Home Ahead of print Instructions Contacts
About us Current issue Submit article Advertise  
Editorial board Archives Subscribe Login   


 
 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 1  |  Page : 47-50

Granular myringitis as a differential diagnosis for chronic ear discharge


Department of Otorhinolaryngology, School of Medical Sciences, Universiti Sains Malaysia; Department of Otorhinolaryngology Clinic, Hospital Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia

Date of Submission28-Aug-2019
Date of Acceptance20-Oct-2019
Date of Web Publication19-Feb-2020

Correspondence Address:
Prof. Mohd Khairi Md Daud
Department of Otorhinolaryngology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
Malaysia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_96_19

Rights and Permissions
  Abstract 


Granular myringitis is a localized chronic inflammation on the lateral surface of the tympanic membrane. It is characterized by the presence of granulation tissue over the involved area in the absence of middle ear disease. It is a poorly understood disease and has received relatively little attention in the literature and easily mistaken for chronic otitis media due to similarity in clinical symptoms and findings. We reported a case of granular myringitis in a 25-year-old female that represents diagnostic and therapeutic challenges of the disease.

Keywords: Granulation tissue, infection, tympanic membrane


How to cite this article:
Draman WN, Rasid NS, Daud MK. Granular myringitis as a differential diagnosis for chronic ear discharge. Indian J Otol 2020;26:47-50

How to cite this URL:
Draman WN, Rasid NS, Daud MK. Granular myringitis as a differential diagnosis for chronic ear discharge. Indian J Otol [serial online] 2020 [cited 2020 Mar 29];26:47-50. Available from: http://www.indianjotol.org/text.asp?2020/26/1/47/278743




  Introduction Top


Granular myringitis is an uncommon ear disease.[1] It is characterized by de-epithelialization of the lateral squamous layer of the tympanic membrane and replacement with granulation tissue in the absence of middle-ear disease. It is a rare disease with a prevalence about 1.2%–1.8% among the adult otology cases.[2] A nonspecific injury involving the lamina propria of the tympanic membrane suppresses epithelialization and leads to the development of granulations. In most cases, it causes a chronic disorder which frequently misdiagnosed as chronic suppurative otitis media. Meticulous microscopic aural toileting and the administration of topical antibiotic and steroid ear drops will successfully manage the majority of cases. We report a case of an intractable disease which was only resolved by surgical intervention.


  Case Report Top


A 24-year-old female presented with unilateral left ear discharge for 9 years, characterized by intermittent, scanty in amount, mucopurulent, and nonfoul smelly. It is associated with ear fullness, hearing loss, and occasional mild otalgia. She had no symptoms of dizziness, tinnitus, and rhinitis. There was no prior history of ear trauma or ear surgery. Otoscopic examination showed minimal nonfoul smelly mucopurulent discharge in the external auditory canal. Following aural toileting, examination revealed diffused granulation tissue on the lateral surface of the tympanic membrane. The tympanic membrane appeared thickened with no evidence of perforation [Figure 1]. An audiogram showed a unilateral left mild conductive hearing loss with tympanometry Type C. Pseudomonas aeruginosa was isolated from a swab for culture and sensitivity.
Figure 1: Granulation tissues occupying the tympanic membrane

Click here to view


High-resolution computerized tomography (HRCT) of the temporal bones was done as there was no symptoms resolution instead of multiple course antibiotics. HRCT findings revealed intact but retracted the left tympanic membrane. However, the middle ear cavity, ossicles, and mastoid air cells were normal. Correlating the clinical and radiological findings, the diagnosis of chronic left granular myringitis was made. She was initially treated conservatively, but no response was noted. She was given a few courses of topical antibiotic eardrop with steroids followed by combination with oral systemic antibiotics. She also has received topical acetic acid 1% eardrop and later on underwent cauterization of granulation tissue using silver nitrate 10%. Unfortunately, the symptoms still persisted. Endoscopic surgical removal of granulation tissue under general anesthesia was performed due to failed medical treatment. Intraoperative findings showed minimal mucopurulent discharge and hyperemic external ear mucosa, and there was granulation tissue at postero-inferior quadrant of the tympanic membrane. The granulation tissue was excised and sent for histopathological confirmation. Endoscopic middle ear inspection through tympanic membrane perforation revealed the healthy middle ear mucosa [Figure 2]. Postoperatively, she was discharged with topical antibiotic eardrop and oral cefuroxime for 1 week. Histopathological examination of granulation tissue showed diffuse infiltration of chronic inflammatory cells confirmed the diagnosis of granular myringitis. The tympanic perforation was healed, and she was completely free from the disease at the 6th-week postsurgical procedure [Figure 3].
Figure 2: Normal middle ear mucosa seen after the excision of the granulation tissue

