Learning Objectives:

Intro: The limited evidence available to guide management has rendered very controversial the management of pars tensa retraction pockets.

Since 2003, we have adopted a policy of minimal intervention for pars tensa retraction pockets and this has allowed us to monitor the natural behaviour of this disorder.

Method: Successive patients with pars tensa retraction pockets that a) contacted the promontory yet b) were not accumulating keratin (“advanced retraction pockets”) have been monitored at least once a year and followed either until surgery was required, the patient was lost to follow-up or some other pathology intervened. Follow-up was censored at five years.

Results: 95 cases were enlisted and followed up.

25% ears advanced to need surgery.

40% ears remained advanced without further progression.

38% ears returned to normal.

4% ears developed pars tensa perforation.

3% ears developed attic cholesteatoma.

Conclusions: Only a minority of advanced pars tensa retraction pockets progress to require surgery.

More advanced pars tensa retraction pockets return spontaneously to normal than progress to require surgery.

Some ears that present with a retracted pars tensa progress to develop attic retraction and then attic cholesteatoma, without devloping cholesteatoma via the pars tensa.

Learning Points: It is not correct to consider an advanced pars tensa retraction pocket as necessarily pre-cholesteatoma.

Because most advanced pars tensa retraction pockets do not progress to become cholestatoma, surgery on advanced pars tensa retraction pockets cannot be justified on the grounds that it is prophylaxis against the development of cholesteatoma.

Attic and pars tensa retraction disease sometimes have a common aetiology.