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Hearing
Hearing Research 236 (2008) 2232
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Research paper

Combined eect of uid and pressure on middle ear function

Chenkai Dai a, Mark W. Wood b, Rong Z. Gan a,*
a
School of Aerospace and Mechanical Engineering and Bioengineering Center, University of Oklahoma, 865 Asp Avenue,
Room 200, Norman, OK 73019, United States
b
Hough Ear Institute, Oklahoma City, OK 73112, United States

Received 22 June 2007; received in revised form 26 October 2007; accepted 9 November 2007
Available online 24 November 2007

Abstract

In our previous studies, the eects of eusion and pressure on sound transmission were investigated separately. The aim of this study
is to investigate the combined eect of uid and pressure on middle ear function. An otitis media with eusion model was created by
injecting saline solution and air pressure simultaneously into the middle ear of human temporal bones. Tympanic membrane displace-
ment in response to 90 dB SPL sound input was measured by a laser vibrometer and the compliance of the middle ear was measured by a
tympanometer. The movement of the tympanic membrane at the umbo was reduced up to 17 dB by the combination of uid and pressure
in the middle ear over the auditory frequency range. The uid and pressure eects on the umbo movement in the uidpressure com-
bination are not additive. The combined eect of uid and pressure on the umbo movement is dierent compared with that of only uid
or pressure change in the middle ear. Negative pressure in uidpressure combination had more eect on middle ear function than posi-
tive pressure. Tympanometry can detect the middle ear pressure of the uidpressure combination. This study provides quantitative
information for analysis of the combined eect of uid and pressure on tympanic membrane movement.
2007 Elsevier B.V. All rights reserved.

Keywords: Laser vibrometer; Middle ear mechanics; Otitis media; Temporal bone; Tympanometry

1. Introduction Several studies (Goodhill and Holcomb, 1958; Majima

Otitis media with eusion (OME) is dened as the pres-
ence of uid in the middle ear and is usually associated with
the middle ear pressure change because of poor Eustachian
tube function or an inammatory response following acute
otitis media. The amount of eusion in OME patients var-
ied from partially lling the middle ear to fully lling the
cavity. The properties of the eusion are highly variable
and related to the pathology process of OME. The middle
ear eusion is classied as serous, mucoid and glue-like
with dierent viscosities in various pathological processes
of OME. The high prevalence of OME and diculties in
diagnosis make the mechanisms behind middle ear function
change seen with OME an important issue in hearing
research.
*
Corresponding author. Tel.: +1 (405) 325 1099; fax: +1 (405) 325 1088.
E-mail address: rgan@ou.edu (R.Z. Gan).
et al., 1988; Ravicz et al., 2004; Gan et al., 2006; Dai
et al., 2007) have investigated possible mechanisms of hear-
ing loss associated with the presence of middle ear eu-
sions. Ravicz et al. (2004) suggested that the primary
mechanism responsible for hearing loss at low frequencies
was the reduction of middle ear compliance by a reduction
in the middle ear air volume. The increased mass of the
tympanic membrane (TM) by entrained uid caused the
hearing loss at high frequencies. In Gan et al.s study
(2006), the amount of uid in middle ear was manipulated
and the vibration of the TM and stapes were measured
with intact and opened cochlea in human temporal bones.
The displacement transmission ratio of the TM to footplate
was derived and the results show that the eect of uid on
middle ear function is dierent between three frequency
ranges.
The eect of middle ear pressure on TM mobility has
been investigated in human temporal bones and animals

