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The following CBME core competencies are covered in this chapter.
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Retraction Pockets of Tympanic Membrane
Definition
A retraction pocket is a localised area of indrawing (invagination) of the tympanic membrane (TM) into the middle ear or attic.
Etiopathogenesis (Pathogenesis)
The initial cause of retraction pockets is recurrent or chronic negative pressure in the middle ear due to dysfunction of the Eustachian tube. During acute otitis media or serous otitis media, inflammatory cells secrete enzymes such as collagenase and elastase, which destroy the middle fibrous layer of the tympanic membrane. This makes the tympanic membrane atrophic and more prone to retraction.
Common Sites of Retraction Pockets
1. Pars flaccida
The pars flaccida is actually thicker than the pars tensa, but it is the weakest part of the tympanic membrane due to thinner and less organised collagen fibres, which are loosely arranged in the lamina propria. There is also an absence of annulus sulcus, which stabilises the insertion of the TM to the surrounding bone.
2. Posterosuperior quadrant of pars tensa
This region has thinner and more sparsely distributed collagen and is highly vascularised, making it more prone to inflammatory reactions. This causes breakdown of the collagen skeleton due to the secretion of the collagenase enzyme. As a result, the tympanic membrane becomes atrophic and susceptible to retraction.
Natural History / Fate of Retraction Pockets
Retraction pockets can:
- Resolve automatically, or
- Remain safe and stable for a long period, or
- Become unstable, leading to invasion of the middle ear cleft and formation of cholesteatoma in later stages.
Types of Retraction Pockets
- Shallow pockets. The full extent of the pocket is visible on examination. These pockets are usually nonprogressive and self-cleaning pockets.
- Deep pockets. The full extent of pocket is not visible on examination. It tends to collect squamous keratin debris and becomes a cyst. When infected, these cysts drain and granulation tissue develops around the sac, causing bone erosion and possible complications.
Classification of Retraction Pockets
1. Sadé and Berco Classification (For Pars Tensa Retractions)
This classification helps doctors decide between medical and surgical management.
| Grade | Description | Key Feature |
| Grade 1 | TM is slightly retracted but does NOT contact the incus | Loss of light reflex |
| Grade 2 | TM retracts onto the long process of incus (tympanoincudopexy) OR contacts the stapes (tympanostapediopexy) | Adhesion to ossicles |
| Grade 3 | Middle ear atelectasis – TM lies on the promontory but is NOT adherent | Can move with Valsalva or suction tip |
| Grade 4 | Adhesive otitis media – TM is adhered to the promontory | Does NOT move with Valsalva or suction tip |
| Grade 5 | Grade 3 or Grade 4 WITH a perforation in the TM | Combination of retraction + hole |
Otoscopy pictures of stages of pars tensa retractions: (Fibrous annulus (FA), Cone of light (COL), Lateral process of malleus (LP), Handle of malleus (HOM), Long process incus (IN), Incudostapedial joint (ISJ), Stapedius tendon (St), Round window (RW), Part of horizontal facial nerve (FN), Promontory (Pr), Stapes suprastructure (SS), Stapedius tendon (St), Tympanic membrane is adhered to promontory (Pm), Posterior malleolar fold (PMF))
2. Tos Classification (For Pars Flaccida Retractions)
| Grade | Description |
| Grade 1 | The pars flaccida is dimpled and more retracted than normal, but it is NOT adherent to the malleus neck |
| Grade 2 | The retraction pocket adheres to the neck of the malleus |
| Grade 3 | Partial erosion of the bony attic wall with the fundus (deepest part) visible |
| Grade 4 | Definitive (complete) erosion of the bony attic wall; unable to visualize the fundus |
Management of Retraction Pockets
Watchful Observation and Medical Management
Retraction pockets are initially managed through careful observation and medical treatments. The medical options include nasal decongestants, oral antihistamines, and steroids. Encourage auto inflation and look for contributing factors (adenoid disease, allergy and GERD) for eustachian tube dysfunction. This approach is appropriate under the following conditions:
• There is no active inflammatory condition affecting the skin in the external auditory canal, and no presence of otorrhea.