Click here to view
Figure 3: Otoendoscopic examination at the 6th-week postoperation showed intact tympanic membrane with the absence of disease recurrence

Click here to view



  Discussion Top


Granular myringitis is defined as a chronic inflammatory disorder, characterized by de-epithelialization of the outer squamous layer of the tympanic membrane and replacement with granulation tissue in the absence of middle ear disease.[2] Etiology is unknown. In these pathologic tympanic membranes, epithelial migration was disturbed to a high degree. It has been suggested that trauma or infection causing nonspecific injury to the lamina propria resulting in the loss of squamous epithelium of the tympanic membrane.[2],[3] Later, the impairment of its re-epithelialization promotes granulation tissue formation.[3] It may progress to involve the whole eardrum or even the ear canal.

Possible predisposing factors could be previous otological surgery such as myringotomy and tube placement. This theory is supported by the high incidence of myringitis occurring in about 60%–93% following otological surgical procedure.[2],[4] Infection may also contribute to the disease by causing aberrant healing of the tympanic membrane which leads to chronic inflammation. This is supported by positive cultures from otorrhea with bacteria such as P. aeruginosa, Staphylococcus aureus, Corynebacterium, and Proteus mirabilis.[3] However, the infectious role of these microorganisms in the pathogenesis of chronic granular myringitis is still obscure.[3],[4],[5] In our reported case, the predisposing factor could be an infection as P. aeruginosa was isolated from ear swab, and she had no history of previous otologic surgery.

Exacerbating factors reported in the literature include sweating, swimming, poor oral hygiene, external canal furunculosis, desquamative otitis externa, and impacted cerumen, although these theories have not been substantiated.[3] The incidence is not related to sex, age, particular systemic diseases, or seasons.[6]

The most common presenting symptom is an aural discharge which may be malodorous. In most cases, it is a chronic in duration for at least 3 months with a remitting and relapsing course.[2],[3] Kim reported that 70% of these patients had symptoms for more than 1 year.[7] Our patient had symptoms of chronic malodorous otorrhea, intrameatal itchiness, and aural fullness that intermittently relieved.

Otoscopic examination may reveal granulation tissue or polyp replacing normal squamous epithelium. Granulation can be localized to part of the tympanic membrane or diffuse.[2],[8] The segmental type is more common, with the posterosuperior segment of the eardrum most frequently affected.[9] It may also involve the skin of the adjacent medial ear canal that may be covered by yellowish dry crust. Uninvolved portions of the eardrum may appear thickened, hyperemic, retracted, or normal.[4] Wolf et al. suggested a staging system for granular myringitis in which Grade 1 is focal de-epithelialization with focal granulation tissue, Grade 2 is focal polypoid formation that bleeds with removal and purulent discharge, Grade 3 is diffuse tympanic membrane involvement while Grade 4 when the disease extending to involve the canal.[6] Even though our patient had only Grade 2 disease based on the focal granulation tissue formation associated with purulent discharge and thickened tympanic membrane, it was refractory that failed on the conservative treatment.

A swab for bacteriological culture and sensitivity is indicated to guide antimicrobial treatment, especially when conservative treatment with antibiotic-steroid ear drops fails. Biopsy to exclude malignancy should be considered, especially when there are concerning clinical features such as significant otalgia or facial asymmetry.[3]

Hearing loss is usually mild with a Type A tympanogram.[2],[8] In our presented case, the audiogram showed unilateral left mild conductive hearing loss with tympanometry Type C that developed due to thickened tympanic membrane. Occasionally, HRCT temporal bone may help to exclude underlying middle ear or mastoid disease. Some published series include a normal radiological finding as essential diagnostic criteria in granular myringitis consistent with our reported case.

Occasionally, squamous epithelium can grow over the surface of the granulation and may even lead to fibrosis, scarring, stenosis of the medial ear canal, and lateralization of the tympanic membrane.[8],[10] Although these sequelae may resolve any otorrhea, there is likely to be a significant resultant conductive hearing loss. Hence, it is crucial to recognize and diagnose the disease so that proper treatment can be planned.

