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Tympanosclerosis

Synonym: Myringosclerosis

Tympanosclerosis is a condition in which there is calcification of tissue in the middle ear.1,2 If extensive it may affect hearing. Tympanosclerosis may be classified as:

  • Myringosclerosis - involving only the tympanic membrane.
  • Intratympanic tympanosclerosis - involving other middle ear sites: the ossicular chain, or rarely the mastoid cavity.
Pathology1,2

There is increased fibroblast activity leading to collagen deposition. Calcium phosphate plaques form in the lamina propria of the tympanic membrane.

Epidemiology

Most of the research studied patients with chronic otitis media and grommets (tympanostomy) rather than the general population:

  • In children with glue ear treated with grommets, 23-40% have tympanosclerosis.3,4,5,6
  • Myringosclerosis (i.e. disease limited to the eardrum) seems to be the more common form.2

In one study of adults involving patients with carotid atherosclerosis and controls, tympanosclerosis was found in 38% of the atherosclerosis group and 11% of controls.7

Aetiology

The aetiology is not well understood. It may be a form of scarring related to chronic middle ear inflammation. Possible causative or associated factors are:

  • Chronic otitis media (chronic suppurative otitis media and otitis media with effusion or 'glue ear')2
  • Grommet (tympanostomy tube) insertion seems to increase the risk of tympanosclerosis.4,8,9 The incidence of tympanosclerosis was higher if aspiration was performed prior to grommet insertion10 or if a larger grommet was used,11 or where a grommet procedure was repeated.6
  • In systemic sclerosis, findings similar to tympanosclerosis have been noted in some patients.12
  • A possible link with carotid atheroma or atherosclerosis has been suggested.7
  • An association with cholesteatoma is debateable - although the two conditions may co-exist.2
Presentation13
  • Characteristic chalky white patches seen on inspection of the eardrum.14,15
  • Conductive hearing loss, in some cases.
Investigations13

Investigations are not usually required if the lesions are typical, not extensive and there is no suspicion of hearing loss or other middle ear disease.

  • Pure tone audiometry - defines extent and type of hearing loss.
  • Tympanometry - the tympanogram result can be affected by tympanosclerosis.16
  • CT may help with diagnosis of disease within the middle ear cavity.17
Differential diagnosis

The opaque or patchy white appearance of the eardrum is fairly unique and usually easy to identify. Cholesteatoma may look similar but the whiteness appears behind, rather than in/on the tympanum.18,19

Hearing loss of a similar pattern may be found in:13

  • Auditory canal obstruction due to wax or debris
  • Otosclerosis
  • Tympanic perforation
  • Chronic otitis media (chronic suppurative otitis media and otitis media with effusion or 'glue ear')
  • Cholesteatoma
  • Glomus tumours (rare)
Management

Treatment is only required if there is hearing loss.

  • Hearing aids can be used, as with any form of conductive hearing loss.
  • Surgery:
    • Surgery for tympanosclerosis involves excision of the sclerotic areas and reconstruction of the ossicular chain.
    • There are various techniques and some involve 2-stage surgery.2,20
    • Reported success rates are variable.21,22,23
    • Damage to the inner ear is a possible and serious complication, which can cause sensorineural deafness.24
Complications2

Conductive hearing loss:

  • With myringosclerosis alone, hearing loss is uncommon, but may occur if the plaques are large or adhere to other structures (as the drum will be less compliant).
  • Significant conductive hearing loss can occur with intratympanic disease.
Prognosis

According to studies following children with chronic otitis media treated with grommets:

