A retracted eardrum, also known as tympanic membrane retraction, is a condition when the eardrum becomes retracted or is pulled back to the middle ear cavity (retraction pocket). Around 8%-10% of children have a mild version of a retracted eardrum worldwide. 

Generally, your eardrum is cone-shaped, and it slightly dips at the centre towards the middle ear. In a retracted eardrum, however, the eardrum dips a lot more towards the middle ear, making the dip more pronounced.^1,2

Causes of retracted eardrum

There are several causes of a retracted eardrum. Normally, the outside air pressure should stay the same as the air pressure inside your ears. Any changes in the balance, such as a fast change in the air pressure, cause a vacuum-like effect which pulls your eardrums towards the middle of the ear.^{3, 4, 5}

Negative middle ear pressure

• Eustachian Tube Dysfunction - Most common cause of retracted eardrum, and it causes a block in the tube connecting the middle part of your ears to the upper throat. 
• Allergies and Sinus Infections
• Barotrauma - Caused by the disruption in the eustachian tube by environmental changes, making the air pressure inside below normal and putting pressure in the middle part of the ear, forming a bulge. 
• Otitis Media - caused by an infection in the middle of the ear. Middle part of the ear may appear red and swollen with a build-up of a clear coloured fluid because of the inflammation.

What are the symptoms?

Most symptoms appear when the eardrums pull back just enough to add pressure on very small bones in the middle of the ear (ossicles). You may experience:¹

• Hearing Loss (permanent hearing loss is less common)
• Ear Pain
• Pressure in your ears
• Ear drainage (otorrhea)
• Tinnitus

How severe can a retracted eardrum get? 

The severity of eardrum retraction can be varied, and doctors may use levels/stages to help understand at what stage you may be in:²

• Stage 1 - Bones of the middle ear are not in contact with the ossicles
• Stage 2 - The eardrum is retracted and touching the ossicles
• Stage 3 - Retracted eardrum causes a narrow middle ear 
• Stage 4 - A chronic infection causes the retracted eardrum to be stuck in the middle ear cavity

How is it diagnosed?

For your doctor to confirm a retracted eardrum, they will conduct a few diagnostic tests that will help to diagnose you promptly:^6,7,8

• Otoscopy -  A test that uses a device which allows the doctor to look at different directions, examining the ear and the eardrum
• Tympanometry - tests the middle ear, allowing the doctor to see how well the middle ear is working by measuring the movement of the eardrums.
• Audiometry - also known as the hearing tests. Tests how well you can hear sounds, and it is based on how loud the sounds are and the the tone of the sounds by measuring it in decibels.

Are there any complications and risks?

Without any kind of treatment, the eardrum retraction can lead to a ruptured eardrum and from that, it can progress to hearing loss. Another complication and risk that you may experience if not having any treatment is cholesteatoma. This is a cyst that is formed in the retraction pocket from the build-up of earwax in the middle ear. You can experience signs similar to those of a ruptured eardrum, which is why it is important to consult the doctor if you experience any discomfort in the ears. If cholesteatoma is left untreated, then the growth of the cyst can affect your ability to hear, resulting in permanent hearing loss. This infection can then spread into the inner ear and or affect the brain, causing more serious infections, such as meningitis, vertigo and facial paralysis.⁹

What are the treatment options?

Watchful waiting 

In certain cases, a retracted eardrum will not need treatment. Your doctor may recommend you monitor the condition until the pressure inside the ear has returned to normal, which can take some time or a few months. So, during this time, your doctor will be keeping an eye on your symptoms. Some exercises can also be recommended by the doctor, such as the Valsalva manoeuvre, to get the pressure back to normal.¹⁰

In more severe cases, however, there may need the use of medications and or surgery.

Medical management

• Decongestants - to relieve congestion and stuffiness 
• Nasal Steroids - reduce inflammation
• Antibiotics - for treatment of infection

Surgical intervention

If the retracted eardrum is pressed against the ossicles and interferes with your ability to hear, then surgery will be recommended by your doctor. More common surgeries include:

• Tympanoplasty - Technique to remove the retracted part from the middle ear and reconstruct the eardrum. 
• Tympanostomy Tubes - This is when the doctor places tubes in your eardrum during the Myringoplasty procedure, which is a technique that helps to equalise the pressure inside your ears. 

How can you prevent it?

 It is not possible to prevent a retracted eardrum from developing, because it is usually something you cannot control.

You can, however, reduce the risk of barotrauma through the use of earplugs or taking decongestants before travelling by plane.¹

What is the prognosis and long-term outlook?

 It is varied for everyone; some people may experience improvement in only 1 week and others in a few months. Post-surgery, it takes up to 2-3 months for the wounds to heal, but the overall outlook is good if you get treatment at the right time.¹⁰

Summary

A retracted eardrum is a fairly common condition that can happen to anyone at any time, from children to adults. In some cases, you may experience milder symptoms, and in other cases, you may show more severe symptoms that can also be treated and healed within a few months. But, more severe cases may need medical attention and require surgery or decongestant and antibiotics, as it can cause permanent damage to your hearing and make you suffer from chronic pain, leading you to more severe complications such as cholesteatoma. So, it is important to seek medical help when needed and at the right time.