• The patient has conductive hearing loss (CHL) of less than 30 decibels (dB).
• CT Imaging shows that the anterior epitympanic recess, the attic, and the antrum spaces are aerated.
Surgical Management
Surgical intervention is considered when the retraction pocket presents more severe clinical symptoms. The following factors are taken into account:
• Clinical description of the retraction pocket, including the presence of debris collection, otorrhea, skin suffering, and granulations.
• Audiological evaluation indicating a conductive hearing loss greater than 30 dB, with an air-bone (AB) gap of 30 dB or more.
• CT findings that show bony erosion of the scutum or condensation images of the anterior epitympanic recess alone, or condensation in the anterior epitympanic recess, the attic, and the antrum spaces.
Surgical Options are: The choice of surgical procedure depends on the clinical findings and may include:
• Myringotomy with ventilation tubes.
• Tympanoplasty.
• Resection of the retraction pocket.
• Mastoid obliteration.
• Masto-atticotomy with anterior epitympanotomy (AER surgery).
Practical Management Summary
- Shallow pockets. Observation with periodic microscopic examination is sufficient. Regular suction cleaning may be needed. Encourage autoinflation and treat adenoid disease, allergy, and GERD. If progression occurs, tympanostomy tube insertion or excision of damaged TM may be performed.
- Deep pockets. Deep pockets usually require early surgical management because they carry high risk of keratin retention, cholesteatoma formation, and irreversible pathological changes. Surgical exploration and corrective surgery are often required depending on clinical findings and CT evidence.
Complications of Untreated Retraction Pockets
- Cholesteatoma: keratin retention forms a sac, causing bone erosion.
- Ossicular erosion: incus is most commonly affected, followed by the stapes.
- Adhesive otitis media: TM becomes permanently adherent to the promontory (Sadé Grade 4).
- Progressive CHL: due to TM dysfunction or ossicular discontinuity.
- Labyrinthine fistula (rare): inner ear erosion causing vertigo and SNHL.
- Facial nerve palsy (rare): erosion of the fallopian canal exposing the facial nerve.
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High-Yield Points
- Retraction pocket occurs due to ET dysfunction → chronic negative middle ear pressure.
- Inflammation releases collagenase and elastase, causing atrophic TM.
- Pars flaccida retraction is strongly linked to attic cholesteatoma.
- Fundus not visible = deep pocket = unsafe until proven otherwise.
- Sadé Grade 3 = atelectasis, Grade 4 = adhesive otitis media.
- Tympanoincudopexy = adhesion to incus, tympanostapediopexy = adhesion to stapes.
- Surgical indication includes debris retention, otorrhea, granulations, CHL >30 dB, scutum erosion.
- Most common ossicle eroded in cholesteatoma is incus.
- Vertigo in retraction pocket suggests labyrinthine fistula and needs urgent evaluation.
- HRCT temporal bone is valuable when the pocket is deep and fundus is not visible.
NEET PG-Style MCQs
- A retraction pocket of tympanic membrane occurs primarily due to: A. Ossicular discontinuity B. Eustachian tube dysfunction C. Otosclerosis D. Cochlear degeneration
- Enzymes responsible for destruction of fibrous layer of TM in retraction pockets are: A. Amylase and lipase B. Collagenase and elastase C. Pepsin and trypsin D. Histamine and serotonin
- The most common site for attic cholesteatoma development is: A. Anterior quadrant pars tensa B. Inferior quadrant pars tensa C. Pars flaccida D. Eustachian tube orifice
- In Sadé classification, Grade 3 pars tensa retraction is called: A. Acute otitis media B. Middle ear atelectasis C. Adhesive otitis media D. Tympanosclerosis
- Tympanoincudopexy refers to adhesion of tympanic membrane to: A. Stapes B. Incus C. Promontory D. Facial nerve canal
- Tos Grade 4 pars flaccida retraction indicates: A. Mild dimpling B. Adhesion to malleus neck C. Partial scutum erosion D. Complete scutum erosion with fundus not visible
- A deep retraction pocket is dangerous mainly because it: A. Always perforates B. Causes SNHL early C. Retains keratin leading to cholesteatoma D. Causes tinnitus always
- A patient with retraction pocket and vertigo should be evaluated urgently for: A. Otosclerosis B. Labyrinthine fistula C. Presbycusis D. Acoustic neuroma
- Surgical management is strongly indicated when conductive hearing loss is: A. 10 dB B. 15 dB C. >30 dB D. Any degree
- The most commonly eroded ossicle in cholesteatoma is: A. Incus B. Malleus C. Stapes D. None
Answers: 1: B. 2: B. 3: C. 4: B. 5: B. 6: D. 7: C. 8: B. 9: C. 10: A.
