Acta Oto-Laryngologica

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Pathogenesis and Treatment of Adhesive Otitis

Urpo Siirala

To cite this article: Urpo Siirala (1964) Pathogenesis and Treatment of Adhesive Otitis, Acta
Oto-Laryngologica, 57:sup188, 9-18, DOI: 10.3109/00016486409134533

To link to this article: http://dx.doi.org/10.3109/00016486409134533

Published online: 08 Jul 2009.

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 PATHOGENESIS A N D TREATMENT OF ADHESIVE O TITIS

BY
Urpo Siirala

From the Otolaryngological Hospital, University of Helsinki

Abstract
Adhesive otitis is an abacterial inflammation of the middle ear and the adjoining pneumatic
spaces. I t has a tendency to become chronic and is characterized by occlusion of the Eustachian
tube and formation of adhesions in the tympanum. Three phases can be distinguished: the early
stage (middle ear secretion frequently mucous and changes reversible), the adhesive stage (in-
flammation still in progress), and the terminal stage (inflammation has subsided).
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The incidence of adhesive otitis seems to be increasing. The following factors may be respons-
ible: sulphonamide and antibiotic therapy, latent mastoiditis, and inadequate treatment of acute
otitis media (neglect of myringotomy and air insufflation). During childhood in particular, some
other factors, such as nasopharyngeal adenoids and sinusitis, may also give rise to chronic oto-
salpingitis. This condition, unless properly treated, may lead to adhesive otitis.
At the early stage, therapy consists of conventional evacuation of secretion from the middle
e n , and care is taken to obtain proper ventilation and tubal function. The formation of ad-
hesions may result in disappearance of the middle ear air space. Restoration of ventilation of the
air space in the tympanum and of the sound conducting mechanism is possible in many cases b)
operation and medication. The air space of the tympanum can be maintained by means of a
polyethylene tube introduced through the operation wound or the Eustachian tube. Air is in-
sufflated into the middle ear daily through the polyethylene tube, through which medical pre-
parations can also be injected.

The term adhesive otitis we apply at the Otolaryngological University Hospital

in Helsinki to an abacterial inflamination of the middle ear and the adjoining
pneumatic spaces characterized by prolonged tubal occlusion and formation of
tympanic adhesions. At the onset there is usually an otosalpingitis with few
symptoms, but adhesive otitis may also be preceded by an acute purulent and
bactcrial otitis media, the infection having been destroyed by the natural de-
fence mechanism of the ear or by antibiotic therapy. The tympanic membrane
is unperforated in this condition. Cases v i t h an open perforation have not been
placed under this diagnostic heading. I n adhesive oeitis the drum membrane is
retracted and mostly very poorly mobile or immobile, and the pneumatic cell-
system is limited and opaque. Figs. 1 and 2 .
The development of adhesive otitis is widely attributed to improper treatment
of acute otitis media. The use of antibiotics without proper drainage, and of air
insufflation, easily leads to retention of inflammatory secretions in the middle
ear, to their organization with resulting adhesions, and to tubal occlusion. In the
case of so-called “glue ears”, in which subacute otitis media is associated with
extremely viscid and mucous secretion, there is evidently a great tendency for
adhesive otitis to develop. It seems to be due in part to anatomical narrowness
of the tube and probably to some other constitutional factor also.

Acta oto-laryng. Suppl. 188

 10 SIIRALA

Allergy is often mentioned as an etiologic factor in adhesive otitis. In our

inaterial we have seen only few patients with an allergic constitution.
Since adhesive otitis resembles mucoviscidosis both histopathologically and as
far as certain secretions of glands are concerned, we have investigated the
chloride content of the sweat of these patients. In cases of mucoviscidosis the
amount of chlorides in sweat is regularly increased, which is typical of this
disease. The results of the present investigations yielded normal chloride values,
so there is no reason to assume that the adhesive process in the middle ear
would be some kind of mucoviscidosis.
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Fig. 1. Retracted and immobile ear drum.

Fig. 2. Typical roentgenogram of second-stage case of adhesive otitis. Pneumatization lii~~ire~l

and opaque.

