Endoscopic Management of Tympanic Membrane Retraction Pockets: A Two Handed Technique with Endoscope Holder

  • Sapna Ramkrishna ParabEmail author
  • Mubarak M. Khan
Original Article


The tympanic membrane retraction pocket is a pathological invagination of tympanic membrane into the middle ear space. The most common sites for formation of retraction pocket are pars flaccida and postero-superior parts. Decision about the procedure and the timing of the treatment of retraction pockets is debatable and depends on the functional and anatomic condition of the ear. To evaluate the results of the technique of two handed endoscopic management of retraction pockets with sliced tragal cartilage. Prospective Non Randomized Clinical Study. The study included 41 ears operated with the technique of two handed endoscopic cartilage tympanoplasty for retraction pockets with endoscope holders from November 2013 to May 2016 with a follow up period ranging from 22 to 53 months. Cases of cholesteatoma and tympanic membrane perforation were excluded from the study. Pre and postoperative symptoms and air–bone gaps were recorded. The average preoperative air–bone gap in the study group was 24.53 ± 4.326 dB. 28 ears were of pars tensa retractions (stage II-4, stage III-15, and stage IV-9) and 13 were pars flaccida retractions (stage III-8 and stage IV-5). 24 ears had ossicular erosion. The follow up revealed that, the results of two handed endoscopic sliced cartilage tympanoplasty for retraction pockets were stable and there was no recurrence of the retraction and the post-operative air–bone–gap closure was achieved to 13.62 ± 4.78, 14.13 ± 5.91 dB, 14.32 ± 3.46 and 14.57 ± 3.88 dB at 6 months, 1 year, 2 years, 3 years respectively. Though, indications for surgery are based mostly on anatomic status and observation of behaviour of retraction pocket over time, we recommend early management of retraction pockets by the technique of endoscopic sliced tragal cartilage tympanoplasty with tragal cartilage of 0.5 mm thickness using endoscope holder.

Level of Evidence: Level 4.


Retraction pockets Two handed endoscopic ear surgery Endoscope holders Endoscopic sliced cartilage tympanoplasty 


Compliance with Ethical Standards

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinski declaration and its later ammendments or comparable ethical standards.

Conflict of interest


Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

12070_2019_1682_MOESM1_ESM.mkv (40.8 mb)
Supplementary material 1 (MKV 41817 kb)
12070_2019_1682_MOESM2_ESM.mkv (50.7 mb)
Supplementary material 2 (MKV 51917 kb)