0378-5955/$ - see front matter 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.heares.2007.11.005
 C. Dai et al. / Hearing Research 236 (2008) 2232
(Teoh et al., 1997; Lee and Rosowski, 2001; Rosowski and
Lee, 2002; Murakami et al., 1997; Dirckx and Decraemer,
1992; Huttenbrink, 1998; Gan et al., 2006; Dai et al., 2007).
The results of Murakami et al. and Gan et al. show that of
the middle ear pressure mainly decreased the TM move-
ment at low frequencies (f < 1k Hz).
In these published studies, the eects of middle ear
uid and pressure were investigated separately. The liter-
ature is lacking evidence that identies how combined
uid and air pressure in the middle ear aect the middle
ear function. In fact, the eusion in patients with OME
is commonly associated with negative pressure. We feel
that it is important to further investigate the combined
eect of pressure and uid on middle ear function in
order to explain the complex mechanisms behind these
combined eects.
In this study, we completed three groups of experiments
in which the middle ear pressure, uid, and uidpressure
combination were manipulated, respectively, in human
temporal bones. Saline solution was selected for simulation
of a serous eusion and 0.3 ml was found to be the critical
amount of uid which produced signicant changes in
umbo displacement in our previous studies of the OME
model in human temporal bones (Gan et al., 2006; Dai
et al., 2007). In those temporal bones, 0.3 ml uid lled
about half of the middle ear cavity and the uid level
was about to the umbo, which was observed under micro-
scope. The TM (umbo) displacement in response to 90 dB
SPL sound input in the ear canal was measured by a laser
Doppler vibrometer and the middle ear compliance change
under these three conditions was measured by
tympanometry.
2. Methods
2.1. Human temporal bone preparation
Four fresh-frozen cadaver temporal bones, obtained
through the Willed Body Program, University of Okla-
homa Health Sciences Center, were used in this study.
The ages of individual donors ranged from 50 to 93 with
a mean of 69 years (3 females and 1 male). To retard putre-
faction and maintain soft tissue compliance, the bones were
immersed in 1:10,000 Merthiolate in 0.9% saline solution at
5 C until use. All bones were used within 1 week of
acquisition.
Before acceptance into the study, each temporal bone
was visually inspected under an operating microscope
(OPMI-1, Zeiss, Thornwood, NY) to conrm a normal
ear canal and an intact TM, and the absence of overt
pathology. The four bones reported in this paper were all
from normal ears without evidence of pathology in the
middle ear after the post-experimental check.
The Eustachian tube (ET) meatus was identied at the
nasopharyngeal end. The cartilaginous portion of the ET
was then bisected and removed up to the boney meatus.
A soft silicone tube, outer diameter of 1 mm, with a white
23
tip was then advanced through the remnant of the ET into
the middle ear while visualizing the TM with an operating
microscope. Once the tip was visualized though the TM,
the tube was glued in place at the skull base using cyanoac-
rylate gel glue (Henkel Consumer Adhesives, Avon, OH).
The silicone tube was then connected to a syringe for inject-
ing uid into the middle ear cavity or adjusting the middle
ear air pressure to simulate a middle ear eusion or pres-
sure variation. The second silicone tube (2 mm outer diam-
eter, named the outow tube) was placed through a hole
that was drilled through the epitympanic tegmen, being
careful not to touch the ossicles. The tube was glued in
place and connected to a syringe and a U-tube manometer
through a three-way stopcock as shown in Fig. 1. The
manometer was used to measure middle ear pressure and
an attached syringe was used to release the middle ear
pressure.
All surgically opened areas were sealed airtight using
cyanoacrylate glue and silicone polymer (Reposil, DDI
Inc., Milford, DL). A leaking test was then conducted in
every bone using the procedure described by Gan et al.
(2006).
After the leaking test, a piece of laser reective tape of
0.5 mm2 and 0.04 mg (3M Co., St. Paul, MN) was placed
as a laser target on the lateral surface of the umbo. The
bone was wrapped in wet gauze (normal saline) to prevent
desiccation of the specimen during the experiment. Before
conducting any laser measurement on temporal bones, we
used a tympanometer (Zodiac 901, Madsen, GN Otomet-
rics, Denmark) to verify normal compliance of the tym-
panic membrane.
After all experiment measurements, a mastoidectomy
was performed by a facial recess approach to check the
middle ear cavity and mastoid. Among the four mastoids
in the temporal bones used in this study, two of them were
air-lled, one is diploetic, and the other one was mixed type
of the above two. Some brous tissues were found near the
aditus in two bones with air-lled mastoid. No substantial
amount of water was found in the mastoid processes of the
four bones.
2.2. Experimental setup with laser vibrometer
Fig. 1 shows the temporal bone experimental setup with
a laser vibrometer and a tympanometer, which was similar
to studies reported by Gan et al. (2006) and Dai et al.
(2007). Briey, the temporal bone was placed in a temporal
bone holder and the bone assembly was set on a vibration
isolation table. Pure tones at 90 dB SPL from a function
generator (Model 193, Wavetek, San Diego, CA) were
delivered to the ear canal near the TM by an inserted ear-
phone (Model ER-2, Etymotic Research, ELK, Grove Vil-
lage, IL). A probe microphone (Model ER-7, Etymotic
Research) used for monitoring the input sound pressure
level (SPL) was secured parallel to the sound delivery tube
and was positioned approximately 2 mm from the umbo
(Gan et al., 2001, 2004).
24 C. Dai et al. / Hearing Research 236 (2008) 2232
Fig. 1. Schematic of the experimental setup with laser vibrometer and tympnometry in human temporal bones.
A laser Doppler vibrometer (Model CLV-700, Polytec
PI, Tustin, CA) was used to measure the vibration of the
TM at the umbo. The heliumneon laser with an associated
positioner-aiming prism was coupled to an operating
microscope (Model OPMI-1FC, Zeiss). Velocity measure-
ments with the HLV were acquired in the frequency
domain by back-weighted averaging of a live, fast-Fourier
transform. A fast acquisition, multichannel, digitizing sig-
nal analyzer (Model DSA 601, Tektronix, Beaverton,
OR) was used for analysis of the spectral magnitude and
phase data from the laser vibrometer and all the data were
recorded on a personal computer. Only data with a total
harmonic distortion of less than 10% of pure tone signals
according to the distortion index shown on the signal ana-
lyzer were accepted. The peak-to-peak displacement (dpp)
of the umbo was directly calculated from the voltage out-
put of the laser vibrometer velocity decoder by a formula:
dpp = k(Avolt/pf), where Avolt is voltage amplitude in mv, f
is frequency in kHz, k is a constant related to selected scale
and calibration factor in unit of lm/mv/s (Gan et al.,
2001,2004).
A tympanometer (Zodiac 901, Madsen, GN Otometrics
Denmark) with a constant frequency of 226 Hz was used in
this study. The detailed tympanometric measurements in
human temporal bones were reported by Dai et al.
(2007). The tympanogram, a graphic display of acoustic
admittance with respect to ear canal pressure variation,
provides information about the mobility and integrity of
the middle ear using three parameters shown in the tym-
panogram: static compliance (SC), middle ear pressure
(MEP), and tympanometric width (TW). SC refers to the
greatest amount of acoustic energy absorbed by the middle
ear system presented in the vertical peak of the tympano-
gram. The MEP refers to the pressure in the ear canal cor-
responding to the peak of the tympanogram, which is
approximately equal to the middle ear pressure. TW refers
to the ear canal pressure range corresponding to a 50%
reduction in static compliance and presented in daPa (Onu-
sko, 2004).
2.3. Experimental protocols
The temporal bone was oriented approximately as a
patient would be seated at a hearing test. The control study
in which the middle ear pressure remained at zero with no
uid in the cavity was performed rst. Three types of
experiments were performed in temporal bones after the
control data were acquired. Although the eects of middle
ear pressure and uid alone have been studied by Gan et al.
(2006), Groups 1 and 2 experiments of either variable pres-
sures only or constant (0.3 ml) uid level in the cavity were
conducted for comparison with the combined eect of uid
and pressure in Group 3. OME patients commonly have
negative pressure in the middle ear; however, we studied
both positive and negative pressure changes to try to gain
a comprehensive understanding of the eects of pressure
changes on middle ear function. Therefore, in our Group
3 experiment, both positive and negative pressures were
combined with uid to complete the study. Both laser
and tympanometry measurements shared the same proto-
cols as follows. In Group 3 experiments, the uid amount
of 0.3 ml was selected because it was reported to be a crit-
 C. Dai et al. / Hearing Research 236 (2008) 2232 25

