Chronic suppurative otitis media

csom

1. Chronic S uppurative Otitis Media Gitanjali kumari 110201312

2. CSOM is a long standing infection of a part or whole of middle ear cleft characterized by- Ear discharge And a permanent perforation

3. EPIDEMIOLOGY Incidence is higher in developing countries Affects both sexes and all age groups Most important cause of hearing impairment in rural population

4. TYPES Clinically it is divided into two types Tubotympanic Atticoantral

5. TUBOTYMPANIC It involves anteroinferior part of middle ear cleft (eustachian tube, mesotympanum) and is associated with a central perforation Safe/benign type No risk of serious complications

6. Atticoantarl It involves posterosuperior part of the cleft (attic ,antrum,mastoid) Associated with an attic or marginal perforation It is often associated with bone eroding process such as cholesteatoma,granulations or osteitis Risk of complications is high Unsafe/dangerous type

7. property Tubotympanic Atticoantral Discharge Profuse,mucoid, odourless Scanty,purulent, foul smelling Perforation Central Marginal Granulations Uncommon Common Polyp Pale Red and fleshy Cholesteatoma Absent Present Complications Rare Common Audiogram Mild to moderate conductive deafness Conductive or mixed deafness

8. 1.TUBOTYMPANIC 1.AETIOLOGY The disease starts in childhood and is common in that age group Sequela of acute otitis media usually following exanthematous fever and leaving behind a large central perforation Ascending infections via eustachian tube causes persistent and recurring otorrhoea Allergy to ingestants (milk,egg) causes persistent mucoid otorrhoea

9. 2.PATHOLOGICAL CHANGES Perforation of pars tensa-it is a central perforation, size and position varies Middle ear mucos a-disease is quiescent/inactive- normal mucosa disease active- oedematous and velvety mucosa Polyp -pale to pink Ossicular chain- intact , mobile but shows some degree of necrosis( long process of incus) Tympanosclerosis -hyalinization and subsequent calcification of subepithelial connective tissue.. Causes conductive deafness Fibrosis and adhesions- result of healing process impair mobility of ossicular chain/block eustachian tube

10. 3.BACTERIOLOGY Pus culture in both aerobic and anaerobic types of csom show multiple organisms Aerobes Anaerobes Pseudomonas aeruginosa Bacteroides fragilis Proteus Anaerobic streptococci Escherichia coli Staphylococcus aureus

11. 4.Alternative classification of Chronic otitis media Mucosal disease-tubotympanic disease: Squamous disease-atticoantral disease;

12. Tubotympanic Atticoantral Mucosal disease with no evidence of invasion of squamous epi. Squamous disease of middle ear Active-perforation of pars tensa with inflammation of mucosa and mucopurulent discharge Active-presence of cholesteatoma in posterosuperior part of pars tensa/in pars flaccida. Erodes bone ,form granulation tissue,has purulent offensive discharge Inactive- permanent perforation of pars tensa but middle ear mucosa isn’t inflamed & there’s no discharge. Inactive-retraction in pars tensa/pars flaccida,no discharge Healed-tm is healed (by 2 layers)is atrophic,easily retracted if –ve pressure in middle ear

13. Clinical features Ear discharge -nonoffensive , mucoid/mucopurulent ,constant/intermittent. Appears at the time of URT infection or on accidental entry of water into ear Hearing loss-conductive type (rarely exceeds 50dB) Perforation - always central ! May lie ant./post./inferior to handle of malleus. Can be small/med./large Middle ear mucosa- seen when perforation is large. normally-pale pink & moist inflamed-red , edematous occasionally polyp is seen

14. INVESTIGATIONS Examination under microscope Audiogram Culture and sensitivity of ear discharge Mastoid xrays/ct scan temporal bone

15. TREATMENT Aural toilet- dry mopping with absorbent cotton buds suction clearance under microscope irrigation with sterile normal saline Ear drops- antibiotic ear drops containing neomycin,polymyxin,or gentamycin are used ).Often combined with steroids Systemic antibiotics- in case of acute exacerbation Precautions- keep water out of ear during bathing.(rubber inserts) hard nose blowing should be avoided Surgical treatment Reconstructive surgery

16. 2.Atticoantral 1.Aetiology It is seen in sclerotic mastoid cholesteatoma

17. 2.Pathology It is associated with the following pathological processes Cholesteatoma- ”skin in wrong place” It is presence of keratinized squamous epithelium in the middle ear or mastoid Osteitis and granulation tissue-involves outer attic wall and posteriosuperior margin of tympanic ring Ossicular necrosis- hearing loss Cholesterol granuloma- mass of granulation tissue with foreign body giant cells surrounding the cholesterol crystals

18. 3.Symptoms Ear discharge- scanty but foul smelling due to bone destruction, purulent Hearing loss- hearing is normal when ossicular chains are intact or when cholesteatoma (cholesteatoma hearer) conductive/mixed deafness Bleeding – from granulation/polyp

19. 4.Signs Perforation- attic/posterosuperior marginal type Retraction pocket – an invagination of tympanic membrane is seen in attic/posterosuperior area of pars tensa. Stages :- Stage 1 – tympanic membrane is retracted but doesn’t contact incus (MILD RETARCTION) STAGE 2 - tympanic memb. Is retracted deep & it contacts the incus ; middle ear mucosa isn’t affected. Stage3 – middle ear atelectasis : middle ear comes to lie on promontory & ossicles Stage 4- adhesive otitis medi : TM is very thin; wraps promontory & ossicles; no middle ear space; mucosal lining of middle ear is absent; retraction pockets formed; erosion of long process of incus stapes superstructure

20. 3 . Cholesteatoma – pearly white flakes of cholesteatoma can be sucked from retraction pockets

21. 5.INVESTIGATIONS Examination under microscope- imp. Part of clinical assessment of any type of CSOM Tuning fork test and audiogram Xray mastoids/CT scan of temporal bone – for extent of bone destruction and degree of mastoid pneumatization Culture and sensitivity of ear discharge

22. 6.Features indicating complications in CSOM Pain- uncommon in uncomplicated CSOM. Persence of pain indicates extardural,perisinis or brain abscess Vertigo-indicates erosion of lateral semicircular canal , may progress to labyrinthis/meningitis Persistent headache-suggestive of intracranial complications Facial weakness- erosion of facial canal

23. A listless child refusing to take feeds and easily going to sleep (extradural abscess) Fever ,nausea & vomiting- intacranial infection Irritability and neck rigidity -meningitis Diplopia (Gradenigo syndrome)petrositis Ataxia (labyrinthitis or cerebellar abscess) Abscess around ear (mastoiditis)

24. 7.Treatment Surgical- mainstay treatment (!)primary aim- remove the disease & render the ear safe (!!)2 nd aim- to preserve/reconstruct hearing Two types of surgical are done to deal with cholesteatoma: Canal wall down procedure - they leave the mastoid cavity open in external auditory canal so that the diseased area is fully exteriorized. *atticotomy *modified radical mastoidectomy *radical mastoidectomy Canal wall up procedures - disease is removed by combined approach through mastoid and meatus but retaining the posterior bony meatal wall intact thus avoiding an open mastoid cavity

25. Reconstructive surgery hearing can be restored by myringoplasty or tympanoplasty Conservative treatment- done when cholesteatoma is small and easily accessible to suction clearance under operating microscope

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