Tympanosclerosis - Understanding the Causes, Symptoms, and Treatment

Introduction:

The accumulation of hyaline in the eardrum and middle ear tissues is called tympanosclerosis. It mainly involves the tympanic cavity and the ossicular chain (consisting of malleus, incus, and stapes). Tympanosclerosis usually occurs due to swelling and frequent middle ear infections. Tympanosclerosis can also cause conductive hearing loss or disruption in the sound transfer from the outer ear to the middle ear.

What Is Tympanosclerosis?

Tympanosclerosis is a condition that affects the tympanic membrane (eardrum) and the middle ear, resulting in inflammation and scarring. If only the eardrum is affected, it is known as myringosclerosis. Tympanosclerosis leads to the deposition of dense hyaline tissue or even bone in the mucous membrane of the middle ear. It mainly occurs due to damage to the eardrum, either by injury or surgical procedures. Calcium deposits harden or thicken over time, become rigid, and cause scarring of the eardrum. If the condition is mild and asymptomatic or if the scar tissue does not impact hearing, treatment may not be necessary. However, severe scarring of the eardrum has the potential to cause hearing loss; therefore, it may require surgical management. Surgery not only repairs scar tissue but also restores hearing in many cases.

What Is the Incidence of Tympanosclerosis?

• The incidence of tympanosclerosis was observed more in patients with chronic and recurrent middle ear infections.

• The incidence of tympanosclerosis was reported more in the younger age group between 15 to 30 years of age.

• Tympanosclerosis affects both males and females, but a higher incidence was reported in males, approximately sixty percent of all cases.

What Are the Types of Tympanosclerosis?

Tympanosclerosis is divided into two types:

• Myringosclerosis: Myringosclerosis is limited to the tympanic membrane only. It presents with alteration in the connective tissue layer of the tympanic membrane due to hyalinization and calcium deposition (white patch or plaque-like deposition), resulting in immobility or restriction in the movements of the ear ossicles (malleus, incus, and stapes), leading to conductive hearing loss.

• Intratympanic Tympanosclerosis: Intratympanic tympanosclerosis affects the middle ear sites along with the tympanic membrane, the ossicular chain, and the mastoid bone in rare cases.

What Are the Causes of Tympanosclerosis?

The exact cause of tympanosclerosis is not known. However, it is supposed to be caused from:

• Recurrent or repetitive middle ear infections.

• Long-standing middle ear infections (chronic otitis media).

• Patients with a history of ventilation tube (grommet) insertion for treating middle ear infections are at higher risk (around 12 to 30 percent) of getting tympanosclerosis.

• Acute middle ear infections.

• Several studies have reported biochemical analysis suggesting high LDL (low-density lipoprotein), homocysteine levels, cholesterols, and triglycerides are associated with the risk of tympanosclerosis.

• Patients with a previous history of myringotomy surgery.

• Side effects due to ototoxic drugs.

• Continuous usage of hearing aids by patients.

• Tympanosclerosis is commonly seen in individuals over 30 years of age.

• Children with cleft palate (a birth defect in which the mouth is not formed properly) and who have a ventilation tube inserted are more prone to develop tympanosclerosis.

• Contact sports injuries, accidents, foreign objects, and loud noises can also cause tympanosclerosis.

What Are the Signs and Symptoms of Tympanosclerosis?

The signs and symptoms associated with tympanosclerosis are:

• It presents with a white patch or plaque-like appearance.

• Conductive or mixed hearing loss.

• Otorrhea (drainage from the middle ear).

• Swelling within the ears.

• Pain in the ears.

• Ear blockage.

• Ringing sensation in the ears (tinnitus).

• Ear fullness.

How Can We Diagnose Tympanosclerosis?