ical volume of uid in the middle ear, which caused signif- 2.3.3. Group 3 eect of combination of middle ear uid and
icant umbo movement change (Gan et al., 2006). In their pressure
experiments on temporal bones, the maximum amount of After the Group 2 experiment, 0.3 ml uid was kept in
uid to ll up the middle ear cavity was between 0.6 and the middle ear. The middle ear pressure was increased or
0.7 ml. With 0.3 ml about half of the middle ear cavity decreased from 0 to 10, 15, and 20 cm H2O, respec-
was lled, and the uid level was about to the umbo which tively. The displacement of the umbo was measured by
was observed microscopically during the experiment. laser vibrometer and the middle ear compliance change
Although such partially lling resulted in smaller decreases was measured by tympanometer at each pressure level.
in umbo displacement or velocity compared to the
decreases observed when the middle ear was completely 3. Results
lled as reported by Gan et al. (2006) and Ravicz et al.
(2004), we prefer to use 0.3 ml uid level as a standard Fig. 2 shows the mean spectral peak-to-peak displace-
amount of uid to see the uid and air combined eect ment of the TM at the umbo measured from four temporal
on middle ear function. bones in three groups with 0.3 ml middle ear uid or/and
positive pressures. The bold solid line is the TM displace-
2.3.1. Group 1 eect of middle ear pressure ment of control or zero uid and pressure in response to
The outow tube was connected to the U-tube manom- 90 dB sound input in the external ear canal at frequencies
eter. The middle ear air pressure was increased stepwise of 2008k Hz. The thin lines without symbols represent
from 0 to +10, +15, +20, then down to 0, 10, 15, the mean curves of TM displacement obtained in Group
20 cm H2O (1 cm H2O = 98 Pa), and nally, back to zero 1, in which positive air pressure was introduced in the mid-
using the syringe attached to the ET catheter. Displace- dle ear. The broken bold line shows the mean TM displace-
ment of the umbo was measured at each middle ear pres- ment curve of Group 2 (0.3 ml middle ear uid). The lines
sure level by laser vibrometer and the compliance was with symbols show the mean TM displacements curves of
measured by tympanometry. Group 3. Results from Group 1 show TM movement
decreased mainly at low frequencies (f < 2k Hz) and there
2.3.2. Group 2 eect of middle ear uid was no signicant reduction at high frequencies
Normal saline solution (0.3 ml) was injected into the (f > 2k Hz). Note that at frequencies from 6k8k Hz, the
middle ear cavity through the ET catheter with the outow umbo displacement in Group 1 was higher than the control
tube open to the atmosphere. The uid level was main- and interestingly, umbo displacement in response to 20 cm
tained in the cavity and visualized through the ear canal H2O middle ear pressure was higher than that in response
using a light microscope. Displacement of the umbo and to 10 cm H2O. In Group 2, the TM displacement was
the compliance of middle ear were measured by laser vib- almost the same as the control at low frequencies of 250
rometer and tympanometry, respectively. 450 Hz and decreased signicantly at high frequencies

