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Health condition · Clinically reviewed

Eardrum retraction, graded, watched, and treated before it becomes cholesteatoma.

A common finding in Eustachian tube dysfunction. Some pockets sit quietly for years, others progress - and grading them properly is how UK otologists decide which is which.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against ENT UK, BSO and peer-reviewed otology sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK otology practice including Sadé and Tos grading, cartilage tympanoplasty and balloon Eustachian tuboplasty.

Key facts

Eardrum retraction at a glance.

The essentials, in plain English - what it is, how it is graded, and how it is managed in the UK today.

  • What it is

    Inward displacement of the tympanic membrane into the middle ear space, often the end result of long-standing Eustachian tube dysfunction.

  • Two anatomical types

    Pars tensa retraction (graded Sadé I to IV) and pars flaccida or attic retraction (graded Tos I to IV) - the attic form carries higher cholesteatoma risk.

  • Why it matters

    A deep or adherent retraction pocket can trap keratin debris and evolve into cholesteatoma, or erode the ossicles and cause conductive hearing loss.

  • Common trigger

    Chronic Eustachian tube dysfunction, glue ear, previous acute otitis media, adenoid hypertrophy, allergic rhinitis and smoke exposure.

  • How it is found

    Usually on routine otoscopy - many mild retractions are asymptomatic and picked up incidentally.

  • Foundation of care

    Treat the underlying tube problem, monitor mild cases, and consider grommets or cartilage tympanoplasty for progressive or symptomatic disease.

Why this guide matters

Watch closely, treat the nose, act before cholesteatoma.

Retraction pockets are quiet by nature. The three points below shape everything else on this page.

  • Grading is not optional

    Every retraction should be graded with Sadé or Tos - it decides who is monitored and who is offered surgery.

  • Treat the underlying tube

    Allergic rhinitis, adenoids, glue ear and reflux drive most retractions - fixing them protects the ear.

  • A pocket you cannot see is a problem

    When the base of the pocket cannot be inspected, surgical exploration or cartilage reinforcement usually wins over watchful waiting.

How the diagnosis is made

From routine otoscopy to a clear plan.

The steps a UK GP or ENT specialist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and otoscopy

    A structured look at the drum to grade the retraction using Sadé (pars tensa) or Tos (pars flaccida) classifications.

  2. 02

    Assessing

    Tympanometry

    A Type B or Type C trace supports Eustachian tube dysfunction or middle ear effusion behind the retracted drum.

  3. 03

    Assessing

    Pure tone audiometry

    Looks for conductive hearing loss - typical of Sadé III to IV or ossicular erosion, and useful for baseline comparison over time.

  4. 04

    Confirming

    Otomicroscopy and microsuction

    Specialist ENT review under the microscope with gentle microsuction to visualise the pocket, clear debris and rule out cholesteatoma.

  5. 05

    Confirming

    Eustachian tube function tests

    Valsalva and Toynbee manoeuvres, sometimes with pressure equalisation testing, to characterise the underlying tube problem.

  6. 06

    Preparing

    CT temporal bone if concern

    Reserved for suspected cholesteatoma, ossicular erosion or surgical planning - not routine for simple retractions.

  7. 07

    Preparing

    Regular ENT monitoring

    Six to twelve monthly review with otoscopic photography and audiometry to catch progression early.

Typical timeline: from routine examination to a graded plan within a few ENT visits.

Symptoms

What eardrum retraction actually feels like.

Often nothing at all in mild cases. When symptoms appear, they range from a blocked feeling to hearing loss, discharge and rarely dizziness.

  • Often asymptomatic

    Many mild retractions cause no symptoms and are picked up on routine ear examination.

  • Aural fullness

    A blocked or pressured feeling in the ear that does not clear with swallowing or yawning.

  • Conductive hearing loss

    More common with Sadé III to IV retractions, adherent pockets or ossicular erosion.

  • Tinnitus

    A low-level ringing or humming that reflects the middle ear pressure change or hearing loss.

  • Otalgia

    Intermittent ear ache, often worse with colds, flights or air pressure changes.

  • Discharge

    Suggests secondary infection or evolving cholesteatoma in a retraction pocket and needs urgent ENT review.

  • Vertigo

    Uncommon - when present it may point to ossicular or labyrinthine involvement and needs specialist assessment.

  • Red flag - cholesteatoma

    Foul-smelling discharge, keratin debris in the pocket or new facial weakness needs urgent ENT and imaging.

Treatment

How eardrum retraction is treated in the UK.

Monitor mild disease, treat the underlying Eustachian tube, and step up to grommets, cartilage tympanoplasty or mastoid surgery when the pocket progresses.

  • Observation and monitoring

    For mild Sadé I to II retractions with no symptoms and no cholesteatoma - six to twelve monthly ENT review with otoscopic photography and audiometry.

  • Treat the underlying tube

    Short-course decongestants, intranasal corticosteroids, autoinflation with an Otovent balloon, allergic rhinitis control and adenoidectomy in children.

  • Balloon Eustachian tuboplasty

    An emerging specialist ENT procedure that dilates the cartilaginous Eustachian tube to restore ventilation. See our guide to Eustachian tube balloon dilation.

  • Ventilation tubes (grommets)

    Standard or long-T tubes to drain fluid, equalise middle ear pressure and prevent further progression of the retraction.