  • In most cases, tympanosclerosis probably does not cause significant hearing loss - however, the longest follow-up was for 10 years, so there is no information as to possible late effects.8,25
  • The sclerotic changes seem to stabilise by 3 years.6
  • The sclerotic changes do not seem to resolve with time.6,26
Document references
  1. Forseni M, Bagger-Sjoback D, Hultcrantz M; A study of inflammatory mediators in the human tympanosclerotic middle ear. Arch Otolaryngol Head Neck Surg. 2001 May;127(5):559-64. [abstract]
  2. Asiri S, Hasham A, al Anazy F, et al; Tympanosclerosis: review of literature and incidence among patients with middle-ear infection. J Laryngol Otol. 1999 Dec;113(12):1076-80. [abstract]
  3. Pereira MB, Pereira DR, Costa SS; Tympanostomy tube sequelae in children with otitis media with effusion: a three-year follow-up study. Rev Bras Otorrinolaringol (Engl Ed). 2005 Jul-Aug;71(4):415-20. Epub 2005 [abstract]
  4. Kay DJ, Nelson M, Rosenfeld RM; Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001 Apr;124(4):374-80. [abstract]
  5. Schilder AG, Zielhuis GA, Haggard MP, et al; Long-term effects of otitis media with effusion: otomicroscopic findings. Am J Otol. 1995 May;16(3):365-72. [abstract]
  6. Maw AR; Development of tympanosclerosis in children with otitis media with effusion and ventilation tubes. J Laryngol Otol. 1991 Aug;105(8):614-7. [abstract]
  7. Ferri M, Faggioli GL, Ferri GG, et al; Is carotid stenosis correlated with tympanosclerosis. Int Angiol. 2004 Jun;23(2):144-6. [abstract]
  8. Johnston LC, Feldman HM, Paradise JL, et al; Tympanic membrane abnormalities and hearing levels at the ages of 5 and 6 years in relation to persistent otitis media and tympanostomy tube insertion in the first 3 years of life: a prospective study incorporating a randomized clinical trial. Pediatrics. 2004 Jul;114(1):e58-67. [abstract]
  9. Lous J, Burton MJ, Felding JU, et al; Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001801. [abstract]
  10. McRae D, Gatland DJ, Youngs R, et al; Aspiration of middle ear effusions prior to grommet insertion an etiological factor in tympanosclerosis. J Otolaryngol. 1989 Aug;18(5):229-31. [abstract]
  11. Hampal S, Flood LM, Kumar BU; The mini-grommet and tympanosclerosis. J Laryngol Otol. 1991 Mar;105(3):161-4. [abstract]
  12. Berrettini S, Ferri C, Pitaro N, et al; Audiovestibular involvement in systemic sclerosis. ORL J Otorhinolaryngol Relat Spec. 1994 Jul-Aug;56(4):195-8. [abstract]
  13. Isaacson J and Vora N; Differential Diagnosis and Treatment of Hearing Loss.; Am Fam Phys 2003 Sep 15;68(6):1125-1134.; Good overview of practical approach to hearing loss in primary care.
  14. American Academy of Paediatrics; Images of tympanosclerosis as revealed by pneumatic otoscopy.
  15. University of Bristol ENT department; Auroscopic image of tymapnosclerosis.
  16. Onusko E; Tympanometry.; Am Fam Phys 2004 Nov 1; 70(9):1713-20; Overview of the use of this tool for diagnostic purposes in ENT.
  17. Swartz JD, Goodman RS, Russell KB, et al; High-resolution computed tomography of the middle ear and mastoid. Part II: Tubotympanic disease. Radiology. 1983 Aug;148(2):455-9. [abstract]
  18. Otoscopy Tutorial: University of Bristol ENT Department. Accessed May 2008. Explanation of otoscopy and photographs of various ear conditions.
  19. Ear, Nose and Throat - U.S.A. Photographs of ear conditions seen by otoscopy. Accessed May 2008.
  20. Bayazit YA, Ozer E, Kara C, et al; An analysis of the single-stage tympanoplasty with over-underlay grafting in tympanosclerosis. Otol Neurotol. 2004 May;25(3):211-4. [abstract]
  21. Vincent R, Oates J, Sperling NM; Stapedotomy for tympanosclerotic stapes fixation: is it safe and efficient? A review of 68 cases. Otol Neurotol. 2002 Nov;23(6):866-72. [abstract]
  22. Albu S, Babighian G, Trabalzini F; Surgical treatment of tympanosclerosis. Am J Otol. 2000 Sep;21(5):631-5. [abstract]
  23. Teufert KB, De La Cruz A; Tympanosclerosis: long-term hearing results after ossicular reconstruction. Otolaryngol Head Neck Surg. 2002 Mar;126(3):264-72. [abstract]
  24. Bellucci RJ; Cochlear hearing loss in tympanoplasty. Otolaryngol Head Neck Surg. 1985 Aug;93(4):482-5. [abstract]
  25. Riley DN, Herberger S, McBride G, et al; Myringotomy and ventilation tube insertion: a ten-year follow-up. J Laryngol Otol. 1997 Mar;111(3):257-61. [abstract]
  26. De Beer BA, Schilder AG, Zielhuis GA, et al; Natural course of tympanic membrane pathology related to otitis media and ventilation tubes between ages 8 and 18 years. Otol Neurotol. 2005 Sep;26(5):1016-21. [abstract]
Acknowledgements EMIS is grateful to Dr N Hartree for writing this article and to Dr Sean Kavanagh for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 661
Document Version: 21
DocRef: bgp25285
Last Updated: 9 Jun 2008
Review Date: 9 Jun 2010
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