100
Peak-to-Peak Displacement (m)

10-1

10-2
Control

Group 1 Group 2 Group 3

-3
10 +10 cm H 2 O 0.3 ml 0.3 ml@ +10 cm H 2O
+15 cm H 2O 0.3 ml@ +15 cm H 2O
+20 cm H 2O 0.3 ml@ +20 cm H 2O
-4
10
100 1000 10000
Frequency (Hz)

Fig. 2. Averaged peak-to-peak umbo displacement measured in four bones using a laser vibrometer in response to 90 dB SPL sound in the ear canal. The
curves with standard deviations represent control (bold solid line) and three experimental groups of positive pressure (Group 1, thin lines without symbol),
0.3 ml uid (Group 2, broken bold line) and combined uidpositive pressure (Group 3, solid lines with symbols).
26
100
PeaktoPeak Displacement (m)
10-1
10-2
Group 1
10-3
10-4
100
Fig. 3. Averaged peak-to-peak umbo displacement measured in four bones using a laser vibrometer in response to 90 dB SPL sound in the ear canal. The
curves with standard deviations represent control (bold solid line) and three experimental groups of negative pressure (Group 1, thin lines without
symbol), 0.3 ml uid (Group 2, broken bold line) and combined uidnegative pressure (Group 3, solid lines with symbols).
(f > 1k Hz). The TM displacements of Group 3 (thin solid
lines with symbols) decreased over all frequencies from the
control curve. Compared with Group 1, the umbo displace-
ment reduction in Group 3 was less at low frequencies
(f < 1k Hz), but signicantly more at high frequencies
(f > 2k Hz). Similar to Group 1, higher middle ear pressure
caused more umbo movement reduction at low frequencies
(f < 1k Hz), but less reduction was observed at high fre-
quencies (f > 2k Hz).
Fig. 3 shows the mean spectral displacement of the TM
at the umbo under conditions of uid or/and negative pres-
sure in the middle ear in Groups 1, 2 and 3. The curves
obtained in control and Group 2 are the same as those in
Fig. 2. In Group 1, negative middle ear pressures resulted
in decreases of umbo movement at low frequencies
(f < 3k Hz). The negative pressure shifted the umbo dis-
placement peak from 1k Hz at Control to 1.8k Hz. In
Group 3, umbo displacement was reduced at all frequencies
by the combination of uid (0.3 ml) and negative pressures.
At low frequencies (f < 1k Hz), the umbo displacement
reduction in Group 3 was less than that in Group 1. How-
ever, umbo displacement decreased signicantly at high fre-
quencies while no obvious change was observed in Group 1
(f > 2k Hz). There are some dierences for Group 3 results
at high frequencies (f > 2k Hz) between Figs. 1 and 2. The
TM displacements in Fig. 2 decreased a little more than
those in Fig. 1. Negative pressure had more eect on TM
movement than positive pressure.
Fig. 4 shows the TM movement changes relative to the
control (in dB) derived from the three groups in Fig. 2.
Solid lines with hollow symbols represent the umbo dis-
placement magnitude change in response to positive pres-
sure in Group 1. The umbo displacement magnitude
C. Dai et al. / Hearing Research 236 (2008) 2232
Control
Group 2 Group 3
-10 cm H 2O 0.3 ml 0.3 ml@ -10 cm H 2O
-15 cm H2O 0.3 ml@ -15 cm H 2O
-20 cm H2O 0.3 ml@ - 20 cm H2O
1000 10000
Frequency (Hz)
change mainly occurred at low frequencies (f < 1k Hz)
and 20 cm H2O middle ear pressure caused up to 10 dB loss
at frequencies below 1k Hz. No signicant change was
observed at frequencies of 26k Hz and the displacement
magnitude increased at frequencies >6k Hz. In Group 2
(bold solid line), umbo displacement magnitude increased
slightly to about 2 dB at 300 Hz and decreased signicantly
up to 1219 dB loss at high frequencies (f > 1k Hz). In
Group 3 (solid lines with solid symbols), umbo displace-
ment magnitude decreased across all frequencies of 200
8k Hz. At low frequencies (f < 1k Hz), 0.3 ml uid com-
bined with 10 cm H2O middle ear pressure caused 35 dB
loss while 0.3 ml uid and 20 cm H2O pressure caused 5
10 dB loss. At frequencies of 45k Hz, 0.3 ml uid com-
bined with 1020 cm H2O middle ear pressure caused 7
12 dB reduction of the umbo displacement. At low frequen-
cies (f < 1000 Hz), TM movement decreased more in
Group 1 than that in Group 3. At high frequencies
(f > 2k Hz), TM displacement decreases in Group 3 are
more than that in Group 1 and less than that in Group 2.
The results in Fig. 5 were derived from Fig. 3 and dis-
play the change of TM (umbo) displacement magnitude
related to the control data in the three experimental
groups. Similar to Fig. 4, signicant umbo displacement
reduction occurred at low frequencies (f < 1k Hz) in Group
1, when negative pressures were induced in the middle ear.
A 14 dB reduction was observed at low frequencies when
the middle ear pressure reached 20 cm H2O. At the high
frequencies (13k Hz), the umbo displacement reduction
was smaller than that at low frequencies. A slight increase
in umbo displacement magnitude occurred at frequencies
of 7k8k Hz. In Group 3, the combination of uid and neg-
ative pressures reduced umbo displacement at all frequen-
 C. Dai et al. / Hearing Research 236 (2008) 2232 27

