In reference to Tympanic membrane retraction: an endoscopic evaluation of staging systems

I would like to congratulate James et al. on an elegant and well-argued article, and have a few additional observations. Although I agree entirely that endoscopic images would be a good basis for follow-up of this difficult group of patients, it is in practice not always easy to obtain adequate images, especially from younger children. The authors do not indicate how frequently the patients should be followed. On the one hand, I have observed the retraction pockets degenerating to cholesteatoma in the space of a few months while the patient was awaiting surgery (usually there is an intercurrent acute otitis media), whereas on the other hand I recently operated on a female patient whose retraction pockets had remained stable for 70 years, before she unexpectedly developed bilateral cholesteatoma. In theory, it would be necessary to follow up the patients every 4 to 6 months for the rest of their lives, although in practice this is unrealistic and unattainable, because the lack of clinical symptoms of hearing problems make it a difficult group to evaluate even by a experienced otologists, apart from the cumulative aspects. The images shown in Figure 2 are not unusual findings, and the importance of the second image is not so much the aeration, but the fact that the drum is still fixed to the incus, which has already been eroded as can be clearly seen in the first image. This makes the situation essentially irreversible. As the authors rightly comment, the erosion of the ossicles is likely to determine the long-term hearing of the patient. The eardrum, once fixed to the ossicles, will not recover spontaneously, whereas the erosion can continue; therefore, it may be useful to consider surgery for this group of patients to prevent further hearing problems. Admittedly, this situation may remain stable for many years, but further erosion is unlikely to be noticed by the patient, who will therefore not seek medical attention until the damage is advanced. The results of ossicular reconstruction in the best hands are still far from perfect. The long-term aim should be to obtain a normal eardrum with normal hearing for these patients. The authors correctly note that the presence of granulation tissue and keratin tracking out of a retraction pocket indicate instability and possibly perforation in the retraction, which should be taken into consideration for early surgery. We would classify those as Erasmus stage 4. The Erasmus classification was primarily designed to evaluate surgical results, and the staging is done at the time of surgery. We agree with the authors that preoperative predictions are not always consistent with operative findings, especially the extent of fixation to the promontory. Fixation to the incus and erosion of the incus are generally consistently determined before surgery.