Chronic Suppurative Otitis Media:

Tubotympanic Disease (CSOM TT, COM Mucosal

type)Dr. Krishna Koirala

2016-05-03

Definition

• Pyogenic infection of middle ear

cleft mucosa lasting for more than

3 months characterized by

persistent perforation of pars

tensa of tympanic membrane, ear

discharge and decreased hearing

Tubo-tympanic vs. Attico-antral

Perforations of Pars Tensa in CSOM TT

Involves only one quadrant or < 10% of pars tensa

Small perforation

Medium perforation

Involves two quadrants or 10 – 40 % of pars tensa

Large perforation

Retraction of pars Tensa of TM

Grade I retraction• Dull, lusterless T.M.• Prominent annulus• Cone of light absent• Prominent lateral

process• Handle of malleus

medialized• Malleal folds sickle

shaped

Grade II retraction

TM touches the incus

Grade III retraction

TM touches the promontory (atelectasis) but mobile on Valsalva

maneuver or Siegelization

Grade IV retraction

TM firmly adherent to promontory & immobile on Valsalva maneuver or Siegelization

Predisposing factors for CSOM TT

• Upper respiratory tract infection (recurrent)

• Upper respiratory tract allergy• Pre-existing otitis media with effusion• Cleft palate• Immune deficiency: diabetes, AIDS • Poor socio-economic status

Bacteria responsible

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Klebsiella

• Proteus

• Streptococcus

• Bacteroides

Routes of infection

1. Via Eustachian tube

– U.R.T.I., nose blowing,

regurgitation of milk

2. Via tympanic membrane perforation

– Following A.S.O.M. or post-

traumatic

3. Haematogenous (rare):

exanthematous fever

Pathological Changes1. Eardrum

– Central perforation; myringosclerosis

2. Ossicles– Destruction (hyperemic

decalcification)– Tympanosclerosis, Fibrosis +

Adhesions

3. Middle ear mucosa: edematous, pale, congested

4. Mastoid bone: sclerosis

Clinical Features• Ear discharge: intermittent, profuse,

mucoid to muco-purulent, whitish, odorless, not blood-stained

• Hearing Loss: – Usually conductive (25-50 dB) but

might be normal in small, dry perforations

– Round window shielding by ear discharge leads to better hearing in acute exacerbations

• Tympanic membrane: central perforation

Stages of Tubotympanic disease

Stage Otorrhoea

Eardrum perforatio

n

Last ear discharge

Active Present Present -

Quiescent

Absent Present < 6 months

Inactive Absent Present > 6 months

Healed Absent Absent -

Investigations for CSOM TTD

• Examination under microscope

• Ear discharge swab: for culture

sensitivity

• Pure tone audiometry

• Patch test• X-ray mastoid: B/L 300 lateral oblique

(Schuller) (Done when cortical mastoidectomy is required in CSOM TT not responding to antibiotics)

Examination under microscope• Confirmation of otoscopic

findings• Epithelial migration at

perforation margin• Cholesteatoma &

granulations • Adhesions &

Tympanosclerosis • Assessment of Ossicular

chain integrity• Collection of discharge for

culture sensitivity

Pure Tone Audiometry• Uses

– Presence of hearing loss– Degree of hearing loss – Type of hearing loss – Hearing of other ear – Record to compare hearing post-

operatively– Medico legal purpose

Patch Test• Performed when deafness is

around 40-50 dB– Do pure tone audiometry: for hearing

threshold – Put Aluminum foil patch over T.M.

perforation– Repeat pure tone audiometry

• Hearing improved Ossicular chain intact & mobile

• Hearing same / worse Ossicular chain broken or fixed

Treatment of CSOM Tubo-tympanic Disease

Non-surgical Treatment

• Precautions• Aural toilet• Antibiotics : Systemic & Topical• Antihistamines : Systemic & Topical• Nasal decongestants : Systemic &

Topical• Treatment of respiratory infection &

allergy• Tympanic membrane patcher

Precautions• Encourage breast feeding with child’s

head raised. Avoid bottle feeding

• Avoid forceful nose blowing

• Plug E.A.C. with Vaseline smeared

cotton while bathing & avoid

swimming

• Avoid putting oil , water or self-

cleaning of ear

•Done only for active stage•Dry mopping with cotton swab•Suction clearance: best method•Gentle irrigation (wet mopping)

• 1.5% acetic acid solution used T.I.D.• Removes accumulated debris• Acidic pH discourages bacterial

growth

Aural Toilet

Antibiotics•Topical Antibiotics:

• Ciprofloxacin, Gentamicin, Tobramycin

•Antibiotics + Steroid: for polyps, granulations

• Neosporin + Betamethasone / Hydrocortisone

•Oral Antibiotics: for severe infections

• Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

Antihistamines and Decongestants

• Antihistamines – Chlorphenirami

ne– Cetirizine– Fexofenadine– Loratadine– Levocetrizine– Azelastine

(topical)

• Systemic Decongestants–

Pseudoephedrine

– Phenylephrine• Topical

Decongestants– Oxymetazoline– Xylometazoline– Hypertonic

saline

Kartush T.M. Patcher• Indicated in:

– Perforation in only hearing ear

– Patient refuses surgery

– Patient unfit for surgery

– Age < 7 years

Surgical Treatment• Indicated in inactive or

quiescent stage–Myringoplasty –Tympanoplasty

• Indicated in active stage–Cortical Mastoidectomy–Aural polypectomy

Methods to close perforation• T.M. perforation < 2 mm

– Chemical cautery with silver nitrate

–Fat grafting

(Myringoplasty if these measures fail)

• T.M. perforation > 2 mm– Tympanic membrane patcher– Myringoplasty

Chemical cautery

Surgical Approaches to the middle ear

Wilde’s post-aural incision

Lempert’s end-aural incision

Rosen’s permeatal incision

Hearing Restoration• Myringoplasty

– Surgical closure of tympanic membrane perforation

• Ossiculoplasty– Surgical reconstruction of ossicular

chain• Tympanoplasty

– Surgical removal of disease + reconstruction of hearing mechanism without mastoid surgery

Principles of hearing restoration

• Intact tympanic membrane• Intact ossicular chain• Functioning receiving & relieving

windows• Acoustic separation of these windows• Functioning Eustachian tube• Absence of sensorineural hearing loss• Absence of active infection / allergy in

middle ear cleft

Myringoplasty

Surgical closure of perforation of pars tensa of Tympanic membrane without ossicular reconstruction

Aims• Permanently stop ear discharge : make

the ear dry and safe

• Improve hearing if ossicles are intact and mobile and there is absence of sensori-neural deafness

• Prevention of ongoing complications like further hearing loss, tympanosclerosis, adhesions, mucosal bands, vertigo

• Wearing of hearing aid• Occupational: military, pilots• Recreation: swimming, diving

Contraindications

• Purulent ear discharge

• Otitis externa

• Respiratory allergy

• Age < 7 yr (Eustachian tube not fully

developed)

• Only hearing ear

• Cholesteatoma

MethodsTechniques

• Underlay: graft placed medial to

fibrous annulus

• Overlay: graft placed lateral to fibrous

annulus

Grafts used

• Temporalis fascia, Tragal

perichondrium, Vein graft, Fascia lata,

Dura mater

Overlay Myringoplasty

Underlay Myringoplasty

Steps of underlay Myringoplasty

Tympanomeatal flap raised

Placement of graft

Tympanomeatal flap replaced

Why temporalis fascia?• Basal metabolic rate lowest (best

survival rate)

• Easy to harvest

• Large size graft can be harvested

• Autograft, so no rejection

• Same thickness as normal tympanic

membrane

• Good resistance to infection

Onlay UnderlayGraft cholesteatoma No

Blunting of anterior tympano-meatal angle

No

Lateralization of graft No

Delayed healing time (6 wk)

3-4 weeks

No middle ear inspection Possible

Difficult & takes more time

Easier & quicker

Advantages of Local Anesthesia

• Minimal bleeding

• Hearing results can be tested on

table

• Facial palsy detected immediately

• Labyrinthine stimulation detected

immediately

• No complications of General

anesthesia

Tympanoplasty

Types

Type Pathology Graft placed on

I Ear drum perforation only

Malleus handle

II Malleus handle eroded Incus

III Malleus + Incus eroded Stapes head

IV Only footplate remains: mobile

Footplate exposed

V Only stapes remains: fixed

Lateral SCC opening

VI Only footplate remains: mobile

Round window exposed

(Sono inversion )

Ossiculoplasty• Ossicular graft material

– Autograft • Ossicles : incus/malleus• Cartilage : Tragal/ conchal• Bone : spine of Henle/mastoid

– Homograft: ossicles/cartilage/bone– Biomaterials:

plastic(polyethylene)/ceramic/ teflon/gold

(Biomaterials available as PORP and TORP)