A normal TM is often described as "pearly" in appearance. In fact, it is almost transparent. Scarring, which occurs in the middle fibrous layer, destroys this lucency. Scarring may result from repeated effusions or
infections, and may have many different patterns. Simple aging often causes a diffusely hazy TM. In patients with a history of earlier ear disease, thickening and opacity may occur in reticular streaks or patches. Incidentally, these changes may be clinically misinterpreted as ear fluid; the pneumatic otoscope and an experienced eye help to distinguish the difference.
In some patients, there may be peripheral scarring with thin central areas of the drum. These thin areas lack the middle fibrous layer and usually represent healed perforations.
They are known as neomembranes (Fig. 5.3), and might actually be mistaken for a perforation if the pneumatic otoscope is not used.
Tympanosclerosis is a severe form of scarring—a dense white plaque of hyaline substance (again, Fig. 5.3), perhaps even thickly calcified. These deposits are located in the middle layer of the drum and probably result from chronic, thick mucoid middle ear effusion ("glue ear") that has finally dried up.
I have repeatedly witnessed a stage in the formation of tympanosclerosis, and briefly publish my findings here for the first time. On three occasions and in three separate patients, years apart in time, tube insertions were planned. At preoperative examination, these children had the findings of shiny, immobile TMs, typical of gluey mucoid effusion, but also showed pinkish, oval plaque-like deposits under the anteroinferior drum. Except for the pinkness, these deposits had the size and location of typical tympanosclerotic plaques. At surgery, I observed the pink deposits and made the myringotomy incisions directly over them. These globules, all roughly 2 mm in diameter, were semisolid and even paler in color than they appeared through the drum. They were removed separately from the remaining thick middle ear mucus and sent to the pathology department The microscopic diagnoses were all reported as "granulation tissue."
Thus, granulation tissue on the inner drum, originating from inspissating mucus, is probably an intermediate stage between glue ear and tympanosclerosis. Surgeons would be advised to suction out as much mucus as possible during tube insertion to prevent this complication.
It is important for the primary physician to recognize scarring and tympanosclerosis. They are sometimes mistaken for fluid, infection, perforation, or even cholesteatoma. Careful examination with the pneumatic otoscope, coupled with experience, will help.
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