Attic aeration in temporal bones from children with recurring otitis media: tympanostomy tubes did not cure disease in Prussak's space.

Hypothesis: Blockage of the aeration pathways to the attic may cause circumscribed or widespread alterations that are difficult to diagnose clinically. The narrow route via the posterior pouch to Prussak's space is especially vulnerable to obstruction in recurring otitis media.

Background: Recent studies of the epitympanic diaphragm and compartments have clarified the anatomy of the attic aeration and drainage pathways and emphasized the role of their patency in the healing process of middle ear infections. In neonatal otitis media, the amniotic fluid cellular content (AFCC) has proved to be a good indicator in outlining the areas where inflammation products concentrate, possibly causing early blockage of ventilation.

Methods: Twenty-eight temporal bones from 14 children were studied; 4 of these children had experienced bilateral recurring otitis media. In the latter group, 1 ear was studied by microdissection and the other by serial sectioning.

Results: Prussak's space was involved in all 4 pairs of bones and either contained thick mucus, contained secretion in the process of organization, or was obliterated. The tympanic isthmus was fully obstructed in 1, partially blocked in 2, and open in 5 specimens.

Conclusions: If a thick mature connective tissue mass develops under the epidermal layer of Shrapnell's membrane during an obliteration process of Prussak's space, the condition may stay stable and benign. Severe retraction of Shrapnell's membrane represents a likely forerunner of a retraction pocket cholesteatoma. Systematic otomicroscopy allows early detection, and cure can be achieved by minor surgery. In some children, despite the treatment of recurring otitis media with ventilation tubes, the attic and mastoid can be extensively involved, necessitating atticomastoidectomy and the creation of new pathways for attic aeration.