  • Cartilage tympanoplasty

    Reinforcement of the drum with a cartilage graft to prevent progression and reverse retraction - a specialist otology procedure for progressive disease.

  • Excision of the retraction pocket

    For advanced retractions or when the pocket cannot be inspected or self-cleans poorly - combined with tympanoplasty to rebuild the drum.

  • Tympanomastoidectomy

    When cholesteatoma or ossicular damage is confirmed - clears disease from the middle ear and mastoid, often with ossicular reconstruction.

  • Hearing aid

    A conservative option for significant conductive hearing loss when surgery is not appropriate or has been declined.

What this guide is based on

The sources behind every claim on this page.

UK ENT guidance, otology society standards and the two classifications that shape day-to-day practice.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or ENT specialist can grade your retraction accurately and tell you which parts apply to you. If in doubt, get seen.

  • ENT UK. Position statements on chronic otitis media and Eustachian tube dysfunction.

  • British Society of Otology (BSO). Guidance on retraction pockets and cholesteatoma.

  • Sadé J. Classification of pars tensa retraction. Otolaryngologic Clinics.

  • Tos M. Manual of Middle Ear Surgery - grading of pars flaccida retraction.

  • NICE Clinical Knowledge Summaries. Otitis media with effusion.

Red flags

When retraction needs urgent attention.

Most retractions are stable and safely monitored. These are the situations that aren't - and where prompt ENT input matters.

  • Suspected cholesteatoma

    Keratin debris in the pocket, foul-smelling discharge or a self-cleaning failure - needs urgent ENT and often CT imaging.

  • New facial weakness

    Facial nerve involvement is a surgical emergency and warrants same-day ENT assessment.

  • Vertigo or imbalance

    Suggests labyrinthine or ossicular involvement and needs urgent specialist review.

  • Sudden hearing drop

    A significant change in hearing on the affected side needs prompt audiometry and ENT input.

  • Persistent discharge

    Discharge that does not settle with topical treatment points to chronic disease behind the retraction.

  • Adherent pocket you cannot see

    When the base of the pocket cannot be inspected under the microscope, surgical exploration is often the safer option.

  • Rapid progression

    Otoscopic photography that shows worsening depth or adherence over six to twelve months usually prompts intervention.

  • Ossicular erosion on imaging

    CT evidence of erosion of the incus or stapes changes the management to surgical reconstruction.

  • Child with cleft palate or Down syndrome

    Higher lifetime risk of chronic tube dysfunction and retraction - needs proactive ENT follow-up.

Living with it

A monitored condition, with a clear ladder.

Four things that make the biggest difference day to day - nasal care, autoinflation, watching for new symptoms and keeping your monitoring appointments.

A quiet reminder

A pocket you watch is a pocket you can act on.

Six to twelve monthly review is not a formality - it is what protects the middle ear from silent progression.

  1. 01 Routine

    Look after your nose

    Treat allergic rhinitis, sinus disease and reflux - the middle ear ventilates through the nose and pharynx.

  2. 02 Practice

    Autoinflation, done properly

    An Otovent balloon used two to three times daily has good evidence for glue ear and mild retractions in children and adults.

  3. 03 Watch

    Never ignore new symptoms

    New discharge, hearing drop, dizziness or facial weakness needs prompt ENT review - not a wait-and-see.

  4. 04 Follow-up

    Keep your monitoring appointments

    Regular otoscopic photography and audiometry are the safest way to catch quiet progression before cholesteatoma forms.

Frequently asked

Everything we get asked about eardrum retraction.

Quick answers on grading, monitoring, cholesteatoma risk and modern otology options.

  • What is an eardrum retraction?

    It is an inward displacement of the tympanic membrane into the middle ear space, usually driven by chronic Eustachian tube dysfunction. Mild retractions are common and often asymptomatic, but deeper or adherent pockets can trap debris and progress to cholesteatoma.

  • What are the Sadé and Tos gradings?

    They are the two classifications used to describe retractions. Sadé I to IV grades pars tensa retractions from mild inward bowing (I), to contact with the incus (II), contact with the promontory and adherence (III), and middle ear obliteration (IV). Tos I to IV grades pars flaccida or attic retractions - deeper Tos grades carry a higher risk of cholesteatoma.

  • Do all retraction pockets need surgery?

    No. Mild Sadé I to II retractions in a stable, self-cleaning ear are usually monitored with six to twelve monthly review, otoscopic photography and audiometry. Surgery is reserved for progressive disease, hearing loss, uninspectable pockets or suspected cholesteatoma.

  • Can it turn into cholesteatoma?

    Yes - this is the main reason ENT specialists follow these pockets. Deep, adherent or self-cleaning-poor pockets can accumulate keratin debris that becomes a cholesteatoma over time. That is why regular monitoring matters.

  • What is cartilage tympanoplasty?

    It is a specialist otology operation that reinforces a thinned, retracted or perforated eardrum with a cartilage graft, usually taken from the tragus or conchal bowl. It resists further retraction better than a soft graft and is often chosen for progressive retractions.

  • Does treating the nose actually help my ear?

    Yes. The middle ear ventilates through the Eustachian tube, which opens in the back of the nose. Controlling allergic rhinitis, sinus disease, adenoid enlargement and smoke exposure improves ventilation, and adjuncts such as autoinflation with an Otovent balloon have reasonable evidence in mild retractions.

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