The proposed treatments in the literature are quite variable, including the usage of antiseptic solutions, cauterizing agents, antibiotic steroid drops, chemical cauterization, surgical curettage, laser therapy, myringoplasty, and more recently, topical chemotherapy with 5-fluorouracil (5-FU).[8]

A systemic review concluded that there is insufficient high-quality evidence to support any particular management plan or treatment protocol for patients with granular myringitis.[8] Meticulous microscopic cleaning and debridement in combination with topical antibiotic or antiseptic agents are the mainstay of the initial treatment. Culture-directed antibiotic steroid drops should be the first step in the management. However, conventional topical antibiotic and steroid drops appear to be less efficacious in certain cases and more likely to lead to symptoms recurrence.[8],[9] Treatment with diluted vinegar solution presents a logical, unharmful alternative to conventional antibiotic drops. Jung et al. demonstrated a 96% reduction of recurrence when managed with diluted vinegar solution.[11] A retrospective study using Castellani solution that contains combination of antifungal (carbol-fuchsin), antibacterial (ethanol and resorcinol), and acidic (acetone) solution showed 96% complete resolution of disease with no recurrence in the mean 14.4 months follow-up.[7] Surgical excision of granulation tissue is limited to the cases that have failed medical management which resulted in 80% reduction of recurrence.[9]

Our patient underwent surgical excision after failed treatment with few courses of topical antibiotic with steroid as well as the trial of topical acetic acid 1% and cauterization of granulation tissues with silver nitrate. Following this procedure, the symptom was resolved and subsequent follow-up showed no recurrence.

Another alternative is an endoscopic carbon dioxide (CO2) laser ablation therapy for refractory cases of granular myringitis.[12] CO2 laser vaporizes the granulation tissue and surrounding altered epithelium. This will stimulate the growth of surrounding diseased epithelium allowing normal physiologic healing to resume. In addition, the topical application of 5-FU cream has been shown beneficial in the treatment of this disease.[13]


  Conclusion Top


Granular myringitis is a chronic inflammation of the tympanic membrane, characterized by granulation tissue formation without middle ear disease. The size of the lesion does not correlate with its intractability. Surgery may be needed in a hard to control cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khairi Md Daud M, Noor RM, Rahman NA, Sidek DS, Mohamad A. The effect of mild hearing loss on academic performance in primary school children. Int J Pediatr Otorhinolaryngol 2010;74:67-70.  Back to cited text no. 1
    
2.
Blevins NH, Karmody CS. Chronic myringitis: Prevalence, presentation, and natural history. Otol Neurotol 2001;22:3-10.  Back to cited text no. 2
    
3.
Makino K, Amatsu M, Kinishi M, Mohri M. The clinical features and pathogenesis of myringitis granulosa. Arch Otorhinolaryngol 1988;245:224-9.  Back to cited text no. 3
    
4.
Levi JR, Ames JA, Gitman L, Morlet T, O'Reilly RC. Clinical characteristics of pediatric granular myringitis. Otolaryngol Head Neck Surg 2013;148:291-6.  Back to cited text no. 4
    
5.
Fechner FP, Cunningham MJ, Eavey RD. Laser therapy for refractory myringitis in children. Otolaryngol Head Neck Surg 2002;127:163-8.  Back to cited text no. 5
    
6.
Wolf M, Primov-Fever A, Barshack I, Polack-Charcon S, Kronenberg J. Granular myringitis: Incidence and clinical characteristics. Otol Neurotol 2006;27:1094-7.  Back to cited text no. 6
    
7.
Kim YH. Clinical characteristics of granular myringitis treated with castellani solution. Eur Arch Otorhinolaryngol 2011;268:1139-46.  Back to cited text no. 7
    
8.
Neilson LJ, Hussain SS. Management of granular myringitis: A systematic review. J Laryngol Otol 2008;122:3-10.  Back to cited text no. 8
    
9.
El-Seifi A, Fouad B. Granular myringitis: Is it a surgical problem? Am J Otol 2000;21:462-7.  Back to cited text no. 9
    
10.
Slattery WH 3rd, Saadat P. Postinflammatory medial canal fibrosis. Am J Otol 1997;18:294-7.  Back to cited text no. 10
    
11.
Jung HH, Cho SD, Yoo CK, Lim HH, Chae SW. Vinegar treatment in the management of granular myringitis. J Laryngol Otol 2002;116:176-80.  Back to cited text no. 11
    
12.
Cheng YF, Shiao AS. Intractable chronic myringitis treated with carbon dioxide laser microsurgery. Arch Otolaryngol Head Neck Surg 2008;134:152-6.  Back to cited text no. 12
    
13.
Atef AM, Hamouda MM, Mohamed AH, Fattah AF. Topical 5-fluorouracil for granular myringitis: A double-blinded study. J Laryngol Otol 2010;124:279-84.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed193    
    Printed0    
    Emailed0    
    PDF Downloaded25    
    Comments [Add]    

Recommend this journal