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Middle-ear disorders: otitis and effusion, cholesteatoma, otosclerosis and ossicular discontinuity
Every middle-ear disease changes the stiffness or mass of the system, so it leaves a predictable signature on the audiogram, the tympanogram and the reflexes. From that signature one can guess the diagnosis even before the doctor looks in the ear.
Why it matters in the exam
Middle-ear effusion (OME) gives a mild to moderate conductive loss and a flat tympanogram with normal canal volume; it is common in children, especially in Down syndrome, where narrow canals, wax and poor tube function add to it. Chronic otitis media, with a perforation or a retraction pocket, can lead to cholesteatoma — a sac of keratin-producing squamous epithelium that keeps growing and erodes the ossicles, the surrounding bone and the facial nerve canal, so it is treated surgically, not with drugs.
In otosclerosis, abnormal bone growth locks the stapes footplate into the oval window; early on the conductive loss is most marked in the low frequencies (stiffness), there is a Carhart notch in bone conduction at about 2000 Hz, an As tympanogram and absent reflexes; it is more common in women and runs in families. In stapedectomy the stapes superstructure is removed, the footplate is opened (wholly, partly or by a small hole — stapedotomy) and a prosthesis is placed from the incus to the oval window. Ossicular discontinuity gives a maximal air-bone gap (about 50–60 dB), an Ad tympanogram (very compliant) and absent reflexes. An eardrum perforation gives a flat tympanogram with a large canal volume and a relatively small gap. Negative middle-ear pressure, from a tube that opens poorly, gives a Type C tympanogram and at most a mild loss.
Key points
- Effusion: conductive, Type B, normal volume.
- Cholesteatoma: keratin-producing epithelium that erodes bone; surgery.
- Otosclerosis: lows, Carhart at 2000, As, no reflexes.
- Discontinuity: maximal gap, Ad.
- Stapedectomy: remove the stapes and place a prosthesis to the oval window.
Summary table
| Condition | Audiogram | Tympanometry and reflexes |
|---|---|---|
| Effusion (OME) | Mild to moderate conductive | Type B, normal canal volume; reflexes absent |
| Negative pressure | Mild conductive or normal | Type C |
| Eardrum perforation | Relatively small gap | Type B with large canal volume |
| Cholesteatoma | Conductive, sometimes mixed | Depends on the stage; needs surgery |
| Early otosclerosis | Conductive in the lows; Carhart notch at about 2000 Hz | Type As; reflexes absent |
| Ossicular discontinuity | Maximal gap, about 50–60 dB | Type Ad; reflexes absent |
| Down syndrome | Recurrent conductive (effusion), sometimes sensorineural too | Narrow canals; hard to test |
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Sources
- Katz (ed.), Handbook of Clinical Audiology, 7th edition (2015) — Disorders of the middle ear
- Rosenfeld et al., Otolaryngology–Head and Neck Surgery, 2016 — Clinical Practice Guideline: Otitis Media with Effusion (update)
- Bluestone & Klein, Otitis Media in Infants and Children, 4th edition (2007) — Complications and sequelae
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.