csom (chronic suppurative otitis media)

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CSOM is the most common cause of deafness in developing countries like Nepal.

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Page 1: CSOM (chronic suppurative otitis media)

Dr.Ramesh Parajuli

Page 2: CSOM (chronic suppurative otitis media)

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

Page 3: CSOM (chronic suppurative otitis media)

Types of CSOM1.CSOM -Tubotympanic (Mucosal): Safe type

2.CSOM-Atticoantral (Squamous): Unsafe type

Page 4: CSOM (chronic suppurative otitis media)

• 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

Page 5: CSOM (chronic suppurative otitis media)

• COM AA (Squamous): Inactive: Retraction of tympanic

membrane(pars flaccida or tensa)

Active: Attic perforation, marginal peforation associated with discharge/cholesteatoma/granulation tissue

Page 6: CSOM (chronic suppurative otitis media)

Retraction of pars tensa Retraction of pars flaccida

Page 7: CSOM (chronic suppurative otitis media)

cholesteatoma & granulation tissue

Page 8: CSOM (chronic suppurative otitis media)

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

Page 9: CSOM (chronic suppurative otitis media)

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Klebsiella

• Proteus

• Streptococcus

• Bacteroides

• E.coli

Bacteriology of CSOM

Page 10: CSOM (chronic suppurative otitis media)

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

Page 11: CSOM (chronic suppurative otitis media)

Clinical Features of CSOM-TT

Symptoms:Recurrent Ear discharge: profuse,mucopurulent,

intermittent, odourless, not blood-stained

Hearing Loss: usually conductive (25-50 dB)

Page 12: CSOM (chronic suppurative otitis media)

Signs:

• Ear discharge• Perforation of pars tensa• Middle Ear Mucosa –

Oedematous• Granulation tissue/aural

polyp

Page 13: CSOM (chronic suppurative otitis media)

Natural history of CSOM TT

I. Progression towards healing

II. Progression with continued activity •Further hearing loss•Ossicular damage•Complications•Secondary acquired cholesteatoma

Page 14: CSOM (chronic suppurative otitis media)

Investigations for CSOM-TT

• Examination under microscope (EUM)• Ear discharge swab: for culture sensitivity• Pure tone audiometry (PTA)

Page 15: CSOM (chronic suppurative otitis media)

(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

Page 16: CSOM (chronic suppurative otitis media)

(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

Page 17: CSOM (chronic suppurative otitis media)

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

Page 18: CSOM (chronic suppurative otitis media)

Approach

1. Postaural Approach

2. Transcanal(permeatal) Approach

3. Endaural Approach

Page 19: CSOM (chronic suppurative otitis media)

Underlay technique

Page 20: CSOM (chronic suppurative otitis media)

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

Page 21: CSOM (chronic suppurative otitis media)

CSOM Attico-antral(Squamous)

Page 22: CSOM (chronic suppurative otitis media)

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

Page 23: CSOM (chronic suppurative otitis media)
Page 24: CSOM (chronic suppurative otitis media)

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

Page 25: CSOM (chronic suppurative otitis media)

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

Page 26: CSOM (chronic suppurative otitis media)

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

Page 27: CSOM (chronic suppurative otitis media)

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)

Page 28: CSOM (chronic suppurative otitis media)

Congenital cholesteatoma

Embryonal Squamous epithelial cell rests fails to disappear during developmentPersistence in middle ear, petrous apex, CPA angle

Page 29: CSOM (chronic suppurative otitis media)

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

Page 30: CSOM (chronic suppurative otitis media)

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

Page 31: CSOM (chronic suppurative otitis media)

Aural polyp

Page 32: CSOM (chronic suppurative otitis media)

PSQ cholesteatoma & granulation tissue

Page 33: CSOM (chronic suppurative otitis media)

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)

Page 34: CSOM (chronic suppurative otitis media)

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

Page 35: CSOM (chronic suppurative otitis media)

Examination under microscope(EUM)

Page 36: CSOM (chronic suppurative otitis media)

X-Ray Mastoid-lateral oblique view

sinus plate

Dural plate

Page 37: CSOM (chronic suppurative otitis media)

Attic bone erosion

Page 38: CSOM (chronic suppurative otitis media)

Treatment for Attico-antral disease

Page 39: CSOM (chronic suppurative otitis media)

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

Page 40: CSOM (chronic suppurative otitis media)

Canal Wall down(CWD)

• Modified Radical Mastoidectomy (MRM)

• Radical Mastoidectomy

Canal Wall up(CWU)

• Combined Approach Tympanoplasty (CAT)

• Cortical mastoidectomy

Surgical Treatment

Page 41: CSOM (chronic suppurative otitis media)

Mac Ewen’s (suprameatal) triangle

Page 42: CSOM (chronic suppurative otitis media)

Mac Ewen’s(suprameatal) triangle

Page 43: CSOM (chronic suppurative otitis media)
Page 44: CSOM (chronic suppurative otitis media)

Canal Wall Up Mastoidectomy

Page 45: CSOM (chronic suppurative otitis media)
Page 46: CSOM (chronic suppurative otitis media)

Canal Wall Down Mastoidectomy

Page 47: CSOM (chronic suppurative otitis media)