10

Group 2
5
0.3 ml

Change in Magnitude (dB)

0

-5

-10

-15
Group 1 Group 3
+10 cm H2O 0.3 ml@+10 cm H2O
-20 +15 cm H2O 0.3 ml@+15 cm H2O
+20 cm H2O 0.3 ml@+20 cm H2O
-25
100 1000 10000
Frequency (Hz)
Fig. 4. Averaged changes of umbo displacement magnitude in dB measured from three experiments in the three groups of positive pressure (Group 1, solid
lines with hallow symbols), 0.3 ml uid (Group 2, bold solid line) and combined uidpositive pressure (Group 3, solid lines with lled symbols).

10

5 Group 2
0.3 ml
Change in Magnitude (dB)

-5

-10

-15
Group 1 Group 3
- 10 cm H2O 0.3 ml@ - 10 cm H2O
-20
- 15 cm H2O 0.3 ml@ - 15 cm H2O
- 20 cm H2O 0.3 ml@ - 20 cm H2O
-25
100 1000 10000
Frequency (Hz)

Fig. 5. Averaged changes of umbo displacement magnitude in dB measured from three experiments in the three groups of negative pressure (Group 1,
solid lines with hallow symbols), 0.3 ml uid (Group 2, bold solid line) and combined uidnegative pressure (Group 3, solid lines with lled symbols).

cies tested. Fluid combined with 20 cm H2O middle ear
pressure caused 611 dB loss at low frequencies (200
500 Hz) and a maximum of 14 dB loss at 2.7k Hz. Umbo
displacement changes in Group 1 and 3 in Fig. 5 at high
frequencies were larger than those in Fig. 4.
Fig. 6 shows the tympanometric results of middle ear
pressure (MEP), static compliance (SC) and tympanomet-
ric width (TW) under control and three experimental
groups. Fig. 6A illustrates that the tympanometric MEP
values are almost equal to the middle ear air pressure
directly read from the manometer (1 cm H2O  10 daPa)
in all tested ears. Fig. 6B shows the mean SC (in ml) values
for control and experimental groups. The Control SC value
was about 0.58 ml and the SC value decreased slightly to
0.41 (still in normal range) when the middle ear pressure
increased to 20 cm H2O in Group 1. The mean SC value
in Group 2 was 0.52 ml, almost equal to the Control value.
In Group 3, the SC values (hollow squares) decreased
slightly when 0.3 ml uid combined with +10, +15 and
+20 cm H2O air pressures was induced into the middle
ear. Fig. 6C shows the TW changes in Control and exper-
imental groups. The TW value (in daPa) was about 80 in
control. No signicant change was observed in Group 1
(hollow triangle) or Group 2 (circle). The TW value
increased when uid combined with negative pressures
was introduced in the middle ear.
28 C. Dai et al. / Hearing Research 236 (2008) 2232

300 that by middle ear uid alone. The results also show that
Mean SE (Control) the combination of uid with negative pressure had more
200 Mean SE (Group 1) eect on umbo movement than positive pressure. This indi-
MEP (daPa)

