Middle Ear Disease Research Articles

Simultaneous Treatment of Vestibular Schwannoma and Concurrent Middle Ear Disease Using the Enlarged Translabyrinthine Approach

Unilateral presentation of vestibular schwannoma with concurrent chronic middle ear disease or cholesteatoma is rare. We report a series of patients with ipsilateral chronic middle ear disease and vestibular schwannoma, which were simultaneously removed via the enlarged translabyrinthine approach. All tumors were near-totally removed, and middle ear disease was completely excised; there were no major postoperative complications such as cerebrospinal fluid leakage, cholesteatoma recurrence, or meningitis. If hearing preservation of the affected ear is not necessary, simultaneous surgical removal of both pathologies is more convenient than staged treatment. The enlarged translabyrinthine approach can achieve complete treatment with one corridor.

Analysing wideband absorbance immittance in normal and ears with otitis media with effusion using machine learning

Wideband Absorbance Immittance (WAI) has been available for more than a decade, however its clinical use still faces the challenges of limited understanding and poor interpretation of WAI results. This study aimed to develop Machine Learning (ML) tools to identify the WAI absorbance characteristics across different frequency-pressure regions in the normal middle ear and ears with otitis media with effusion (OME) to enable diagnosis of middle ear conditions automatically. Data analysis included pre-processing of the WAI data, statistical analysis and classification model development, and key regions extraction from the 2D frequency-pressure WAI images. The experimental results show that ML tools appear to hold great potential for the automated diagnosis of middle ear diseases from WAI data. The identified key regions in the WAI provide guidance to practitioners to better understand and interpret WAI data and offer the prospect of quick and accurate diagnostic decisions.

Rapidly progressive labyrinthitis ossificans in an immunocompromised pediatric patient

In this report, we present a case of rapid otic capsule obliteration within an exceedingly short timeframe in the setting of Chronic Suppurative Otitis Media (CSOM) in an immunocompromised pediatric patient with Down Syndrome. Following maximal therapy for a right sided cholesteatoma, the patient developed a multi-drug resistant infection that cause CSOM, which within 6 weeks progressed to complete obliteration of the right cochlea and otic capsule. The possibility of congenital temporal bone microscopic dehiscence allowing infection propagation cannot be excluded. Nonetheless, this case highlights the importance of appreciating how quickly chronic middle ear disease can progress to involve the labyrinth and cause intracranial complications, even with adequate concurrent medical therapy in the form of antibiotics and surgical therapy. A greater awareness as physicians should be made on management of refractory chronic middle ear disease to better treat their potential complications, which is made apparent in this case report. Keywords: Otic capsule; Chronic suppurative otitis media; Otic capsule; Tympanomastoidectomy; Multi-drug resistance. Abbreviations: CSOM: Chronic Suppurative Otitis Media; MDR: Multi-Drug Resistant; CT: Computed Tomography; MRI: Magnetic Resonance Imaging; ID: Infectious Disease.

35 Comparative Performance of Prediction Model, Non-Expert and Tele-Diagnosis of Common External and Middle Ear Disease Using A Patient Cohort from Cambodia That Included One Hundred and Thirty-Eight Ears

Abstract Introduction Globally 6% of the population suffers from disabling hearing loss and the majority resides in low- and middle-income countries, but diagnosis and treatment are hampered by poor availability of expert diagnosis. We compared the utility of tele-diagnosis, non-expert diagnosis, and prediction model diagnosis as a screening tool for common external and middle ear disorders. Method We recruited consecutive adult and paediatric patients presenting with ear or hearing symptoms to ENT outpatients at Children’s Surgical Centre, Cambodia. Each participant underwent sequential symptomatic and otoscopic assessment by a non-specialist and an ENT specialist. The non-specialist captured data using a novel automated symptom questionnaire loaded onto a smartphone otoscope. An ENT specialist in the UK subsequently reviewed these data. Results 138 ears were recruited. The prediction model performed poorly, but absence of otorrhoea was found to reliably exclude a diagnosis of chronic suppurative otitis media (negative predictive value=0.99). Both on-site non-expert and expert tele-diagnosis had high diagnostic specificity (90-99% and 86-99%), but low sensitivity (<43% and 32-100%). Conclusions We report the first study to directly compare approaches for non-specialist diagnosis of disorders of the middle/external ear, which shows suboptimal but comparable performance using an automated questionnaire, on site non-expert diagnosis, or remote expert diagnosis

