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Conditions

Retraction pocket

Part of the eardrum drawn inwards by low pressure in the middle ear. Most retraction pockets stay stable for years and need only watching; a few deepen, trap skin and turn into a cholesteatoma, and the purpose of follow-up is to recognise those early.

What a retraction pocket is

The eardrum has two parts. The large lower part, the pars tensa, is taut, with a fibrous middle layer that keeps it stiff. Above it sits a small, looser segment, the pars flaccida (Shrapnell’s membrane), whose fibres are weak. Behind it lies the attic, the upper part of the middle ear that holds the heads of the malleus and incus.

A retraction is any part of the eardrum drawn inwards. A localised area drawn in far enough to form a sac is a retraction pocket; collapse of the whole pars tensa onto the inner wall of the middle ear is called atelectasis. Pars tensa pockets most often form in the back upper quadrant, close to the incus and stapes. Pars flaccida (attic) pockets sit at the very top of the drum, and their depth is often hidden behind the bony rim of the ear canal.

The outer surface of the eardrum is skin, which normally migrates outwards and carries its own debris away. This self-cleaning keeps a shallow retraction harmless. A deep pocket with a narrow neck loses it: shed skin (keratin) collects at the bottom, and that is the step at which a retraction becomes a cholesteatoma.

Why it happens

The Eustachian tube opens briefly on swallowing and yawning to let air into the middle ear, while the middle-ear lining slowly absorbs gas. If the tube does not open well, the pressure behind the drum falls below that outside and the drum is pushed inwards.

Over months or years, negative pressure and inflammation thin the fibrous layer and the drum loses its stiffness. Common backgrounds are glue ear or repeated ear infections in childhood, grommets, long-standing nasal or adenoid problems, and a cleft palate, which affects the muscles that open the tube. Once the drum has stretched, it does not regain its original strength, even if ventilation later improves.

Staging: Sadé and Tos

Retractions are graded so that the same ear can be compared over time and between examiners.

Sadé grading, pars tensa (Sadé and Berco, 1976):

  1. Slight retraction, not touching the ossicles.
  2. Retraction onto the incus or stapes.
  3. Retraction onto the promontory, the bony inner wall of the middle ear; the drum can still be lifted off.
  4. Adhesive otitis: the drum is stuck to the promontory.

Tos grading, pars flaccida (Tos and Poulsen, 1980):

  1. Retracted, not touching the neck of the malleus.
  2. Retracted onto the neck of the malleus.
  3. Extending beyond the malleus neck, with limited erosion of the bony outer wall of the attic (the scutum).
  4. Severe erosion of the scutum.

A grade describes a pocket; it does not decide the treatment. At least twelve staging systems have been published, and none reliably predicts which pocket will progress. Clinicians therefore add three questions: can the bottom of the pocket be seen, is it dry and self-cleaning, and is keratin collecting in it?

Staging in practice

Sadé and Tos describe depth and contact, not mobility or control. Charachon's classification and the Erasmus system add the features that drive management: whether the pocket lifts on Valsalva or pneumatic otoscopy, whether the fundus is visible, and whether it self-cleans. A mobile, dry, fully visible Sadé 3 pocket is a different problem from a Sadé 2 pocket running into the sinus tympani with keratin at its fundus.

How often does a pocket become a cholesteatoma?

Not often, but often enough to justify follow-up. From observational series:

  • Pars tensa, all ages. In 81 ears with a back upper-quadrant retraction, followed without surgery for a median of just over five years, 1% developed a cholesteatoma, 6% a perforation and 6% ossicular damage. Hearing worsened by 10 dB or more in 12% of ears; Sadé 1 ears had better hearing outcomes than grade 3.
  • Children with cleft palate. Of 37 retracted ears photographed over a median of 6.4 years, 76% were stable or better; two (5%) developed a cholesteatoma.
  • Across studies. A systematic review of watchful-waiting series found 76–96% of retractions stable or improved, perforation in 4–6% and cholesteatoma in 1–5%; the pockets that progressed had touched the promontory.
  • The attic. A long-term study re-examined 527 ears three to eight years after grommets for glue ear: 34% had some pars flaccida retraction, 4.2% a pronounced one with bone loss, and 0.2% an attic cholesteatoma.

