholesteatoma in 3(10%)
patients. It is observed that in Grade IV, Glue is present in
17 (100%) patients, cholesteatoma in 6 (35%) patients,
Granulations in 14(82%) patients and granulations with
cholesteatoma in 6 (35%) patients. The results are tabulated
in Table9 .
Table 10: Showing ossicular pathology observed during
posterior tympanotomy
Pathology

Necrosis of long
process of incus
Necrosis of
incudostapedial
complex
Necrosis of stapes
suprastructure
Fibrous adhesions

Grade III
Grade IV
Total
(n=30) No. (n=17) No. (n=47)No.
of patients
of patients
of patients
(percentage) (percentage) (percentage)
14 (47%)
3 (18%)
17 (36%)
19 (63%)

13 (76%)

32 (68%)

14 (47%)

10 (59%)

24 (51%)

14 (47%)

16 (94%)

30 (64%)

It is observed that in Grade III, necrosis of long process is

seen in 14 (47%) patients, necrosis of incudostapedial
complex in 19 (63%) patients, necrosis of stapes
suprastructure in 14 (47%) patients, fibrous adhesions in 14
(47%) patients. In Grade IV, necrosis of long process is seen
in 3 (18%) patients, necrosis of incudostapedial complex in
13 (76%) patients, necrosis of stapes suprastructure in

Paper ID: NOV152881

Factor taken

Grade III
Grade IV
Total (n=47)
(n=30) No. of (n=17) No. of
No. of
patients
patients
patients
(Percentage) (Percentage) (Percentage)
Complete removal
30(100%)
17 (100%)
47 (100%)
of disease
Ossicular
24 (80%)
6 (35%)
30 (64%)
reconstruction
possible
Residual disease
0 (0%)
0 (0%)
0 (0%)
Temporary facial
2 (7%)
1 (6%)
3 (6%)
nerve palsy
Permanent facial
0 (0%)
0 (0%)
0 (0%)
nerve palsy
Reperforation
1 (3%)
3 (18%)
4 (8%)
Sensorineural
0 (0%)
0 (0%)
0 (0%)
hearing loss

It is observed that disease clearance was present in all the

cases. Ossicular reconstruction is possible in 30 (64%)
patients. There was no residual disease or permanent facial
nerve palsy or sensorineural hearing loss.Temporary facial
nerve palsy is present in 3(6%) patients. Results are
tabulated in Table.11

5. Discussion
1. Incidence Retraction Pockets.
It is observed in our study an incidence of 25% retraction in
posterior superior quadrant of pars tensa and 75% of attic
retractions. Similar Incidence was found in Luntz
(1997)90.However, in the study reported by JE.Xenelis229 had
41% of retraction in posterior superior quadrant of pars tensa
and 59% of attic retraction.
2. A study of retraction pockets by staging.
It is observed in our study an incidence of retraction pockets
as 35%, 45%, 14% and 7% of grade I, II, III and IV by Sade
classification respectively. Majority of retraction pockets is
observed in stage I & II. However, in the study reported by
Borgstein J (2007)13 had incidence of retraction as 22%,
27%, 28% and 23% in grade I, II, III and IV respectively
showing equal number of retraction pockets for each grade.
This difference may be due to his study group consisted of
children in contrast to our study group which had only
adults.
3. Audiological Study of hearing loss in posterior superior
retraction pockets.
It is observed in our study to have moderate conductive
hearing loss of 25-40dB of 43-57% in Grade III & IV
retraction pocket. However Mills (1991)104 have reported an
observation of moderate conductive hearing loss of 25-40dB
in 93% in all Grades.
4.To study various pathologies like fibrous tissue adhesions,
glue, granulations, cholesteatoma.It is observed in our study
to have fibrous adhesions in Grade III & IV to be 47%-94%.

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Similar observation were observed by Grewal (1997)56 to be
25%-82%.It is observed in our study to have cholesteatoma
to be 10-35% in Grade III & IV retraction pockets which
had similar observation of 35% in the study by V.P.Sood
(1973)196.It is observed in our study to have granulations in
81% of Grade III & IV retraction pockets.
5. To study the ossicular status in contrast to EUM.It is
observed in our study to have necrosis of long process of
Incus in 36%, necrosis of Incudostapedial joint in 68% and
necrosis of Stapes superstructure in 51%. These observations
were similar to the study by V.P.Sood (1993)196.
6. To evaluate the efficacy of disease clearance.It is
observed in our study to have disease clearance as 100%
which is similar to other studies by Luntz M (1991)89,
Steven Y.Ho (2003)199, Yangihara (1993)230.It is observed in
our study to have re-perforation in 3-18% of grade III & IV
retraction .All the cases of Grade III & IV retraction pockets
were operated by posterior tympanotomy even though there
is no significant hearing loss.

6. Conclusion
It is well known fact that retraction pockets are the
precursors for cholesteatoma formation. Surgical planning
for retraction pockets is based on knowledge for the
mechanism of retraction pocket formation, meticulous preoperative evaluation rational application of surgical
technique for the patients and individualization of the
surgical technique.

References
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Majority of retraction pockets are in attic followed by

posterior superior retraction pockets. Majority of posterior
superior retraction pockets are in Grade I & II of Sade J
(1979) classification. Conductive hearing loss of more than
40dB is present in 51% and moderate conductive hearing
loss of 25-40dB in 43-57% of patients. The common
pathology identified is Glue (100%), followed by
Granulations (80%), followed by fibrous adhesions (47%),
cholesteatoma (35%), cholesteatoma with granulations
(35%). Incus is damaged in majority of cases followed by
stapes, followed by malleus. Necrosis of the incudostapedial
joint (68%) is present in majority of cases followed by
stapes superstructure (51%), followed by long process of
incus (36%).Disease clearance was successful in all the
cases. Posteriortympanotomy is successful in clearing the
whole disease and able to reconstruct hearing mechanism
with good aeration of middle ear with minimal postoperatively complications. Posteriortympanotomy in
selected cases is a good option.

7. Acknowledgement
Dr Srikanth Myla. Professor of ent .s v s medical college
,yengonda,Mahaboobnagar,Telanganastate.India.
Dr Ramesh Elma. Senior resident, s v s medical college,
yenugonda,Mahaboobnagar,Telanganastate.India.

Paper ID: NOV152881

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