|Year : 2015 | Volume
| Issue : 3 | Page : 219-221
Tympanic membrane gangrene
DR Surya Prakash, Altaf Hussain
Department of ENT, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||17-Jul-2015|
D R Surya Prakash
Department of ENT, M. S. Ramaiah Medical College, MSRIT Post, Bengaluru - 560 054, Karnataka
Source of Support: None, Conflict of Interest: None
Necrosis of tympanic membrane (TM) can be due to infections, drugs, radiation, and foreign body. Strain of group A Streptococcus is associated with acute otitis media or in immunocompromised individuals resulting in TM necrosis. Gangrene of lower limb has been described, but the selective loss of TM due to emboli is an uncommon finding. A 62-year-old female presented with sudden behavioral changes and irrelevant talk. After 2 days, she noticed a discharge from left ear. There was perforation of left TM in posterior superior and inferior quadrant with areas of the black patch around the perforation suggesting a loss of blood supply. Patient was recently detected retrovirus positive with multiple lung shadows. Patient is not on any anti-retroviral medications or other medications. The discharge started 2 days after an episode of left middle cerebral artery infarct due to emboli with no previous history of ear symptoms. Culture of discharge showed no growth. This suggests that TM might have gone for gangrene due to emboli affecting deep auricular artery branch or posterior tympanic branch, which is a branch of the stylomastoid artery.
Keywords: Blood supply, Gangrene, Necrosis, Stylomastoid artery, Tympanic membrane
|How to cite this article:|
Surya Prakash D R, Hussain A. Tympanic membrane gangrene. Indian J Otol 2015;21:219-21
| Introduction|| |
Tympanic membrane (TM) is the lateral wall of middle ear cleft. Blood supply to TM is by vascular loop of arteries supplied mainly by anterior tympanic artery, stylomastoid branch of the posterior auricular, anastomosing with the artery of the pterygoid canal and caroticotympanic branch from the internal carotid artery. Lateral part of TM is also supplied by branches of the deep auricular artery.
Anterior tympanic artery is branch first mandibular portion of internal maxillary artery, which passes above temporomandibular joint and after passing through petrotympanic fissure, it divides to supply malleus, incus, and inferior branch supplies the anterior half of TM.
Stylomastoid artery is branch of posterior auricular artery which traverses the stylomastoid foramen, passes in canal with chorda tympanic and gives a posterior tympanic branch supplying posterior superior quadrant of TM. It also supplies antrum and mastoid air cells. It anastomoses with branches of anterior tympanic artery anteriorly.
Artery of pterygoid canal is a branch of third pterygopalatine portion of internal maxillary artery passing along with corresponding nerve. After it supplies upper pharynx and auditory tube, a small tympanic branch supplies TM.
Caroticotympanic artery is branch of internal carotid artery which arises from carotid canal, passes in small foramen and supplies TM.
Deep auricular artery is branch of first mandibular division of internal maxillary artery which arises just before anterior tympanic artery supplying mainly temporomandibular joint. It pierces bony or cartilaginous wall of external auditory canal and Supplies the epithelial lining of TM in lateral part.
Tympanic membrane gangrene can result from selective loss of membrane due to loss of blood supply. It can be due to various causes like infections (chronic suppurative otitis media), trauma, foreign body, toxins, radiation, drugs, alkaline batteries, etc.,  TM gangrene due to emboli has not been described in the literature.
| Case Report|| |
A 62-year-old lady presented to the emergency of our hospital with complaints of sudden onset of irrelevant talk, behavioral changes on November 13, 2014. There was no history of deviation of the mouth, weakness of limbs, giddiness, tingling and burning sensation of limbs, loss of consciousness, seizures, fever, headache and vomiting.
She was a known case of diabetes mellitus type II, hypertension and recently detected retroviral disease. Not on any anti-retroviral medications. Left lower limb amputation was done 1-year back.
On examination, vitals were stable. General examination is normal. In central nervous system examination, patient was conscious, looking around. Obeying simple step commands. Reading, writing, naming, and comprehension was impaired. Motor examination was normal. Left below knee amputation noted. Power is normal in all three limbs normal. Sensory examination could not be done. Cerebellar signs were negative. Eye examination showed right pseudophakia with left eye 2 mm reactive. Extraocular mobility and fundus examination was normal.
Other system examination was normal except occasional crepitations on auscultation.
Patient was taken for emergency magnetic resonance imaging (MRI) with gadolinium contrast with other routine investigations. MRI showed left middle cerebral artery infarct territory. Other investigations showed serum creatinine 2.4 mg% and CD4 count to be 628. Echocardiography showed global hypokinesia with ejection fraction 48%.
After a period of 2 days, she noticed a discharge from left ear for which ENT consultation was sought. On examination, mucoid discharge with otomycotic debris was seen in the external auditory canal. Suction clearance done. TM showed 33% central perforation involving posterior superior and inferior quadrant with blackish area surrounding perforation. Anterior half of TM was pale. Middle ear mucosa was pale. Right TM was normal [Figure 1].
|Figure 1: (a) Photograph of patient and (b) patient's left ear (c) magnetic resonance imaging of patient (d) left tympanic membrane (TM) with central perforation involving posterior quadrant with area of blackish necrosis around perforation. (e) Normal right TM. (f) TM with blood supply|
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Tuning fork examination showed Rinne's negative on left side, Weber's lateralized to left ear and absolute bone conduction was normal. No nystagmus. Fistula sign was negative.
Pure tone audiometry was consistent with examination findings with a moderate conductive hearing loss on the left side.
She was started on anticoagulants, statins, and neuroprotective drugs with control of diabetes. She was started on ear drops to control otomycosis and discharge decreased over a period of 2 days.
Follow-up was done after 7 days and 21 days. Discharge was not seen, but there were no signs of healing of perforation.
Patient was evaluated for Kaposi's sarcoma as she developed multiple lung opacities on X-ray and cough with expectoration.
| Discussion|| |
Tympanic membrane gangrene is a term to describe the sudden loss of blood supply to TM. TM is supplied by the vascular loop formed by various arteries, but it can go for necrosis due to conditions like infection, toxins, etc. Sudden loss of blood supply to TM causes wet gangrene involving the area supplied by the corresponding artery.
Magnetic resonance imaging with gadolinium scanning was only able to detect large middle cerebral artery infarct, but small artery emboli could not be visualized.
Drugs like tarceva (Erlotinib) has caused TM necrosis, which is used commonly for maintenance therapy, as well as second- or third-line therapy in advanced nonsmall cell lung cancer. 
Facial nerve palsy after embolization of external carotid artery done for epistaxis may be due to emboli blocking the petrosal branch from the middle meningeal artery, which supplies facial nerve. 
Numerous studies have been done to assess the blood flow in TM in cadavers and normal humans,  but the exact blood supply that gets affected has not been validated.
This is 1 st time in literature that TM has undergone gangrene.
| Conclusion and Summary|| |
Tympanic membrane blood supply is vital for its survival and function. Any loss of blood supply due to various conditions causes a selective loss of tissue leading to perforation. Ischemic necrosis is widely described, but sudden embolus which causes cessation of blood causing wet gangrene of tissue has been described for lower limb gangrene, but gangrene of TM is not seen. Posterior tympanic artery which is branch of stylomastoid artery may have been blocked by thrombi from heart.  Since it's a small vessel, revascularization has not helped as perforation is not showing any signs of healing and patient may have to be planned for tympanoplasty at a later date.
| References|| |
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