36 A Randomised Trial to Compare How Undergraduates Diagnose Common Ear Pathology Using A Smartphone Otoscope and Standard Otoscope in A Simulated Setting

Abstract Introduction Competent otoscopy is a key otolaryngology skill for a broad range of medical careers, yet undergraduate’s confidence to perform otoscopy is reported as low. This study aimed to evaluate whether a smartphone-otoscope could enhance medical undergraduates recognition of common ear pathology. Method 52 medical students were randomised into a standard group (traditional otoscope) and an intervention group (smartphone-otoscope). Following a short didactic presentation, participants were asked to diagnose four simulated pathologies. Force response items and 5-point Likert scales loaded on an electronic platform recorded their diagnosis and their perceptions towards the otoscope. Results The smartphone-group (n = 20) had higher overall rates of correct diagnosis compared to control (n = 22) (84% vs 39%, p = <0.001). Only the grommet station did not show a significant improvement between the two groups (100% vs 91%, p = 0.49). 90% (n = 20) of participants felt the smartphone-otoscope was preferential for their learning. The same number expressed they want to use it in future learning. The remainder were indifferent. Conclusions The smart-phone otoscope enabled learners to better observe and recognise middle ear pathology. This popular learning tool has the potential to accelerate the learning curve of otoscopy and therefore improve the proficiency of future doctors at recognising middle ear diseases.

Mastoid cavity obliteration with allogenic and autologous material

Surgical obliteration is the treatment of choice for symptomatic mastoid cavities. Various methods and materials are available. Allogeneic material is easily available but can lead to wound infections due to rejection, granulation and inflammatory reactions. Consequently, autologous material is often preferred due to its good biocompatibility. The aim of this study was to compare the long-term outcomes of patients after mastoid cavity obliteration with allogeneic and autologous material with regard to the occurrence of recurrent cholesteatoma, the number of revision surgeries and the impact of surgery on the health-related quality of life. Patients who underwent mastoid cavity obliteration with an allogeneic material (hydroxyapatite matrix [HMM]) were retrospectively included in the study. In a prospective part, patients who underwent mastoid cavity obliteration with autologous reconstruction material (AutoM) were included. In addition to a detailed chart review, all patients underwent pure tone audiometry and completed the Zurich Chronic Middle Ear Inventory (ZCMEI-21) at the postoperative examination to assess health-related disease-specific quality of life. A total of 22 patients with a mean age of 56.9 (SD 18.7 years) receiving HMM (mean follow-up interval: 88.3 months [SD 21.9 months]) and 25 patients with a mean age of 52.4 years (SD 13.7 years) receiving AutoM (mean follow-up interval: 13.5 months [SD 9.5 months]) were included in the study. The revision-free rate for audiological indication after one year was 100% for HMM and 85% for AutoM. The recurrence-free rate at one year was 95% for HMM and 100% for AutoM. 55% of the patients with alloplastic material and 8% of the patients with autologous material required revision surgery due to ear discharge or recurrent cholesteatoma. The groups did not differ in terms of postoperative hearing outcome or postoperative quality of life. Obliteration of mastoid cavities is a surgical challenge. There was no relevant difference between the materials used in terms of recurrence rate, hearing and health-related quality of life within the 13.5-month observation period of both groups. The lack of subjective symptoms together with the high rate of recurrent cholesteatoma and revision indications emphasises the need for regular clinical follow-up including ear microscopy in chronic middle ear disease and strongly suggests regular follow-up examinations.

Do morphological differences in orientation of the Eustachian tube and dilator tubae muscle distinguish populations with high rates of middle ear disease?

