CHRONIC SUPPURATIVE OTITIS MEDIA (TUBOTYMPANIC)

CSOM

1. CHRONIC SUPPURATIVE OTITIS
MEDIA (TUBOTYMPANIC)
Dr Harjitpal Singh
Assistant Professor(ENT),
Dr RKGMC, Hamirpur

2. DEFINITION
•Chronic suppurative otitis media is a long-standing infection of the
middle ear cleft. It is characterized by ear discharge and a
permanent perforation of tympanic membrane.
•The perforation’s edges are covered by squamous epithelium. It
does not heal spontaneously and become, a sort of an epithelium-
lined fistulous track.

3. MIDDLE EAR INFECTION
Recorded in the Hippocratic era(380 B.C.), described “bony suppuration
originating from the ear”
Multi factorial, multi faceted disease
Manifests itself in the middle ear, mastoid and Eustachian tube
Contributing factors
•Eustachian tube dysfunction
•Bacterial or viral infections
•Allergic rhinitis and upper airway infection
•Trauma
•Poor living conditions, over crowding and poor hygiene and nutrition
have been suggested to be predisposing factors

4. TYMPANIC MEMBRANE
Separates the external ear from middle ear
Hippo crates (460-377 BC) was the first to regard
tympanic membrane as part of the organ of hearing
and described it as “dry thin spun web”
Round structure, 8mm wide 9mm height, with Surface
area of 90 square mm and one-tenth mm in thickness
Circumference is thickened to form fibro Cartilaginous
ring, :tympanic annulus, sits in a groove : tympanic
sulcus

5. TYMPANIC MEMBRANE(cont.)
TWO PARTS:
Pars flaccida: between the notch of Rivinus, and anterior and
posterior malleolar fold
Pars tensa: forms rest of the tympanic membrane.
THREE LAYERS:
Outer layer of epithelium
Middle fibrous layer or lamina propria,
Inner mucosal layer

6. TYMPANIC MEMBRANE(cont.)

7. THE MIDDLE EAR OR TYMPANIC CAVITY
DIVIDED INTO:
•Epitympanumor Attic lying medial to pars flaccidaand bony lateral
attic wall
•Mesotympanumlying opposite the pars tensa, and
•Hypotympanumlying below pars tensa.
•Six wallsnamely roof, floor, anterior wall, posterior wall, lateral wall
and medial wall.
•Two openinglower one of the Eustachian tube and upper one for
the canal of tensor tympani.

8. THE TYMPANIC CAVITY(cont.)
•Aditus :Attic communicates with antrum
•Three ossicles namely malleus, incus and stapes,
•Facial nerve: On posterior and nedial wall
•Lateral wall: Tympanic membrane& bony outer attic wall called
scutum.
•Medial wall :Promontory & two openings; Fenestra vestibuli (Oval
window), Fenestra cochlea (round window)

9. CROSS SECTION OF EAR

10. MIDDLE EAR CLEFT

11. EPIDEMIOLOGY
•Incidence is higher in poor socioeconomic standards, poor
nutrition and lack of health education.
•It affects both sexes and all age groups.
•In India prevalence rate is higher in rural area (46/1,000
persons) and lesser in urban area (16/1,000 persons).
•CSOM is the leading cause of hearing impairment in rural
population.

12. TYPES OF CSOM
Traditionally CSOM is divided into two types: TUBOTYMPANICand ATTICOANTRAL
Tubotympanic type (safe or benign)
•Anteroinferior part of middle ear cleft
•Associated with a permanent central perforation.
•A perforation of pars tensa
ANTEROINFERIOR PERFORATION

13. TUBOTYMPANIC TYPE(cont.)
•Also known as Chronic Otitis Media without Cholesteatoma
•Healing and destruction go together and depend upon the
virulence of organism resistance of the patient.
•Acute exacerbations occur frequently.
•No risk of serious complications.
•The cochlea may be damaged due to absorption of toxins from
the oval and round windows .

14. TUBOTYMPANIC TYPE(cont.)
LARGE CENTRAL
PERFORATION
Handle of Malleus

15. ATTICOANTRAL TYPE
•Unsafe, dangerous, posterosuperiorlesion or cholesteatoma
•Perforation or retraction of pars flaccida.
•Involves attic and posterosuperiorregions of the middle ear cleft.
•Attic or marginal perforation in posterosuperiorquadrant of the pars tensa.
•Risk of serious complications due to the bone erosion nature of
cholesteatoma, it is called unsafe or dangerous CSOM.

16. Attic Perforation Attic Cholesteatoma

17. MICROBIOLOGY of CSOM
•The incriminating microorganisms are identical in both
the types of CSOM.
•Aerobic organisms: Pseudomonas aeruginosa (most
common), Proteus, Escherichia coli and
Staphylococcus aureus.
•Anaerobic organisms : Bacteroides fragilis (most common)
and anaerobic streptococci.

