csom (chronic suppurative otitis media)
DESCRIPTION
CSOM is the most common cause of deafness in developing countries like Nepal.TRANSCRIPT
Dr.Ramesh Parajuli
CSOM/COM: Definition
• Chronic (> 3 months) infection of middle ear cleft mucosa characterized by perforation of tympanic membrane, ear discharge (continuous or intermittent) & decreased hearing.
• Most likely a result of earlier AOM, negative
middle ear pressure or OME
• Most important cause of hearing impairment in rural population
Types of CSOM1.CSOM -Tubotympanic (Mucosal): Safe type
2.CSOM-Atticoantral (Squamous): Unsafe type
• COM T T (Mucosal):
Inactive: Central perforation of pars tensa, Dry (middle ear mucosa not inflmmed)
Active: Central perforation of pars tensa associated with discharge or granulation tissue
Stages of COM
• COM AA (Squamous): Inactive: Retraction of tympanic
membrane(pars flaccida or tensa)
Active: Attic perforation, marginal peforation associated with discharge/cholesteatoma/granulation tissue
Retraction of pars tensa Retraction of pars flaccida
cholesteatoma & granulation tissue
Predisposing factors for CSOM
• URTI
• Allergy
• Pre-existing otitis media with effusion(OME)
• Eustachian tube dysfunction
• Negative middle ear pressure
• Cleft palate
• Immune deficiency
• Poor socio-economic status
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Klebsiella
• Proteus
• Streptococcus
• Bacteroides
• E.coli
Bacteriology of CSOM
Routes of infection for CSOM-TT
1.Via Eustachian tube: URTI, nose blowing, regurgitation of milk
2.Via tympanic membrane perforation:
Following AOM or post-traumatic
3.Haematogenous (rare):
Viral exanthematous fever
Clinical Features of CSOM-TT
Symptoms:Recurrent Ear discharge: profuse,mucopurulent,
intermittent, odourless, not blood-stained
Hearing Loss: usually conductive (25-50 dB)
Signs:
• Ear discharge• Perforation of pars tensa• Middle Ear Mucosa –
Oedematous• Granulation tissue/aural
polyp
Natural history of CSOM TT
I. Progression towards healing
II. Progression with continued activity •Further hearing loss•Ossicular damage•Complications•Secondary acquired cholesteatoma
Investigations for CSOM-TT
• Examination under microscope (EUM)• Ear discharge swab: for culture sensitivity• Pure tone audiometry (PTA)
(I) Medical treatment:
Active stage
Topical antibiotics with aural toilet: Ocupol-D/Betnor ear drops
Oral antibiotics: Ciprofloxacin, Amoxycillin
Inactive stage:Aural Precautions
Treatment of CSOM-TT
(II) Surgical treatment
Myringoplasty: Aims 1.To make ear dry 2.To improve hearing 3.Occupation 4.Recreation 5.To prevent
complications 6.Hearing aid
Graft materials 1.Temporalis fascia 2.Cartilage (Tragal, Conchal)3.Fat 4.Vein5.Canal skin6.Split Thickness Skin Graft 7.Composite
cartilage/perichondrium8.Pericardium, Dura
Approach
1. Postaural Approach
2. Transcanal(permeatal) Approach
3. Endaural Approach
Underlay technique
Post operative instructions
To insure proper healing, avoid the following:
Avoid Blowing nose Sneezing open mouth sneezing Exposing ear to water Flying: for 3 months Heavy weight lifting and straining Return of hearing may take up to 6 - 8
weeks PTA after 3 months
CSOM Attico-antral(Squamous)
Cholesteatoma
• Definition: Sac lined by keratinising squamous epithelium (KSE) containing desquamated epithelial debris in the middle ear cleft ,which has bone eroding property.
• Hallmark: Retention of desquamated keratin debris
• Narrow neck and inner surface of sac continuously produce keratin Desquamated dead keratin collects in & sac expands
• Misnomer: Not a tumor & has no cholesterol
Histologically made up of:1.Center: Desquamated epithelial debris(keratin)2.Matrix: Keratinizing stratified squamous epithelium(KSE)3.Perimatrix: Granulation tissue in contact with bone
perimatrix
Causes of bone erosion/destruction in cholesteatoma
1.Enzymatic theory: Osteoclastic bone resorption due to release of various enzymes: Acid phosphatase Collagenase Acid proteases Proteolytic enzymes Leukotrienes Cytokines2. Pressure necrosis3. Pyogenic osteitis
Classification Types of cholesteotoma1. Congenital 2. Acquired (I) Primary: Occurs where there is no previous
history of ear discharge (II)Secondary:Occurs in already diseased ear i.e.
CSOM-TT (III)Tertiary (Implantation): iatrogenic eg. post-
tympanoplasty
Theories of origin of cholesteatoma
1. Theory of invagination (retraction pocket) (Wittmaack’s)
2. Theory of epithelial invasion (Habermann’s)
3. Theory of basal cell hyperplasia (Ruedi’s)
4. Theory of squamous metaplasia (Sade’s)
Congenital cholesteatoma
Embryonal Squamous epithelial cell rests fails to disappear during developmentPersistence in middle ear, petrous apex, CPA angle
Clinical Features1. Ear discharge: scanty, purulent, continuous, foul- smelling,
blood-stained
2. Hearing Loss: conductive or mixed
3. TM perforation: attic or marginal; or central perforation with
inward growing epithelium towards middle ear
4. TM retraction pocket:
5. Cholesteatoma flecks
6. Aural polyp & granulation tissue
Features of Complications
• Severe otalgia, painful swelling around ear• Vertigo, nausea, vomiting• Headache + blurred vision + projectile vomiting• Fever + neck rigidity + irritability / drowsiness• Facial asymmetry • Gradenigo syndrome (apex petrositis)• Ataxia
Aural polyp
PSQ cholesteatoma & granulation tissue
Attico-antral(squamous) Tubo-tympanic(mucosal)
Quantity/Amount of discharge:Scanty Profuse
Continuous IntermittentCharacter: Purulent Mucoid
Blood-stained No
Smell: Foul smelling Non foul smelling
Perforation: Attic or marginal Central perforation
Cholesteatoma: present Absent
Polyp & Granulation tissue: common Uncommon
Hearing loss:Mod.to Sev., mixed HL Mild to moderate,CHL
Complications: common(unsafe COM) Rare(Safe COM)Treatment: surgical i.e. MRM Medical or surgical(M’plasty)
Investigations for AA disease
1. EUM (examination under anesthesia): Confirmation of
otoscopy findings
2. Ear discharge swab: for culture sensitivity
3. PTA (pure tone audiogram):
4. X-ray mastoid: Towne’s view and lateral oblique view
5. CT scan: Revision surgery, complications, children
Examination under microscope(EUM)
X-Ray Mastoid-lateral oblique view
sinus plate
Dural plate
Attic bone erosion
Treatment for Attico-antral disease
Topical ear drops + frequent suction clearanceIndications:1. Early disease with shallow retraction pocket2. Only hearing ear with cholesteatoma3. Elderly patients4. Patients who are not fit for surgery under G.A.5. Patients who can regularly come for follow up
Medical Treatment
Canal Wall down(CWD)
• Modified Radical Mastoidectomy (MRM)
• Radical Mastoidectomy
Canal Wall up(CWU)
• Combined Approach Tympanoplasty (CAT)
• Cortical mastoidectomy
Surgical Treatment
Mac Ewen’s (suprameatal) triangle
Mac Ewen’s(suprameatal) triangle
Canal Wall Up Mastoidectomy
Canal Wall Down Mastoidectomy