# Posterior Quadrants and Malleolar Perforations as Key Predictors of Hearing Loss in Chronic Otitis Media: A Clinicoradiological Correlation

## TL;DR

This study finds that the location and size of eardrum perforations in chronic ear infections strongly affect hearing loss, with posterior areas being most impactful.

## Contribution

The study identifies posterior quadrants and malleolar perforations as key predictors of hearing loss in chronic otitis media, beyond just perforation size.

## Key findings

- Posterior quadrant perforations and malleolar involvement are strongly linked to greater hearing loss.
- Four-quadrant perforations showed the highest air-bone gap (32.47 dB).
- Perforation site was a stronger predictor of hearing loss than size.

## Abstract

Introduction

Chronic otitis media (COM) of the mucosal type, characterized by a central tympanic membrane (TM) perforation, is a common cause of preventable conductive hearing loss in developing countries. While the impact of perforation size on hearing loss is established, the independent and combined roles of perforation site, malleolar involvement, and mastoid pneumatization remain underexplored. The primary objective of the study is to assess the relationship between hearing loss and the size and site of TM perforation. The secondary objective is to assess the effect of the duration of discharge and mastoid bone pneumatization on hearing loss.

Methods

This prospective observational study was conducted over a period of two years, during which a total of 210 ears from 161 patients with inactive mucosal COM were evaluated. TM perforations were categorized by size (small ≤4 mm, medium 4-8 mm, large >8 mm) and site (anterosuperior (AS), anteroinferior (AI), posterosuperior (PS), posteroinferior (PI), umbo). Pure-tone audiometry was used to measure the air-bone gap (ABG), and radiological assessments (Schuller’s view) were used to evaluate mastoid pneumatization. Statistical analysis included analysis of variance (ANOVA), t-tests, chi-square tests, and two-way ANOVA.

Results

Larger perforations, and those involving posterior quadrants, showed significantly greater ABGs (p < 0.001). Among single-quadrant perforations, PS (23.9 ± 7.6 dB) and PI (19.3 ± 7.6 dB) had the highest hearing loss. Four-quadrant perforations had the greatest ABG (32.47 ± 9.04 dB). Malleolar perforations were associated with higher ABG (29.26 ± 9.4 dB) than non-malleolar perforations (18.25 ± 8.7 dB). Two-way ANOVA revealed site as a stronger predictor of hearing loss than size. Duration of discharge and reduced mastoid pneumatization further exacerbated hearing loss.

Conclusion

Posterior site and larger size of TM perforations independently contribute to significant hearing loss. Incorporating perforation characteristics and radiological findings can improve diagnostic precision, guide surgical planning, and enhance patient outcomes in COM.