Mean SE (Group 2) cates that the inuence of negative and positive pressure in
100
Mean SE (Group 3) combination with uid in the cavity on TM movement is
0 not the same.
The tympanometric results show that the MEP can pre-
-100
dict the middle ear pressure changes with the combination
-200 of uid and pressure. No signicant change of middle ear
static compliance (SC) as middle ear pressure changes
-300 (Fig. 6B) does not mean the middle ear compliance is inde-
-25 -20 -15 -10 -5 0 5 10 15 20 25
pendent of pressure. However, this indicates that the pri-
2.0 mary reason for the change in compliance is a change in
1.8 middle ear static pressure as measured by laser Doppler
Mean SE (Control)
1.6 vibrometer in temporal bones with zero ear canal pressure.
Mean SE (Group 1)
1.4 The uid has little eect on the tympanometric static com-
Mean SE (Group 2)
SC (ml)

pliance (Fig. 6), which is consistent with the umbo displace-

1.2 Mean SE (Group 3)
1.0
ment measurement at low frequency (i.e., 200 Hz) shown in
0.8
Figs. 4 and 5. The introduction of positive or negative mid-
0.6
dle ear pressure shifts the tympanogram peak to the right
or left and reduces compliance at zero ear canal pressure.
0.4
This is consistent with the umbo displacement measured
0.2
in temporal bone in Figs. 4 and 5, and reported by Dai
0.0
-25 -20 -15 -10 -5 0 5 10 15 20 25 et al. (2007) in previous study. In the clinical setting, the
tympanograms of OME patients are at without a tympa-
250 nometric peak. The tympanometric peak shown in the
measurements in the experimental partially lled ears indi-
Mean SE (Control)
200 cates the articial conditions which is dierent from the
Mean SE (Group 1)
TW (daPa)

Mean SE (Group 2) measurements in OME patients. However, tympanograms

150 Mean SE (Group 3) from patients with air/uid levels often show a slight peak.
The experimental data measured from four temporal
100 bones in this study was rst compared with the results
reported by Gan et al. (2006) from seven bones when the
50 middle ear pressure was varied or 0.3 ml of saline was
infused into the middle ear cavity (Figs. 3 and 9 in Gan
0 et al.s paper, 2006). As can be seen in Fig. 7, the displace-
-25 -20 -15 -10 -5 0 5 10 15 20 25
Middle ear pressure (cm H2O)
ment curves obtained in this study at control (without uid
and zero middle ear pressure), 0.3 ml uid in the cavity
Fig. 6. Averaged tympanometric data in response to variation of pressure (Group 2), and 20 cm H2O of middle ear pressure (Group
and uid in control and three experimental groups. (A) Middle ear 1) are in good agreement with Gan et al.s (2006) results.
pressure (MEP) data in daPa, (B) static compliance (SC) data in ml, (C) This indicates our experimental setup was reliable for the
tympanometric width (TW) data in daPa.
uidair pressure combination study.
Furthermore, we compared the results from our Group
4. Discussion 2 in this present study with the results from comparable
studies by Ravicz et al. (2004). The frequency range cov-
4.1. Summary of results and comparison with published data ered by Ravicz et al. was up to 3k Hz while the current
study measured up to 8k Hz. There were some variations
Results of this study show that the umbo movement was between our data and Ravicz et al.s (2004) results, but
reduced by a combination of uid and pressure at all fre- the measurements reported here generally agree with the
quencies. At low frequencies (f < 1k Hz), the TM move- data obtained by Ravicz et al.
ment reduction caused by the combination of middle ear The eect of graded variations in middle ear pressure on
uid and pressure (Group 3) was higher than that by mid- umbo movement in human temporal bones was also
dle ear uid alone (Group 2), but less than that by middle reported by Murakami et al. (1997). They used a video
ear pressure alone (Group 1). At high frequencies measuring system to detect umbo displacement when a
(f > 2k Hz), the umbo displacement reduction by the com- constant sound pressure of 134 dB was delivered at the
bination of uid and pressure was more signicant than TM across the frequency range of 200 to 3.5k Hz. In our
that by middle ear pressure alone, but less signicant than Group 1 experiment of middle ear pressure, the umbo
 C. Dai et al. / Hearing Research 236 (2008) 2232 29

10 0

Peak-to-Peak Displacement (m)

10 -1

10 -2
This work (Control)
This work (0.3 ml saline)
Gan et al., 2006 (Control)
10 -3
Gan et al., 2006 (0.3 ml saline)

10 -4
100 1000 10000
Frequency (Hz)

10 0
Peak-to-Peak Displacement (m)

10 -1

10 -2
This work (+20 cm H2 O)
This work (-20 cm H2 O)

10 -3 Gan et al., 2006 (+20 cm H2 O)

Gan et al., 2006 (-20 cm H2 O)

10 -4
100 1000 10000
Frequency (Hz)

Fig. 7. Comparison of the data obtained from this study with the published results by Gan et al. (2006). (A) Umbo displacements measured in control and
lled with 0.3 ml saline in the middle ear cavity (Group 2). (B) Umbo displacements measured in bones with middle ear pressure of +20 cm H2O and
20 cm H2O, respectively.