  1. 1.
    Michaels L (1989) Biology of cholesteatoma. Otolaryngol Clin North Am 22:869–881PubMedGoogle Scholar
  2. 2.
    Yoon TH, Schachern PA, Paparella MM, Aeppli DM (1990) Pathology and pathogenesis of tympanic membrane retraction. Am J Otolaryngol 11(1):10–17CrossRefGoogle Scholar
  3. 3.
    Li Y, Hunter LL, Margolis RH, Levine SC, Lindgren B, Daly K, Giebink GS (1999) Prospective study of tympanic membrane retraction, hearing loss, and multifrequency tympanometry. Otolaryngol Head Neck Surg 121(5):514–522CrossRefGoogle Scholar
  4. 4.
    Maw AR, Bawden R (1994) Tympanic membrane atrophy, scarring, atelectasis and attic retraction in persistent, untreated otitis media with effusion and following ventilation tube insertion. Int J Pediatr Otorhinolaryngol 30(3):189–204CrossRefGoogle Scholar
  5. 5.
    Sade J, Berco E (1976) Atelectasis and secretory otitis media. Ann Otol Rhinol Laryngol 85(2 Suppl 25 Pt 2):66–72CrossRefGoogle Scholar
  6. 6.
    Mierzwiński J, Fishman AJ (2014) Retraction pockets of tympanic membrane: protocol of management and results of treatment. Otorynolaryngologia 13(2)Google Scholar
  7. 7.
    Huy PTB (2005) Otites moyennes chroniques. Histoire e´le´mentaire et formes cliniques. EMC-Oto-rhino-laryngologie 2(1):26–61CrossRefGoogle Scholar
  8. 8.
    Ars BM (1991) Tympanic membrane retraction pockets. Etiology, pathogeny, treatment. Acta Otorhinolaryngol Belg 45(3):265–277PubMedGoogle Scholar
  9. 9.
    Kasbekar AV, Patel V, Rubasinghe M, Srinivasan V (2014) The surgical management of tympanic membrane retraction pockets using cartilage tympanoplasty. Indian J Otolaryngol Head Neck Surg 66(4):449–454CrossRefGoogle Scholar
  10. 10.
    Akyildiz N, Akbay C, Ozgirgin ON, Bayramoglu I, Sayin N (1993) The role of retraction pockets in cholesteatoma development: an ultrastructural study. Ear Nose Throat J 72(3):210–212CrossRefGoogle Scholar
  11. 11.
    Ramakrishnan Y, Kotecha A, Bowdler DA (2007) A review of retraction pockets: past, present and future management. J Laryngol Otol 121:521–525CrossRefGoogle Scholar
  12. 12.
    Bours AF, Decat M, Gersdorff M (1998) Our classification of tympanic retraction pockets. Acta Otorhinolaryngol Belg 52(1):25–28PubMedGoogle Scholar
  13. 13.
    Sadæ J, Avraham S, Brown M (1981) Atelectasis, retraction pockets and cholesteatoma. Acta Otolaryngol 92(5–6):501–512CrossRefGoogle Scholar
  14. 14.
    Tos M, Poulsen G (1980) Attic retractions following secretory otitis. Acta Otolaryngol 89:479–486CrossRefGoogle Scholar
  15. 15.
    Sade J (1979) The atelectatic ear. In: Sade J (ed) Monograms in clinical otolaryngology, secretory otitis media and its sequelae. Churchill-Livingstone, New York, pp 64–88Google Scholar
  16. 16.
    Alzahrani M, Saliba I (2014) Tympanic membrane retraction pocket staging: is it worthwhile? Eur Arch Oto-Rhino-Laryngol 271(6):1361–1368CrossRefGoogle Scholar
  17. 17.
    Chiossone E (1995) Preventive tympanoplasty in children: a new approach. Rev Laryngol Otol Rhinol (Bord) 116(2):137–139Google Scholar
  18. 18.
    Khan MM, Parab SR (2016) Novel concept of attaching endoscope holder to microscope for two handed endoscopic tympanoplasty. Indian J Otolaryngol Head Neck Surg 68(2):230–240CrossRefGoogle Scholar
  19. 19.
    Khan MM, Parab SR (2015) Concept, design and development of innovative endoscope holder system for endoscopic otolaryngological surgeries. Indian J Otolaryngol Head Neck Surg 67(2):113–119CrossRefGoogle Scholar
  20. 20.
    Khan MM, Parab SR (2016) Endoscopic cartilage tympanoplasty: a two-handed technique using an endoscope holder. Laryngoscope 126:1893–1898. CrossRefPubMedGoogle Scholar
  21. 21.
    Khan MM, Parab SR (2011) Primary cartilage tympanoplasty: our technique and results. Am J Otolaryngol 32(5):381–387CrossRefGoogle Scholar
  22. 22.
    Khan MM, Parab SR (2013) Reinforcement of Sliced Tragal Cartilage Perichondrium Composite Graft with Temporalis Fascia in Type I Tympanoplasty: Our Techniques and Results. J Rhinol-Otol 1:57–62Google Scholar
  23. 23.
    Khan MM, Parab SR (2012) Day care ear surgery: our experience of 4 years. Indian J Otolaryngol Head Neck Surg 64(3):280–284CrossRefGoogle Scholar
  24. 24.
    Khan MM, Parab SR (2014) Sliced Island tragal cartilage perichondrial composite graft: early results and experience. J Rhinol-Otol 2:4–9Google Scholar
  25. 25.
    Khan MM, Parab SR (2015) Comparative study of sliced tragal cartilage and temporalis fascia in type I tympanoplasty. J Laryngol Otol 129(1):16–22CrossRefGoogle Scholar
  26. 26.
    Khan MM, Parab SR (2015) Average thickness of tragal cartilage for slicing techniques in tympanoplasty. J Laryngol Otol 129(05):435–439CrossRefGoogle Scholar
  27. 27.
    Parab SR, Khan MM (2018) New cartilage slicer for slicing techniques in tympanoplasty: design and applications. Indian J Otolaryngol Head Neck Surg. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Charachon R, Barthez M, Lejeune JM (1992) Spontaneous retraction pockets in chronic otitis media medical and surgical therapy. Ear Nose Throat J 71(11):578–583CrossRefGoogle Scholar
  29. 29.
    Singh I (ed) (2004) Textbook of human histology. New Delhi: Jaypee Brothers Medical Publishers. 89–93Google Scholar
  30. 30.
    Zahnert T, Huttenbrink KB, Murbe D et al (2000) Experimental investigations of the use of cartilage in tympanic membrane reconstruction. Am J Otol 21:322–328CrossRefGoogle Scholar

Copyright information

© Association of Otolaryngologists of India 2019

Authors and Affiliations

  1. 1.Sushrut ENT Hospital and Dr. Khan’s Research CentreTalegaon DabhadeIndia

Personalised recommendations