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Granular myringitis (GM) is considered an uncommon infection of the tympanic membrane (TM) with possible involvement of the external ear canal. Previous reports were essentially addressed to adults [1, 2] with sporadic descriptions of pediatric-age patients [3].

GM is characterized by de-epithelization of the TM with formation of granulation tissue and muco-purulent discharge. It may involve a small part or the entire surface of the eardrum. The granulations may appear tiny and shallow or may form a raised polypoid mass. Symptoms are often mild, expressed by plugged ear and aural discharge, and it is commonly accepted that the middle ear is not involved in the disease [1, 4, 5]. Bacteriological studies [1, 4] mainly revealed Staphylococcus coagulase positive and Gram-negative pathogens, i.e. Proteus and Pseudomonas. GM has scarcely been described among children in the English literature and this work summarizes our extended experience on GM in the pediatric population.

The clinical characteristics of GM in children were prospectively studied during a 4-year period (1998–2001) in a primary otolaryngologic practice. GM was defined by de-epithelization of the TM with granulation tissue formation and aural discharge. Children with middle ear infection were excluded. Treatment included eardrops (five drops t.i.d. for 7 days of either neomycin–polymyxin plus dexamethasone or ofloxacin, randomly) and topical application of 80% phenol solution in unresponsive cases. Polypoidal granulations were sent for histological examination. All patients were followed weekly until recovery and then periodically, every 3 months, with a mean follow-up period of 7.5 months.

Fourteen children, eight boys and six girls, aged 1–16 years (mean=10.1), were diagnosed with GM, comprising 0.17% of children (1 out of 588) visiting a primary ENT practice. Symptoms included plugged ear (9), aural discharge (8) and mild pain (5). The youngest child (11 months of age) presented with recurrent bouts of allegedly painless, foul-smelling aural discharge over a several-month period. The medical history was remarkable for documented episodes of secretory otitis media during the previous 1-year period in three children. GM was found to be focal in all but one child in whom the infection included the entire surface of the TM and part of the external ear canal. The involved de-epithelized area of the TM was characterized by a shiny and wettish surface, well demarkated from a normal TM epithelium. The granulations appeared either as shallow and tiny (8) or as a prominent polypoid mass (6). The discharge was found to be either dry-yellowish crusts-adhered to the involved site of the TM (in the less aggressive forms) or as muco-purulent and foul smelling (in the more aggressive forms). Four children with prominent granulations were treated by topical application of phenol solution.

Recurrent GM was noted in one child, altogether three episodes in the same ear. Perforation of the TM was noted in two children; in one child, the perforation developed and healed within two consecutive episodes of recurrent infection. In both children, the mucosa of the middle ear appeared normal with no apparent discharge. Two children failed previous treatment with intravenous Ceftazidime for an assumed diagnosis of chronic suppurative otitis media with Pseudomonas infection. Recovery was noted in all cases between 3 and 11 weeks (mean=3.6). Histopathological specimens revealed non-specific features of granulation tissue.

The first case-series report on GM among children was published in 2001 by Wolf et al. [3] summarizing a group of 9 children. Thus, the clinical characteristics of the disease as presented in most publications were based essentially on adults [1, 2]. Pathogenesis of GM was presumed to be related to idiopathic-suppressed epithelial migration and trauma to the TM that reaches the lamina propria and fails re-epithelization. Proliferation of granulation tissue that arises from the lamina propria may then progress beyond the edge of the epithelial layer of the TM, suppress proper healing and ingite GM [2, 6]. Symptoms including mild pain, discharge and plugged ear [1] were usually mild and may go unnoticed, especially in young children. The presentation of a polypoid mass and muco-purulent discharge was mistakenly considered as chronic otitis media in a series of 13 of 40 patients [2], leading to wrong conclusions as occurred in two of our children.

In a previous report [7], related mainly to adults, we described four grades of macroscopic appearance, based on the extent of the involved area of the surface of the TM: a small area versus a wide area, and on the appearance of the granulations-shallow and tiny or large and polypoid. Stenosis of the ear canal, also termed obliterative external otitis, was considered an end result of prolonged, untreated GM involving the TM and the external ear canal [1].

It was accepted that the middle ear is not involved in the disease although concomitant perforations of the TM, either due to the inflammatory reaction or due to caustic effect of the treatment, were described [2, 7]. Chronic suppurative otitis media was described alongside GM, and also "arrested" mastoid pneumatization was described in about one-quarter of two series of patients [2, 5]. The most common protocol of treatment includes meticulous cleaning of discharge with topical application of antibacterial, antiseptic or caustic solutions. Mechanical removal of polypoid granulations has also been suggested [1, 5]. Histopathological studies, including ours, revealed non-specific inflammatory reactions [1, 3, 7] and did not help in clarifying its pathogenesis.

GM was not rarely encountered in a primary ENT practice. GM has a benign course with mild symptoms. Local treatment with antibiotic or caustic solution was successful in all cases. GM may appear in various forms of aggressiveness. When polypoid granulations develop, GM may mistakenly be considered as chronic suppurative otitis media.