Acta oto-laryng. suppl. 188

 Pathogenesis und treutment of udhesive otitis 11

The negative pressure in the middle ear, and as its results, disturbed circulation
and retention, seem to be the basic causes of the middle ear pathology charac-
teristic of adhesive otitis.
Three phases may be distinguished. The curly stuge consists in a subacute
otosalpingitis characterized by blocking of the tube The tympanic membrane
is retracted and - as already stated - the middle ear frequently contains
sticky mucous secretion. Air insufflation normalizes the tympana1 air pressure
and results in “opening” of the ear, but in the absence of tubal function, the ear
is soon blocked again because of the diminishing pressure. The pneumatic spaces
adjoining the middle ear are also involved. A chronic abacterial mastoiditis
develops.
Granulation tissue and adhesions gradually form in the inflamed spaces, which
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limits the movements of the tympanic membrane. Progress of inflammation

leads to the second stuge, inarked by formation of adhesions.
In some cases there seems to be a third stuge: inflammation has subsided, the
tube is patent and adhesions dominate.
The pathological changes in the niucous meinbrane develop from the acute
inflammation present a t the early stage to hyperplasia cholesterosis and fibrosis.
The middle ear secretion, initially low in protein with few cells, becomes
mucous during the first few weeks and phagocytizing cells and cholesterol crys-
tals are seen in it. The pneumatic cell system of young patients develops poorly
because of absent ventilation and of inflammation. Reduction of the cell system
evidently takes place in a later phase of the illness.

The treatment of adhesive otitis depends on the stage of disease. At the sub-
acute curly stuge particular attention should be given to the elimination, by
medical and operative treatment, of the factors maintaining occlusion. Cases
of sinusitis must be treated and nasopharyngeal adenoid tissue removed by opera-
tion and/or radiation. Any secretion should be removed and air irisufflated into
the middle ear. If these procedures do not suffice for curing the disease, it is ad-
visable to perform inastoidectomy as the inflammation in the air spaces - even
an abacterial one - seeins productive of middle-ear secretions and maintains
inflammation and tubal occlusion. Should the tube be narrow, it may be of
benefit to inflate air through a mastoidectomy incision with the aid of a drainage
tube placed in the aditus of the antrum. Air content of the middle ear can thus
be ensured. The same drain also temporarily takes over from the tube the ven-
tilation of the tympanum. Instillation of penicillin-cortisone-alfa-chyinotrypsine
i n our experience helps to clear the inflammation and restore patency of the
tube. In view of the fact that patients with adhesive otitis seein to have a parti-
cular tendency to adhesions, we have tried a t this early stage and also in general
to avoid trauma to the middle ear inucosa. Proper treatment a t the subacute
initial stage usually results in cure. In the case of child patients with a parti-
cularly narrow eustachian tube it is advisable to go on with air inflations to pre-
clude recurrences, which otherwise tend to develop. Often it is impossible to
avoid stretching of the drum membrane in these cases. This does not seem to

A c t J oto-ldiyng. Suppl. 188

 12 SIIRALA

affect hearing very much, however. What is most important is the prevention
of adhesions and tuba1 blockage.
I n some cases we have used the polyethylene tubing recommended by Arm-
strong for drainage and ventilation of the middle ear through an opening in
the drum membrane (Fig. 3 ) . This tubing has been left in place for several weeks
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Fig. 3. Polyethylenc tubing inserted into the niiddlc ear through an opening in the drum
membrane.

and kept open by daily aspiration. After removal of the tube the opening in the
drum membrane has closed rapidly.
Once udhesions huve developed, successful therapy is much more difficult
than at the initial stage, when restitutio ad integrum is generally possible. The
changes in the middle ear vary considerably with the degree of intensity of the
adhesive process. At the beginning of the second stage there is still air-filled
space in the middle ear and the adhesions are string- or sail-like. The ossicular
chain and the tympanic membrane are mobile at least to some extent and the
middle ear shows areas where the mucous membrane is well preserved. In ad-
vanced cases the tympanic membrane may be entirely fixed by adhesions and
immobile, the middle-ear rnucosa inay be fibrotic or destroyed, and the ossicular
chain rigid or, in the area of the long process of the incus, atrophied or broken
off, or the stapes may be decalcified and soft. The windows may be free or closed
by adhesions. The changes in the tympanum vary widely from one case to an-
other. Even though the air space of the middle ear may be entirely lost, remnants
of lumen are usually found in the region of the tympana1 opening.