Bone can also be lost without a cholesteatoma: the incus was eroded in over a third of Sadé’s original atelectatic ears, and in about 30% of children’s ears operated for posterior pockets stuck to it.

These series are small, selected and graded differently. They support watching most pockets, and they place the risk in the deep, fixed and hidden ones.

Monitoring

For most pockets, follow-up is the treatment, and it works only if each visit can be compared with the last.

  • Examination under the microscope or endoscope, after cleaning the canal: can the whole pocket be seen, is it dry, is keratin collecting, does it touch or stick to the incus, stapes or promontory, and does it lift when you gently blow against a pinched nose?
  • Photographs at each visit, because images side by side show slow change better than memory or notes.
  • An audiogram with air and bone conduction. A widening air-bone gap can be the first sign of ossicular erosion; tympanometry shows negative pressure or fluid.
  • Imaging only when it changes the plan. CT is not routine; it is used when the bottom of a pocket cannot be seen, when erosion or cholesteatoma is suspected, and before surgery. A non-echo-planar diffusion-weighted MRI can show a cholesteatoma hidden behind a pocket.

A stable, shallow pocket is commonly reviewed every six to twelve months, more often after a change. Intervals vary between specialists; follow the advice given for your own ear.

Treatment options

A Cochrane review found only two small randomised trials, with 71 participants between them, and no evidence either to support or to refute surgery.

Watchful waiting. Reasonable for a shallow, visible, dry, self-cleaning pocket with stable hearing, which is the majority. In one small trial, cartilage reconstruction of the attic wall was not significantly better than waiting, for progression or hearing, over twelve months.

Improving ventilation. Nasal and adenoid problems are treated where present. Eustachian-tube balloon dilation is used for some adults with tube dysfunction, but whether it makes an established retraction recede is not known.

Grommets. A ventilation tube equalises the pressure and may let a mobile pocket lift back; in a child with glue ear it is often the first step. It does not strengthen a thinned drum, the pocket may return when the tube comes out, and a pocket stuck to the ossicles or promontory rarely lifts. In the second trial, adding a grommet to cartilage tympanoplasty gave no extra hearing benefit. See grommets in adults.

Excision. The thin pocket is removed, often with a grommet placed at the same time, and the drum is left to heal. Across observational series the hole persisted in 3–13% of ears and the retraction returned in 11–25%.

Cartilage tympanoplasty. The pocket is lifted off the ossicles and middle-ear wall, or removed, and the drum is reinforced with thin cartilage from the ear, which resists being drawn in again. Eroded ossicles (ossiculoplasty) and an eroded scutum can be rebuilt at the same operation. The hearing result depends mainly on whether the ossicles are intact. See tympanoplasty and recovery after tympanoplasty.

If the pocket has already become a cholesteatoma, or runs where it cannot be followed, the operation becomes cholesteatoma surgery, sometimes with a mastoidectomy. For a retraction without cholesteatoma, opening the mastoid is usually not needed.

Surgical notes

Palisade or island cartilage–perichondrium grafts from tragus or concha are the usual reinforcement; thinning the cartilage reduces its acoustic cost. Elevate the pocket intact where possible: keratin left in the sinus tympani or under the graft seeds an iatrogenic pearl. Attic pockets with scutum erosion need reconstruction of the lateral attic wall, with cartilage or bone, to prevent re-retraction into the epitympanum.

When surgery is usually advised

Practice varies, but these findings commonly tip the balance towards an operation: the bottom of the pocket cannot be seen, even with an endoscope; keratin collects and cannot be cleared in clinic; the pocket discharges repeatedly; photographs show it deepening or becoming fixed; or bone is being eroded and the air-bone gap is widening. Whether this is the better-hearing ear, age, and how reliably follow-up can be attended also count.

Warning signs

Between scheduled visits, arrange an earlier review if the ear starts to discharge (particularly a smelly or recurring discharge), if hearing in that ear gradually worsens, if white or grey debris (keratin) is seen in the pocket, or if pain or a blocked feeling persists.

A sudden drop in hearing, severe or spinning vertigo, facial weakness, a severe headache, fever with ear pain, or swelling behind the ear needs medical assessment the same day. See also chronic middle-ear disease and when to contact your surgeon.