displacement had a signicant reduction at frequencies
below 1.5k Hz which is similar to Murakami et al.s results.
The experimental measurements (Group 3) were com-
pared with clinical data and are illustrated in Fig. 8. Pure
tone air and bone conduction audiometric thresholds at
standard frequencies (0.25, 0.5, 1, 2, 4 kHz) were obtained
from 30 OME patients in the private clinical practice of Dr.
Mark Wood (co-author). The 30 patients were diagnosed
with OME by otoscopy and tympanometric acoustic reex
testing in a sound booth. The averaged age of the 30
patients was 56 years old ranging from 23 to 72 (14 male
and 16 female). Fig. 8A shows the averaged airbone gap
data from the 30 patients who had middle ear eusions
examined by the pneumatic otoscopy. None of the patients
had other middle ear pathology or a history of ear surgery,
and none of the middle ear eusions were associated with
clinical signs of infection. All patients complained of acute
or sub-acute hearing loss (3 weeks to 3 months) and most
of the tympanic membranes appeared to be retracted.
None of the middle ears had bubbles or observable air
uid levels, thus it was concluded that the middle ear was
lled with uid.
Fig. 8A shows the hearing loss in the OME patients is
higher at 250 Hz and 4k Hz than that at 500, 1k, 2k or
3k Hz. This change was similar to the displacement reduc-
tion shown in Fig. 8B and C (0.3 ml uid and 20 cm H2O
combination) except that the airbone gap was highest at
250 Hz and the highest reduction in our temporal bones
occurred at 3k Hz. The averaged conductive hearing losses
collected from 30 OME patient ears were larger than the
umbo displacement reduction measured from temporal
bones. These clinical ndings dier from the results of tem-
poral bones (Fig. 8B and C) and those of Gan et al. (2006)
and Ravicz et al. (2004) in the amount of low frequency
30 C. Dai et al. / Hearing Research 236 (2008) 2232

A
35

30
Air-bone Gap (dB)

25

20

15

10

0
250 500 1K 2K 3K 4K
Frequency (Hz)

B
16
Displacement Reduction (dB)

14
12
10
8
6
4
2
0
250 500 1K 2K 3K 4K 6K 8K
Frequency (Hz)

-10 cmH2O -15 cmH2O -20 cmH2O

C
Displacement Reduction (dB)

16
14
12
10
8
6
4
2
0
250 500 1K 2K 3K 4K 6K 8K
Frequency (Hz)
+10 cmH2O +15 cmH2O +20 cmH2O

Fig. 8. Airbone data obtained from 30 OME patients and umbo displacement reduction measured from temporal bones in Group 3 experiments. (A)
Mean airbone gap data from 30 OME ears at frequencies of 250, 500, 1k, 2k, 3k and 4k Hz. (B) Data extracted from Group 3 results of Fig. 5 (combined
uid and negative pressure) at frequencies of 250, 500, 1k, 2k, 3k, 4k, 6k, and 8k Hz. (C) Data extracted from Group 3 results of Fig. 4 (combined uid and
positive pressure) at frequencies of 250, 500, 1k, 2k, 3k, 4k, 6k, and 8k Hz.