Acta oto-laryng. Suppl. 188

 Pathogenesis and treatment of adhesive otitis 13

The aims of the surgical procedures in these cases are: separation of the tym-
panic membrane from the promontory; restoration of the middle-ear airspace and
of patency of the tube; freeing the window niches and ossicles from adhesions; and
reconstruction or mobilization of the ossicular chain. As a t the early stage, it is
also now necessary to treat any sinusitis or mastoiditis that may maintain in-
flammation and to remove stenosing adenoid tissue blocking the tube. It is our
experience that patients with adhesive otitis have an extremely great tendency t o
formation of new adhesions. This must be kept in mind in surgical therapy
especially and needless traumatizing of the mucosa avoided.
The surgical approach in our clinic has been through an endaural or retro-
auricular incision. The latter has been used when performing at the same time a
mastoidectomy, which is usually necessary during the second stage. The middle
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ear is opened by freeing the meatal skin and the margin of the tympanic mem-
brane from the bony ear canal. Freeing of the tympanic membrane without
damage to it often requires chiselling of the inner portion of the bony meatus as
the tympanic membrane generally is so much retracted as to rupture easily when
the annulus is dissected free. Great care is essential in dissecting the tympanic
membrane free; ruptures impair the chances of a good end result. The ossicular
chain and the window niches are freed from adhesions and the tubal opening
exposed. If there are few adhesions, sectioning may be desisted from: experience
lias shown that mastoidectomy and air insufflation through the aditus into the
middle ear often suffice for aeration and restoration of the middle ear mucosa
and of tubal function. Fig. 4.
If the tympanic membrane is entirely fixed to the medial tympana1 wall, then

Fig. 4. Insufflation of air through a drain (placed in aditus a d antruni) in the mastoidectomy
wound.

Actn oto-laryng. Suppl. 188

 14 SIIRALA

a large portion of the tympanic mucosa is also usually destroyed. The drum is
flaccid and the ossicular chain rigid, atrophic or broken. In these cases it may be
best to be content initially with restoration of the air space of the middle ear,
which as such seems to have a curative effect on hearing. A 1.5 mm polyethylene
tube is introduced into the eustachian tube and pushed out through the nostril on
the same side. Its aural end is attached with a knot to the operation wound.
A polyethylene tube with a funnel-shaped end is inserted into the middle ear.
The funnel prevents the tube from slipping out. If the tympanic membrane is
very thin and flabby, or if ruptures have occurred in it, support can be obtained
by placing a thin piece of temporal fascia on the inner side of this membrane.
During postoperative care it is attempted as far as possible to keep the sur-
gically created middle-ear lumen open by air insufflation (Fig. 5) and instillation
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of saline or penicillin-cortisone solution. At the same time the patients have

received dexamethason tablets, which we hope also will prevent the development
of adhesions. The results are expected to improve gradually with increasing
experience.
A t the terminal stage, when inflaininatory change; are no longer present and

Fig. 5. Insufflation of air with needle and syringe through polyethylene tubing into the middle
car after operative restoration of air-filled tympanum.