18. ETIOLOGY/PREDISPOSING FACTORS
•Sequela of a large central perforation of childhood AOM, which usually
follows after exanthematous fever.
•Middle ear infection, aascending infection from the tonsils adenoids and
sinuses may result in persistent or recurring otorrhea.
•Trauma to the ear drum.
•Iatrogenic tympanic membrane injury including myringotomy, tympanotomy,
ventilating tube insertion, inadvertent removal of cerumen and
hyperbaric oxygen therapy
•Allergy: Allergy may be from foods (such as milk, eggs, fish) and inhalants
(pollen, fungi, dusts).
Perforationallowsrepeatedinfectionthroughtheexternal
earcanalcausingotorrhea,middleearmucosaisexposedtotheenvironment,
getssensitizedtodust,pollenandotheraeroallergensfromenvironment.

19. CLINICAL FEATURES
SYMPTOMS:
•Ear discharge: The odorless, mucoid or mucopurulent, ear discharge
profuse or scanty ,constant or intermittent. Discharge is common at
the time URI and when water enters into the ear.
•Hearing loss: The hearing loss is usually of conductive type. The severity of
hearing loss varies but is rarely profound.
•Less often : Tinnitus, vertigo or otalgia
•Round window shielding effect:
The hearing may improve in the presence of discharge due to “round
window shielding effect”, because the discharge helps to maintain the
phase differential. In the dry ear sound waves reach both the oval and
round windows simultaneously and cancel each other’s effect

20. CLINICAL FEATURES(cont.)
HearinglossinCSOM:predominantlyconductiveinnature
•Factorsinfluencingdegreeofconductivedeafness
Thesizeandpositionofperforation
Impairmentofossicularchain
Middleearpathology:
•Sensorineural hearing lossalso occur :passage of bacterial toxin across round
window membrane to the cochlea
•Persistent perforationin the tympanic membrane not only causes decreased
hearing but also becomes route of infection of middle ear cavity from the
external environment.

21. CLINICAL FEATURES(cont.)
Otoscopy/Endoscopy
•Central perforation of pars tensa
•Shape: round, oval or kidney shaped.
•Position: anterior, posterior, or inferior to the handle of malleus.
•Middle ear mucosa: It is normal (pale pink and little moist) when the disease
is inactive but looks inflamed red edematousand velvety when disease is
active.
•Tympanosclerosis: The hyalinization and subsequent calcification occurs in the
subepithelialconnective tissue of tympanic membrane and middle ear
mucosa.
•Polypoidalmiddle ear mucosa or severe tympanic membrane retraction
without cholesteatoma.

22. AURAL POLYP
Polyp : An edematous
and inflamed mucosa
protrudes through the
perforation and presents in
the external canal as polyp,
which is usually pale (pink
and fleshy polyp in cases of
atticoantral cholesteatoma)

23. PERFORATION WITH EDEMATOUS MIDDLE
MUCOSA

24. CLINICAL FEATURES(cont.)
•Ossicular chain: Ossicular chain usually remains intact
and mobile.
•Fibrosis and adhesions: They result from the healing
process and may impair mobility of ossicular chain or
block the ET.
•Granulations: They may be seen over the remnant of
tympanic membrane.
•Rule out in-growth of squamous epithelium from the
edges of perforation. Though rare, cholesteatoma
can coexist with a central perforation.

25. CLINICAL FEATURES(cont.)
•The regeneration is common
•Vigorous proliferation of stratified squamous epithelium from the
drum remnant migrates towards the perforation edge &close
the defect initially
•Reformation of fibrous component occurs only later, opposite to
that other type of wound healing.
•In permanent perforation,outer squamous epithelium grows
mediallyto contact inner mucosal layerlimiting factor for
healing
•Epidermal growth factor and other mediators of healing were
scantly distributed at the perforation site,

26. MANAGEMENT
INVESTIGATIONS
Examination under microscope(EUM)
To confirm otoscopy finding
Aural toilet
To collect secretions for C& S
Rigid tele –otoscope:
2.7 mm 0 degree endoscopes; accurate photographic
documentation
Ear swab: Culture & sensitivity(C&S)

27. MANAGEMENT(cont.)
Audiometry:
Pure tone audiomertyis done to know
Type of hearing loss
Degree of hearing loss
Cochlear reserve
Documentation
Radiological (not mandatory)
X-ray Mastoids: Law’s view or lateral oblique view shows:
Degree of pneumatisation
Bony land marks
Cavity( not seen in tubotympanic)

28. TUNING FORK TEST
•Should be performed in every case
•Very sensitive
•256 Hz, 512 and 1024
•Rinne’sTest : negative BC > AC
Can tell about degree of hearing loss
•Weber Test : Lateralised to poor ear in Conductive loss
Lateralised to better ear in SNHL