Middle ear disease or otitis media (OM) is among the most common pediatric conditions globally. It is nearly ubiquitous among every human population, usually occurring within the first three postnatal years. The etiology of OM is known to be rooted in the short, horizontal cartilaginous Eustachian tubes (CET) of infants which are mechanically inefficient relative to those of adults. Yet, despite the presence of OM among all human populations, Inuit and Aboriginal Australian communities have been documented as exhibiting some of the highest rates globally. Little information exists on the normal morphology of the bony nasopharyngeal boundaries of these groups. We tested whether they could be distinguished from other human populations in the orientation of the cartilaginous Eustachian tube and dilator tubae (DT) belly of the tensor veli palatini muscle (TVP), the sole dilatory apparatus of the CET. Any morphological feature distinguishing groups with higher rates of OM may impact susceptibility. We reconstructed soft tissue CET and DT morphology from adult dry crania. The sample represented eight populations: Alaska (n=156); Aleutian Islands (n=14); China (n=37); Greenland (n=28); Australia (n=39); Germany (n=22); India (n=15); and West Africa (n=19). Alaskans, Aleuts, Greenlanders, and Australians were considered populations with high rates of OM while the remainder were used as comparator populations with relatively lower documented rates of OM. We assessed morphology from coordinate data collected along the posterior edges of the medial pterygoid plates, the hard palate, the basicranial midline, and the osseous orifice of the Eustachian tube. Angular measures were assessed from the coordinate data and Bonferroni-Dunn-adjusted multiple t-tests were performed. Results showed that the Alaskans exhibited the most horizontal orientation of the DT relative to the axis of its common tendon with the TVP palatal sub-belly (an infant-like trait), being significantly more horizontal (P<0.05) than among all other groups. This trait could impact the function of the CET, especially among infants whose DT orientation would be even more horizontal. The only measure that distinguished Alaskans, Greenlanders, and Australians from all other populations was the sagittal orientation of the CET, an additional trait that may impact DT function. The presence of these morphological features may thus be related to increased rates of OM.

Cystic fibrosis mutation classes in pediatric otitis media — Fickle or faulty?

PurposeRecent data have challenged the historical paradigm that cystic fibrosis (CF) protects against otitis media (OM). These findings raised questions about the pathogenesis of this ostensible change. In this study our aim is to characterize acute OM (AOM) risk based on CF genotype. MethodsA retrospective chart review was completed at a tertiary care pediatric hospital. Charts of 159 CF patients seen at our facility from 2010 to 2019 were reviewed. Data collected included demographics, AOM infections, cystic fibrosis transmembrane conductance regulator (CFTR) allele mutations, pulmonary exacerbations (PE), and pancreatic insufficiency (PI) status. Mutation alleles were divided into five classes based on CF guidelines, which were further classified as severe (classes I–III) or mild (classes IV–V). Results54% of patients had at least one episode of AOM with a mean of 1.5 episodes of AOM (standard deviation = 2.3). 86% of patients had severe/severe (S/S) alleles and 14% had severe/mild (S/M). S/S patients had significantly more PE (p = .004) and increased rates of PI (p < .001). Of the 131 patients with S/S mutations, 57% had an episode of AOM while only 46% the 22 S/M patients had an AOM episode (p = .357). ConclusionsTo our knowledge this is the first report showing a clinical trend towards increased middle ear disease in patients with severe CFTR mutations. Future prospective studies will be powered to demonstrate whether this trend is statistically significant. Patients with S/S mutations not only have more severe clinical phenotypes but may have additional unexpected complications such as middle ear disease.

COMPARISON OF THE EFFICACY OF ENDOSCOPIC TYMPANOPLASTY WITH MICROSCOPIC TYMPANOPLASTY

Introduction: Otological surgery has progressed rapidly over the past century. With the recent introduction of the 3-chip camera system and high denition video systems, endoscopes now provide ultra high resolution images of the middle ear that were never seen previously. We conducted this study to compare the efcacy of endoscopictympanoplasty over microscopic tympanoplasty in terms of preoperative ease of surgery including visualisation of ossicles and eustanchian tube and intraoperative bleeding, graft uptake, hearing improvement, post-operative pain score, post-auricular hypoesthesia, duration of hospital stay etc. Methods: The present study is prospective observational study, conducted in a Tertiary Health Care Centre. Results: Endoscopic tympanoplasty has many advantages over microscopic tympanoplasty and can be a better alternative or adjuct to microscopic tympanoplasty. Conclusion: Endoscopic ear surgery provides a better magnication, wide eld view, and the ability to look around corners. Further more transcanal endoscopic ear surgery (TESS) approaches transform external auditory canal into a minimally invasive surgical portal to access middle ear disease. The ease of surgery improves with time and has a gradual learning curve. The graft uptake rate is comparable with both approaches. The overall satisfaction score in terms of reduced pain and hypoesthesia with decreased hospital stay is higher in endoscopic approach.

Aeration of the Human Prussak's Space: A 3D Synchrotron Imaging Study.

