ORGAN SYSTEMS Otolaryngeal system (ENT)

Tympanic membrane retraction (TMR)

Tympanic membrane retracted into middle ear cavity (also called retraction pocket)

Tympanic membrane retracted into middle ear cavity (also called retraction pocket)

  • Frequently seen in (pediatric) otorhinolaryngology with a prevalence of 8-10%, mostly being mild cases
  • Mainly caused by persistent/temporary negative middle ear pressure, which is caused mainly by a dysfunction of the Eustachian tube or by inflammation, is considered a main causal factor in the etiology of TMRs


The first staging system of TMRs was proposed by Sade and Berco in 1976, classifying pars tensa retraction by otoscopic image into stage I till IV, based on the reversibility of the retraction after ventilation.

Sade classification:

Grading for pars tensa retraction
The adjusted Sade classification | Bayoumy, A. B., Veugen, C., Rijssen, L. B., Yung, M., & Bok, J. M. (2021). The Natural Course of Tympanic Membrane Retractions in the Posterosuperior Quadrant of Pars Tensa: A Watchful Waiting Policy. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 42(1), e50–e59.
  • Sade I: Mild retraction
  • Sade II: TM touches incus
  • Sade III: TM touches incus and promontory, but mobile on seigalization (atelectasis of middle ear)
  • Sade IV: TM plastered onto middle ear (adhesive otitis media)
  • Sade V: Spontaneous perforation of atelectatic TM

Tos classification:

Grading for pars flaccida retraction
  • Tos I: Mild attic retraction not touching neck of malleus
  • Tos II: TM touching neck of malleus
  • Tos III: Limited outer attic wall erosion
  • Tos IV: Severe outer attic wall erosion

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