Acta oto-laryng. Suppl. 188

 Pathogenesis and treatment of adhesive otitis 15

deafness is due to inflammatory adhesions and to fixation of the ossicles, we

have mostly used a stapes operation similar to the one employed in otosclerosis.
At this operation the stapes plate is replaced by temporal fascia and either the
crura or a polyethylene tube are utilized for conducting sound from the long
process of the incus, or directly from the drum membrane, to the oval window.
In two thirds of the patients the disease was bilateral and most of the patients
were young people. The disease seems to be equally frequent among men and
women. I n the early stage, however, - the majority of the patients being
children -boys seem to be more commonly affected than girls. I n the later stages
of the disease female patients predominate. I n the initial stage the average age
of the patients was 10 years, in the second stage, marked by formation of
adhesions, average age was 26, and in the terminal stage 41 years.
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Treatment at the initial stages has usually led to good results; hearing has
returned to normal or nearly normal. These are not yet cases of adhesive otitis
in the proper sense of the term.
As a rule hearing was badly impaired in all ears at the adhesive or the terininai
stage. By means of the operation used by us a considerable improvement has
been achieved in many cases. Of the ears operated upon during the last two
years hearing has improved in ca. 8 O o / o to a variable extent according to the
degree of serverity of the case. The results of therapy areseen in Table I and Figs.
6-9. The time of observation varies from almost 1.5 years to two months.

T a b l e I. Results of therapy

Adhesive stage 43 ears

Eustachian tube: open 41 ears
Improvement of hearing 3 5 ears
Improvement of hearing more than 10 d b 22 ears
Terminal stage 1 5 ears
Eustachian tube open 1 5 ears
Improvement of hearing 11 ears
Improvement of hearing more than 10 d b 7 ears

Fig. 6. Results of surgery in ears operated in 1962.

Black bars show postoperative air conduction improvement. Open bars indicate corresponding
postoperative loss.

Acta oto-laryng. Suppl. 188

 16 SIIRALA
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Fig. 7. Results of surgery in ears operated in 1963.

- 20
0 0

30 ao
1
3.

60 t I I I "
.A, 68

90

110

Fig. 8 Fig. 9

Fig. 8. Postoperative improvement of hearing in a case of adhesive otitis in terminal stage.

Fig. 9. Audiograms in a case of second stage adhesive otitis. 1. Preoperative audiogram. 2. Audio-
gram after restoration of air-filled tympanum. 3. Audiogram after stapes operation (fenestro-
plasty) performed after restoration of air-filled tympanum.

The purpose of this paper is to stimulate interest in the problem of adhesive

otitis. This disease, already excellently described by Politzer, has not aroused the
attention it deserves as one of the commonest causes of impaired hearing, parti-
cularly in school children (Juselius). Several papers on adhesive otitis
have appeared (Beck, Cawthorne, Ersner and Alexander, van Eyck, Fischenich,
Fuller, Hallpike, Hamberger, Hutchinson, Large, Lumio, MacNaughtan, Mas-
petiol, Math&, Moure, Ojala, Palva, Riskzr, Shambaugh, Siirala, Urbant-
schitsch, Wittmaack, Wullstein, Yarsley and Zollner), and we have studied with

Acta oto-laryng. Suppl. 198

 Pathogenesis and treatment of adhesive otitis 17

great interest the thorough investigations of Ingelstedt, Urtegren and Flisberg

published in a recent series of papers from the Lund-clinic. Their work will be
of invaluable help to us and other investigators in studying the function of the
middle ear and the Eustachian tube.
I n my opinion it is generally possible by adequate treatment to avoid the
formation of tympanic adhesions which may otherwise arise in cases of chronic
tympanosalpingitis if the anatomical conditions are unfavourable and con-
stitutional factors contribute. But even cases where an adhesive otitis has al-
ready developed it still is often possible to restore an air-filled middle ear cavity,
function of the Eustachian tube, and a normal or at least satisfactory conduction
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CONCLUSIONS
Proper treatment of cases of acute otitis and subacute otosalpingitis is essential
with a view to avoiding adhesive otitis and the resulting deafness. This is the
best prophylaxis of adhesive otitis. Once adhesions have developed it is still
possible to improve hearing by restoring the tuba1 function, an air-filled middle
ear, and a mobile ossicular chain. Treatment of adhesive otitis a t the terminal
stage aims at overcoining the obstacles in sound conduction due to the rigidity of
the ossicular chain or to the obliterated fenestrae.

ACKNOWLEDGEMENT
The financial support of the Sigrid JusPlius Foundation is gratefully
acknowledged.

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