Prussak's space (PS) is an intricate middle ear region which may play an essential role in the development of middle ear disease. The three-dimensional (3D) anatomy of the human PS and its drainage routes remain relatively unknown. Earlier studies have histologically analyzed PS, by micro-dissection and endoscopy. Here, we used synchrotron-radiation phase-contrast imaging (SR-PCI), 3D reconstructions, and modeling to study the framework of the human PS, including aeration pathways. It may lead to increased understanding of development of middle ear pathology. Nine human temporal bone specimens underwent in-line SR-PCI at the Canadian Light Source in Saskatoon, Saskatchewan, Canada. Data were processed with volume-rendering software to create 3D reconstructions using scalar opacity mapping and segmentations to visualize its walls in fixed, undecalcified human temporal bones. The PS was found to be an irregular, variably shaped chamber with different aeration systems. Three different drainage pathways were found: 1) via the posterior malleolar pouch of von Tröltsch in seven of nine ears; 2) directly posterior-inferior into the mesotympanum medial to the posterior malleolar pouch in one ear; and 3) anteriorly in another. The posterior-inferior communications depended on the anatomy of the posterior malleolar fold. In one bilateral case, the aeration differed between the ears. Earlier descriptions of upper ventilation routes between the PS and the epitympanic spaces could not be substantiated. The 3D anatomy of the membrane folds organizing the PS in humans was demonstrated for the first time using in-line SR-PCI. The PS was always aerated into the mesotympanum, suggesting its relative independence of attic ventilation. The impact of its various drainage routes on middle ear ventilation and disease were discussed.

Current trends and applications in endoscopy for otology and neurotology.

There has been a rapid increase in endoscopic ear surgery for the management of middle ear and lateral skull base disease in children and adults over the last decade. In this review paper, we discuss the current trends and applications of the endoscope in the field of otology and neurotology. Advantages of the endoscope include excellent ergonomics, compatibility with pediatric anatomy, and improved access to the middle ear through the external auditory canal. Transcanal endoscopic ear surgery has demonstrated comparable outcomes in the management of cholesteatoma, tympanic membrane perforations, and otosclerosis as compared to microscopic approaches, while utilizing less invasive surgical corridors and reducing the need for postauricular incisions. When a postauricular approach is required, the endoscopic-assisted transmastoid approach can avoid a canal wall down mastoidectomy in cases of cholesteatoma. The endoscope also has utility in treatment of superior canal dehiscence and various skull base lesions including glomus tumors, meningiomas, and vestibular schwannomas. Outside of the operating room, the endoscope can be used during examination of the outer and middle ear and for debridement of complex mastoid cavities. For these reasons, the endoscope is currently poised to transform the field of otology and neurotology.

Patterns of hearing changes in women and men from denarians to nonagenarians

BackgroundHearing loss needs to be diagnosed and treated early, especially in older individuals, since presbycusis potentially increases the risk of depression and dementia. However, standard data on hearing thresholds across the life-span in Japanese individuals are lacking. MethodsIn a retrospective consecutive sample of 10681 native-Japanese speakers (37.3% men; 10–99 years; left-right hearing threshold difference of <15 dB for all tested pure tones; free of external, middle, or inner ear disease), we determined standard age-decade and sex-specific pure-tone air-conduction (125, 250, 500, 1000, 2000, 4000, and 8000 Hz) hearing threshold norms. The main outcome measures were pure-tone averages for both ears by age-decade and sex. FindingsFor participants in their 20s, hearing thresholds at higher frequencies (>1000 Hz) were significantly worse in men than in women. For participants ≥70 years, hearing thresholds at low frequencies were higher in women. Hearing thresholds at 1000, 2000, and 4000 Hz tended to deteriorate, starting in the teenage years through the 50s, with some decades showing significantly worse decline. Sex differences were absent in the youngest and oldest groups. InterpretationStandard age- and sex-specific audiometric data reported here for Japanese individuals over nine age-decades are based on the largest dataset analyzed to date. While hearing thresholds of men and women in the very young and the very old age groups were indistinguishable in their cohorts, patterns of hearing changes for other age cohorts differed by direction and sex. FundingThe authors had no outside funding for this study.