The following methods can diagnose tympanosclerosis:

• Clinical Examination: A thorough patient history is noted to rule out ear drainage, use of ototoxic drugs, and prior ear surgery. The clinical examination of the ear is done by an ENT (ear, nose, and throat) specialist to evaluate any acute or chronic middle ear infection, ear swelling, perforated eardrum, and white plaque or chalk-like deposits present on the tissues of the eardrum, middle ear, and tympanic membrane should be ruled out.

• Computed Tomography (CT) Scans: The computed tomographic scans of the temporal bone reveal a small, radio-opaque mass of tissue in the involved areas. This helps diagnose the size and extent of the spread of calcification and hyalinization within the tympanic membrane and middle ear.

• Pure Tone Audiometry Test (Hearing Test): This test is done to rule out the type and severity of hearing loss in patients in whom hearing loss is suspected. It helps to identify if the hearing loss is conductive (due to a defect in the mechanism of sound transfer), sensory (due to involvement of the hearing nerve, the eighth cranial nerve), or mixed type.

• Transtympanic Endoscopy: The transtympanic endoscopic procedure is used to diagnose the immobility of ossicles and stapes fixation, especially in cases of myringosclerosis where restriction of the movement of ear ossicles is present.

• Histopathological Diagnosis: The confirmatory diagnosis of tympanosclerosis can be made based on histopathological features of tympanosclerosis. Histopathological assessment of tympanosclerosis presents with hyalinization and calcification of fibrous connective tissues and mineralization of the lamellar bone.

What Are the Treatment Methods for Tympanosclerosis?

Different treatment modalities for tympanosclerosis are:

• Surgical Management: Surgical treatment can be performed to remove the sclerotic mass of tissue within the tympanic membrane. Depending on the severity of the spread, the reconstruction and repair of the tympanic membrane and ossicular chain should be performed. Surgery is not indicated in patients with isolated myringosclerosis without hearing loss.

Following surgical treatment of tympanosclerosis, most individuals recover in about one or two weeks. However, people involved in strenuous physical jobs or sports activities must wait for a few more weeks before resuming their normal work. Surgical management in patients with tympanosclerosis results in improved functioning of the eardrum, hearing efficiency, and prevention of further damage.

• Manubrio-Stapedioplasty: This procedure reconstructs and repairs the immobile ear ossicles, which are the malleus, incus, and stapes, that have occurred due to tympanosclerosis.

• Canaloplasty: It is a safe surgical procedure performed with a diamond bur attached to an electric motor to remove areas of white patches or plaques without damaging the surrounding normal structures.

• Hearing Aids: Artificial hearing aids are recommended for patients who develop hearing loss due to tympanosclerosis. Bone-anchored hearing devices or cochlear implants are also suggested for the management of hearing loss.

• Stapesplasty: It is a procedure done to treat stapes footplate fixation.

• Tympanoplasty: This procedure removes the excessive plaque deposits from the tympanic membrane except for the sensitive areas around the facial nerve and near the stapes.

What Are the Complications Associated With Tympanosclerosis?

The complications associated with tympanosclerosis are:

• Conductive hearing loss.

• Sensorineural hearing loss.

• Facial nerve paralysis during surgical procedures.

Can Tympanosclerosis Be Prevented?

Tympanosclerosis cannot be prevented; however, certain precautions can be taken to reduce the risk of the condition. These include:

• Using protective earplugs during exposure to loud noises.

• Foreign objects or cotton swabs must not be inserted into the ear canals.

• Earplugs can be used during flight travel or air pressure variations.

• Ear infections must be treated appropriately.

Conclusion:

Tympanosclerosis is an uncommon condition that results in white patches or plaque accumulation in the tympanic membrane and middle ear. It is mostly seen in patients with recurrent middle ear infections or a history of ear surgery, such as ventilation tube insertion for the management of chronic middle ear infections and myringotomy. Tympanosclerosis symptoms include tinnitus, ear fullness, and blockage in the ears. Surgical management of tympanosclerosis helps to improve and preserve hearing abilities. Hence, it is very crucial to diagnose early and manage tympanosclerosis in order to prevent its progression to complications like permanent loss of hearing.