Sources

  • Sadé J, Berco E. Atelectasis and secretory otitis media. Ann Otol Rhinol Laryngol. 1976;85(2 Suppl 25 Pt 2):66-72. PubMed
  • Tos M, Poulsen G. Attic retractions following secretory otitis. Acta Otolaryngol. 1980;89(5-6):479-86. PubMed
  • Alzahrani M, Saliba I. Tympanic membrane retraction pocket staging: is it worthwhile? Eur Arch Otorhinolaryngol. 2014;271(6):1361-8. PubMed
  • Bayoumy AB, Veugen CCAFM, Rijssen LB, et al. The natural course of tympanic membrane retractions in the posterosuperior quadrant of pars tensa: a watchful waiting policy. Otol Neurotol. 2021;42(1):e50-e59. PubMed
  • Parkes W, Vilchez-Madrigal L, Cushing S, et al. Natural history of tympanic membrane retraction in children with cleft palate. J Int Adv Otol. 2018;14(2):250-254. PubMed
  • Bayoumy AB, Veugen CCAFM, van der Veen EL, et al. Management of tympanic membrane retractions: a systematic review. Eur Arch Otorhinolaryngol. 2022;279(2):723-737. PubMed
  • Nankivell PC, Pothier DD. Surgery for tympanic membrane retraction pockets. Cochrane Database Syst Rev. 2010;(7):CD007943. PubMed
  • Borgstein J, Gerritsma TV, Bruce IA. Erosion of the incus in pediatric posterior tympanic membrane retraction pockets without cholesteatoma. Int J Pediatr Otorhinolaryngol. 2008;72(9):1419-23. PubMed

Common questions

Is a retraction pocket the same as a cholesteatoma?

No. A retraction pocket is part of the eardrum drawn inwards; it is still lined by normal skin and, as long as it stays shallow and self-cleaning, it does no harm. A cholesteatoma begins when a pocket becomes so deep that shed skin can no longer escape and collects inside it, slowly eroding bone. Most retraction pockets never reach that point, which is why the first approach is usually careful observation.

Will my retraction pocket turn into a cholesteatoma?

Usually not. In follow-up studies lasting five years or more, most retractions stayed the same or improved, and roughly 1 to 5 in 100 progressed to cholesteatoma. The risk is higher when the pocket is deep, lies against the inner wall of the middle ear, cannot be fully seen or is collecting debris. Regular checks are meant to pick up that change early, while treatment is still simpler.

Can a retraction pocket heal on its own?

A mild retraction can lift back to normal, particularly in children whose Eustachian tube matures and whose glue ear clears. In adults complete recovery is less common, although most pockets remain stable. Once the eardrum has stretched and thinned it does not regain its original strength, so a pocket that has settled can deepen again if the ventilation problem returns.

Will a grommet fix a retraction pocket?

A grommet (ventilation tube) equalises the pressure across the eardrum, and a retraction that is still mobile may lift back while the tube is in place. It does not restore the strength of a thinned eardrum, and the pocket can return once the tube comes out. A pocket stuck to the ossicles or to the inner wall of the middle ear usually does not lift with a grommet alone. The evidence is limited and practice varies between surgeons.

How often should a retraction pocket be checked?

There is no fixed rule. A stable, shallow pocket is commonly reviewed every six to twelve months, with a photograph and a hearing test for comparison, and the interval can be lengthened once it has been stable for several years. A deeper pocket, a recent change or new symptoms justify closer follow-up. Follow the interval your own specialist advises, and ask for an earlier review if the ear starts to discharge or the hearing drops.

What operation is done for a retraction pocket?

Most often a cartilage tympanoplasty: the thin pocket is lifted or removed and the eardrum is reinforced with a thin slice of cartilage, which resists being drawn in again. If an ossicle has been eroded, the chain can be rebuilt at the same operation, and for pockets at the top of the drum the eroded bony rim can be rebuilt too. If a cholesteatoma is found, the operation becomes cholesteatoma surgery.

This page provides general educational information. It cannot replace an individual assessment, which depends on a full history, examination, audiometry and, where relevant, imaging. If you have sudden hearing loss, severe pain, facial weakness, severe dizziness or discharge with fever, seek medical care promptly.