Extended high frequency audiometry thresholds in healthy school children

ObjectivesExtended high frequency (EHF) audiometry is the recommended method for monitoring oxotoxic hearing loss in children. This study aims to provide high quality reference audiological data for the EHF range in healthy children. MethodsParticipants were 126 healthy schoolchildren between 6 and 14 years of age. All participants were term born with normal birthweight, had not suffered severe neonatal illness and had no history of middle ear disease. ResultsThe averaged mean (SD) hearing threshold for the EHF 9, 10, 11.2, 12.5, 14 and 16 kHz was −0.4 (6.0) dB HL. The lowest mean hearing thresholds were observed at 14 kHz with −4.2 (8.7) dB and at 16 kHz with −6.4 (12.1) dB HL. We found significantly lower thresholds at 16 kHz for children aged 6–9 years (−8.7 dB HL) compared to age 10–14 years (−3.9 db HL), p 0.042. For both age groups the inter-subject variability increased in the highest frequencies. We found no significant differences in mean hearing thresholds between right and left ears at any frequency, and no gender differences in the EHF range. ConclusionOur findings support that decreased hearing sensitivity in the EHF's may start around or even before the age of 10 years. In order to use EHF audiometry for ototoxic monitoring in children, we suggest to establish an international reference standard for hearing levels in children under the age of 18. Specific references for different age groups are needed as hearing in the EHF range appears to gradually deteriorate from an early age. Clinical trial registrationNCT03253614.

Hydroxyapatite bone cement in the reconstruction of defects of the long process of the incus: Personal experience and literature review

ObjectiveErosion of the long process of the incus is the most common ossicular chain pathology occurring in the course of chronic middle ear disease. The aim of this study was to evaluate our experience in the reconstruction of short-length defects of the long process of the incus using hydroxyapatite bone cement over a period of 15 years. MethodsThe medical records of all patients treated with hydroxyapatite bone cement for an isolated short-length erosion of the long process of the incus or the lenticular process at an academic tertiary referral center between 2005 and 2019 were studied retrospectively. Results48 patients made up our study sample (19 men, 29 women). The mean age at the time of surgery was 38.1 years. The mean preoperative air-bone gap (ABG) was 21.36 dB. The mean postoperative ABG was 15.89 dB within 8 weeks of surgery and 11.81 dB at least 6 months after surgery. The postoperative ABG had significantly improved compared to preoperative ABG values at both the short- and middle-term follow-up (p < 0.001 for both). An ABG ≤ 20 dB was achieved in 68% in the short term and 83% in the middle term. The mean ABG in the long term (< 12 months) was 11.1 dB. ConclusionRestoration of the anatomic and functional continuity of the ossicular chain using hydroxyapatite cement in defects of the long process of the incus seems to warrant a satisfactory audiologic outcome in the majority of cases.

Evaluating the Frequency of Ear Problems in Patients with Cleft Lip and Palate

Background: Orofacial cleft is one of the most common congenital malformations of craniofacial region. Otitis media with effusion causing conductive hearing loss is a considerable challenge for many children with cleft lip and palate. The aim of this study was to evaluate the prevalence of hearing disorders and associated malformations in these patients. Methods: The research population consisted of patients with cleft palate, between years 2012 and 2014, who were referred to Children’s Medical Center and Vali-e-Asr hospital in Tehran, Iran. Otoscopic examination, tympanometry, pure tone audiometry and echocardiography were performed for each patient. Results: Among patients with cleft palate, 73% suffered from hearing disorders. There was no relationship between prevalence of hearing loss and sex, presence of other congenital anomalies and degree of cleft, but middle ear diseases were significantly higher in children younger than 2 years. Among patients with cleft lip or palate, 10% suffered from cleft lip, 63% suffered from cleft palate and 27% suffered from cleft lip and palate. There was at least one congenital anomaly in 53% of patients. Conclusion: This study demonstrates high prevalence of otitis media with effusion and conductive hearing loss in patients with cleft. However, audiologic problems are alleviated when patients become older.

IgG4 Expression in Patients with Eosinophilic Otitis Media

Objective: Eosinophilic otitis media (EOM) is an intractable middle ear disease recognized by an eosinophil enriched middle ear effusion and mucosa. Although precise pathogenesis of EOM remains unclear, it is characterized by type 2 inflammation. Since IgG4 is an IgG subclass induced by type 2 cytokines such as IL-4 and IL-13, we sought to characterize and compare local IgG4 expression in patients with and without EOM. Methods: Twelve patients with bilateral profound hearing loss, 9 of which underwent a cochlear implant surgery, were enrolled in this study (6 with EOM and 6 without EOM). The surgical specimens were harvested during surgery and were subjected to IgG4 immunostaining. Result: The middle ear mucosa showed the presence of a large number of IgG4-positive cells in patients with EOM, which was significantly higher than that in patients without EOM. Conclusion: Local IgG4 expression was observed in patients with EOM in comparison to those without EOM, suggesting that IgG4 contributes to EOM pathogenesis.