29. TREATMENT
MEDICAL TREATMENT
Aim:Eliminate infection & control otorrhoea
Aural toilet: Facilitates entry of topical agents into the middle ear.
Topical medication:Combination of anti biotic, antifungals, antiseptics,
solvents and steroids.
•Antibiotics:Amino glycosides, Polymixin-B, Chloramphenicol
Ciprofloxacin& ofloxacin
•Antiseptics: Acetic acid, Aluminum acetate, Boric acid etc. to create
acidic solution as most microbes prefer alkaline environment
•Corticosteroids: Hydrocortisone&Dexamethasoneimparts anti
inflammatory action ( useful in presence of edema or
granulation)

30. SURGICAL TREATMENT
•The definitive treatmentfor persistent perforation is surgery-using
grafts
History
•First recorded attempt :Marcus Banzerin 1640 ; using pig’s bladder
•Berthold 1878 : introduced the term “Myringoplastik”& used full
thickness skin graft
•Myringoplasty reconstructive process is limited to repair of a
tympanic membrane perforation.
•Implicit in the definition is that the ossicular chain is intact and
mobile and there is no middle ear disease
•With advent of modern surgical microscopy and antibiotics: 1951;
Zollner& Wullsteinreintroduced the technique and coined the
term “Tympanoplasty”

31. SURGICAL TREATMENT(cont.)
•Techniques in myringoplasty:two commonly performed
techniques
1)Overlaymethod(onlaymethod)
2)Underlaymethod(inlaymethod)
•overlaytechnique:squamouslayerhasbeenmeticulously
removedthegraftisplacedlateraltotheannulus
•underlaytechnique:graftisplacedentirelymedialtothe
remainingdrumandmalleus;relativelysimple.

32. SURGICAL TREATMENT(cont.)
UNDERLAYMETHODcanbeaccomplishedbyeither
Endauralapproach:placinggraftthroughtheexternal
auditorycanal.
Postauralapproach:tympanicmembraneapproachedbya
separatepostauralincision(Williamwild’s).
Underlaytechniquewasbetterthanoverlaytechniqueas
itwastechnicallymoreeasiertoperform,hearingresultswere
significantlybetter,complicationswereminimal

33. SURGICAL TREATMENT(cont.)
GRAFTING MATERIALS:
a)Temporalis fascia {Herman (1958 )} currently the preferred grafting
material because it is easily available, low BMR and texture
almost similar to that of tympanic membrane. primary take
rate of 92-99%
b) Tragalperichondrium
c) Vein graft
d) Other’s: Autologous periosteum, autologous fat, Allograft
duramater,Homograft tympanic membrane.

34. TEMPORALIS FASCIA

35. MYRINGOPLASTY
SURGICAL STEPS
•Ear has to be dryi.e., no active discharge for at least four weeks
•Anesthesia: GA/LA(EAC infiltrated at four quadrants with 2%
xylocaine with 1:50,000 adrenaline)
•Preparation:Two finger breadth above the Ear
•Harvesting temporalis fascia graft:horizontal incision 3 to 4cm
long; two finger breadth above the pinna
•Temporalis fascia exposed:rectangularpiece cut out
•Margin of perforation is freshened.
•EndomeatalVon Rosen’s incisionwas given from 12
o
clock to
6
o
clock position posteriorly.

36. MYRINGOPLASTY(cont.)
SURGICAL STEPS
•Tympanomeatal flap is elevated down to fibrous annulus, ossicular
chain continuity verified & graft was placed medial to the
handle of malleus
•Tympanomeatal flap is put back into position & graft adjusted to
cover the perforation in entire.
•Gel foam pieces were placed over the tympanomeatal flap
•Ear canal is packed with cotton soaked in antibiotic ointment

37. MYRINGOPLASTY(cont.)
COMPLICATIONSOFMYRINGOPLASTY:
Graftfailure:Pooradaptationofthegraft,Technicalfaults,poor
eustachiantubefunction,Infection
Sensorineuralhearingloss(SNHL):Cochleardamageinducedby
excessivemovementsofossicularchain.
Othercomplications:postoperativewoundinfection,facialnerve
palsy,chordatympaninervedamage,perichondritis,
postoperativedrumatelectasis,tinnitus,andexternalauditory
canalstenosis

38. MYRINGOPLASTY(cont.)
RECENTADVANCES:
•Endoscopic myringoplasty.The 0º deflection angle and 2.7 mm
external diameter endoscopes were used underlay technique
was the method of choice
•Laser myringoplasty :KTP-532 laser was used, being minimally
invasive incidence of ossicular damage was less

39. TEMPORALIS FASCIA

40. POST MYRINGOPLASTY
RESIDUAL PERFORATION

41. ROLE OF MASTOID
•Pneumatic reservoir during period of Eustachian tube dysfunction
•The mastoid pneumatisation & the presence of inflammatory
focusin the mastoid are important factor influence the
success of myringoplasty
•Simple mastoidectomy: Useful adjunct to tympanoplasty by
repneumatising the sclerotic mastoid and eradication of
mastoid focus infection

42. CORTICAL MASTOIDECTOMY

43. THANK YOU