Clinical Case Scenarios
1. Case 1
A 16-year-old boy has mild hearing loss. Otoscopy shows pars tensa retraction with loss of cone of light. TM does not touch ossicles.
Most likely stage: Sadé Grade 1.
Best management: Observation + treat Eustachian tube dysfunction + autoinflation.
2. Case 2
A 25-year-old patient has intermittent ear discharge. Otoscopy shows deep attic retraction pocket with fundus not visible and keratin debris.
Most likely diagnosis: Unsafe pars flaccida retraction with early cholesteatoma suspicion.
Best next step: HRCT temporal bone + surgical planning.
3. Case 3
A 30-year-old has conductive hearing loss of 35 dB. Otoscopy shows pars tensa retraction touching promontory and not moving with Valsalva.
Most likely diagnosis: Adhesive otitis media (Sadé Grade 4).
Best management: Surgical evaluation (tympanoplasty ± ventilation tube depending on findings).
4. Case 4
A patient with known attic retraction develops vertigo and worsening discharge.
Most likely complication: Labyrinthine fistula.
Best next step: Urgent ENT evaluation + imaging + surgery if confirmed.
Frequently Asked Questions in Viva
- What is a retraction pocket of tympanic membrane? Retraction pocket is localized inward collapse of TM into middle ear due to chronic negative pressure.
- Why is pars flaccida retraction more dangerous? Pars flaccida easily traps keratin and frequently progresses to attic cholesteatoma.
- What is the most important sign of an unsafe retraction pocket? Fundus not visible with keratin debris retention suggests an unsafe deep pocket.
- What is Sadé Grade 4 retraction? Grade 4 is adhesive otitis media where TM is adherent to promontory and does not move.
- When is surgery needed in retraction pockets? Surgery is indicated if debris retention, otorrhea, granulations, CHL >30 dB, or scutum erosion is present.
- Which investigation is most useful in deep retraction pockets? HRCT temporal bone is most useful to detect scutum erosion and attic extension.
- What is the most common complication of untreated retraction pocket? Cholesteatoma formation is the most important complication.
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Download full PDF Link:
Retraction Pockets Best Lecture Notes Dr Rahul Bagla ENT Textbook
Reference Textbooks.
- Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
- Glasscock-Shambaugh, Textbook of Surgery of the Ear.
- P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
- Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
- Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
- Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
- Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
- Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
- Rob and smith, Textbook of Operative surgery.
- Anirban Biswas, Textbook of Clinical Audio-vestibulometry.
- Arnold, U. Ganzer, Textbook of Otorhinolaryngology, Head and Neck Surgery.
- Gordon B. Hughes, Myles L. Pensak, H. B. Broidy. Textbook of Clinical Otology.
- Mario Sanna. Textbook of Color Atlas of Endo-Otoscopy Examination–Diagnosis–Treatment.
Author:
Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India
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- Please read. Anatomy of External Ear. https://www.entlecture.com/anatomy-of-ear/
- Please read. Anatomy of Temporal Bone. https://www.entlecture.com/anatomy-of-temporal-bone/
- Please read. Stenger’s, Chimani Moos, Teal test. https://www.entlecture.com/special-tuning-fork-tests/
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