Unlearning the ABCs of Tympanometry.

Interpretation of tympanometry commonly relies on the historical convention of classifying findings according to large and arbitrary threshold shifts of tympanometric peak pressure (TPP). This convention had value for prior generations of otolaryngologists in diagnosing severe, chronic middle ear disease requiring surgical intervention but may not be well suited for the present-day evaluation of less severe disease. The existing definition of a type C curve (less than -100 daPa) is likely insensitive to detect subtle abnormalities, including some presentations of obstructive eustachian tube dysfunction. The accuracy of clinical diagnosis may be improved by reporting the absolute values of TPP and moving beyond classification according to arbitrary thresholds.

Identification of critical windows in early development of human upper respiratory tract and middle ear disease.

Otitis media (OM) or middle ear disease is a prevalent pediatric condition generally related to early growth of the cartilaginous Eustachian tube (CET). This study used a developmental series of dry crania to reconstruct CET and dilator tubae (DT, the muscle opening the CET) morphology. Timing and directionality of CET and upper respiratory tract (URT) growth were investigated. Traditional and 3D geometric morphometrics (GM) were used to assess bony landmarks on the crania. The series was divided using dental eruption into seven growth stages ranging from before eruption of deciduous dentition (approximately the first 6 postnatal months) to eruption of the first permanent maxillary molar (after approximately 6 years). Bony endpoints of the CET and DT were used to calculate their morphology. GM analysis showed substantial shape differences between newborns, early infants, and all later developmental stages. Univariate measures showed the largest growth change between birth and 6months. Subsequently, CET morphology changed little in the latter half of year 1, instead maturing gradually until approximately 3 years whereas DT relative length and orientation finish growth by the end of year 1. Incongruence in slower CET growth and faster DT growth could impact CET function between 6 and 12 months and be a contributing factor of OM. Tubal aeration may improve after this time when both CET and DT morphology mature, coinciding with clinically reported drop-off in ear infections.

Ear disease determination on computer-assisted outer and middle ear images

This paper proposes a method to determine the outer and middle ear disease from image files in computer data efficiently and developed the environment friendly unit. The proposed method starts its method by analyzing the accessed file. If a file is labeled as a file that needs to be classified, the proposed method collects the list of image files in the directory, then it starts to run CNN-based classification to determine the type of ear disease suffered by the patient based on the information contained in the input image. If an image file is detected as a certain outer and middle ear disease, that file will be given a label and its probability. The CNN engine work for classifying the input image captured by Endoscope Ear Cleaning Tool Kit. The classification machine was developed using 1800 images for 18 disease classes with each class having a sample of 100 to 105 sample images. The sample image was augmented from 900 patient data. The experimental result shows that the Ear Disease Determination on Computer-Assisted Outer and Middle Ear Images which is based on CNN has run properly which is indicated by 80% accuracy and potentially implemented for the rural health center facility.

Rising Resonance Frequency Is the Sole Sign of Early Middle Ear Disease in Children With Adenoid Hypertrophy.

The present study seeks to estimate the potential of multifrequency tympanometry in the diagnosis of primal otologic disorder in children with adenoid hypertrophy (AH). Prospective observational study. Tertiary pediatric institution. One hundred thirty-one children presenting consecutively at the otolaryngology clinic were divided on the basis of AH into 98 patients and 33 controls. Middle ear status was assessed using pneumatic otoscopy, standard, and wide band tympanometry. Tympanogram type/intratympanic pressure, and resonance frequency (RF) were correlated with each other as well as with a set of clinical parameters. Receiver operating characteristic analysis was employed to reveal the diagnostic value of RF. Mean RF declined in chronic otitis media with effusion by 43.25% (p < 0.001). In our entire cohort, children with AH under the age of 7 years presented with a relative risk = 2.43 of producing "B" tympanogram (p = 0.016) than their older peers. In patients' ears with normal, type "A," tympanogram, RF was the sole tympanometric marker of AH, being elevated by 28.26% in mean value (p = 0.010). On receiver operating characteristic analysis of RF's discriminating capability, the area under the curve was equal to 0.647 (p = 0.010). The optimal cut-off value of RF was set at 899 Hz. AH may induce middle ear stiffening, as RF's increase indicates. Wide band tympanometry output could be a warning sign of ongoing compliance reduction to the sound transmission apparatus, at a time point when physical examination and 226 Hz tympanometry are still unremarkable.