conductive hearing loss that is recorded in the clinical set- eects of viscosity, inammation and pressure dierences
ting. These dierences may reect the small amount of uid which are not measurable within the scope of the clinical
volume that was used in this experimental setup, the chro- setting. Other eects which may result in more low fre-
nicity of the uid noted in our clinical patients, the possible quency loss in the clinical setting include chronic eects
 C. Dai et al. / Hearing Research 236 (2008) 2232
on the tympanic membrane, such as stretching, entrained
uid or thickening of the inner membranous layer and
the possibility of eects on the ossicular chain. However,
Fig. 8A shows the OME patients have about 27 dB loss
at high frequencies (4k Hz) and that is similar to the results
of Gan et al. (2006) when the temporal bone model was
lled with uid. The similar results between a lled middle
ear cavity and clinical OME patients indicate that the uid
was the primary cause of hearing loss in OME patients and
this was veried by recovery of hearing loss when the uid
was drained in these patients.
The volume of the tympanic cavity in humans ranges
between 0.5 and 2 ml. The maximum volumes were found
to be 0.60.7 ml in the post-experiment check of the four
bones used in this study. In this experimental setup, the
uid amount of 0.3 ml was selected since it was the critical
amount that caused signicant umbo movement change in
the previous study reported by Gan et al. (2006). In this
preliminary study for understanding the eect of uid
and pressure combination on umbo movement, the selected
0.3 ml uid volume in the middle ear might also show some
critical eect on middle ear function. In fact, the results
obtained from Group 3 show that 0.3 ml is most sensitive
to the umbo movement reduction. However, we realized
that partially lling the temporal bones does not predict
the hearing loss from patients who have hearing levels con-
sistent with completely lled ears. It is similar to the work
of Ravicz et al. (2004) in which they provided a good model
for hearing loss in patients with uid lled middle ears, but
not good for assessing hearing loss in patients with par-
tially lled middle ear. So it is not surprising that in the
present study, which partially lled the middle ear cavity,
the model did not demonstrate the same amount of hearing
loss as is seen in patients who had completely lled middle
ears (Fig. 8). In future temporal bone studies, larger
amounts of uid will be used in the middle ear along with
pressure to simulate OME in the clinical setting.
4.2. Possible mechanism of combined eect on middle ear
function
At low frequencies, the umbo displacement reduction by
the combination of middle ear uid and pressure was less
than that by pressure alone (Figs. 25). One possible expla-
nation is the combined changes of TM stiness with the
uid and air pressure in the middle ear. Stiness of the
TM increased when the middle ear pressure increased
and the mobility of the umbo was decreased at low fre-
quencies, where the stiness of the TM dominated its
motion. According to the report by von Unge et al.
(1995), OME seems to decrease the stiness of TM
promptly and it may relate to the edema. When uid was
present in the middle ear and attached to the TM, the water
entrained in TM may result in the stiness decrease of the
TM. Thus, the stiness of the TM in uidpressure combi-
nation was lower than that in pressure alone case, and the
displacement reduction of the umbo was accordingly lower
31
in uidpressure combination case (Group 3). Ravicz
et al.s (2004) study indicated that a uid-related reduction
in middle ear compliance due to a reduction in middle ear
air volume was another possible explanation for the reduc-
tion at low frequencies. At low frequencies, changes of
movement of the umbo is compliance-dominated in the
normal state and continues to be compliance-dominated
as the middle ear air volume is changed by uid (Ravicz
et al., 2004).
At high frequencies, the displacement reduction of the
TM was mainly caused by uid in the middle ear as
reported by Gan et al. (2006). The main mechanism behind
this reduction seemed to be the increased TM mass by
entrained uid. Compared with middle ear uid alone,
the reduction of umbo displacement by uidpressure com-
bination was smaller. This observation reects the inuence
of middle ear pressure on umbo displacement reported by
Gan et al. (2006) and shown in Figs. 2 and 3 of present
study. The peak frequency of the displacement curve was
shifted toward the high frequencies when middle ear pres-
sure was changed, which helped to release the displacement
reduction at high frequency. Thus, the mobility of the
umbo in uidpressure combined state was lightly better
than the uid only case at high frequencies.
The laser measurements displayed in Figs. 4, 5 and 8
show some dierences between positive and negative pres-
sure eects on TM or umbo movement. For example,
0.3 ml middle ear uid combined with 20 cm H2O pres-
sure caused 12 dB loss at 300 Hz and 15 dB at 3k Hz while
0.3 ml uid with +20 cm H2O pressure caused 9 and 11 dB
at the 300 Hz and 3k Hz, respectively. The reason for
more reduction by negative pressure in the uidpressure
combination may be due to the air volume change in
the middle ear cavity in response to pressure variation.
Positive middle ear pressure increases the tympanic space
air volume by pushing the TM laterally and negative pres-
sure decreases this volume by retracting the TM medially.
This phenomenon was similar to the observation by
Murakami et al. (1997). Calculated from the data in Figs.
2 and 3, the increased cavity volume by 20 cm H2O pres-
sure was about 0.005 ml, about 0.9% of the whole normal
middle ear cavity, and 20 cm H2O pressure only caused
0.6% middle ear cavity decrease. Thus, the small dierence
of the TM motion between positive and negative pressures
may not completely, but slightly relate to the small cavity
volume change by middle ear pressure. At low frequencies
of 250 and 500 Hz, the umbo displacement reduction
(Fig. 7B and C) increased when the pressure in the middle
ear varied from 10 to 15 and 20 cm H2O. At frequen-
cies of 4k and 6k Hz, the umbo displacement reduction
increased as the pressure varied from 10 to 15 and
20 cm H2O (Fig. 7B) while the umbo displacement
reduction decreased as pressure changed from 10 to 15
and 20 cm H2O. A possible explanation for the dierent
eect of negative and positive pressure is the geometric
changes of the TM induced by dierent pressure
variations.
32 C. Dai et al. / Hearing Research 236 (2008) 2232
5. Conclussion
Both laser interferometry and tympanometry were used
to detect the combined eects of uid and pressure changes
on middle ear function. The combination of uid and pres-
sure reduced the TM (umbo) movement at all audible fre-
quencies tested. The uid and pressure eects on the umbo
movement are not additive in the uidpressure combina-
tion. The combined eect of uid and pressure on TM
movement is dierent from that of uid or pressure only
in the middle ear. The negative pressure in the uidpres-
sure combination has more eect on umbo movement than
that of positive pressure. Tympanometry can detect the
middle ear pressure of the uidpressure combination. This
study provides useful, quantitative information for analysis
of the combined eect of uid and pressure on TM move-
ment. The mechanism behind TM movement reduction by
a combination of middle ear uid and pressure variations
needs further studies.
Acknowledgments
This work was supported by NIH/NIDCD Grant
R01DC006632. The authors thank Don Nakmali at Hough
Ear Institute for his expert technical help.
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