Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT)

Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT) is an important topic for MBBS and MS ENt students. Dr Krishna Koirala will be explaining this topic in a simplified way.

1. Chronic Suppurative Otitis Media: Tubotympanic Disease (CSOM TT, COM Mucosal type) Dr. Krishna Koirala 2016-05-03

2. 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

3. Tubo-tympanic vs. Attico-antral

4. Perforations of Pars Tensa in CSOM TT

5. Involves only one quadrant or < 10% of pars tensa Small perforation

6. Medium perforation Involves two quadrants o r 10 – 40 % of pars tensa

7. Large perforation

8. Retraction of pars Tensa of TM

9. Grade I retraction Dull, lusterless T.M. Prominent annulus Cone of light absent Prominent lateral process Handle of malleus medialized Malleal folds sickle shaped

10. Grade II retraction TM touches the incus

11. Grade III retraction TM touches the promontory ( atelectasis) but mobile on Valsalva maneuver or Siegelization

12. Grade IV retraction TM firmly adherent to promontory & immobile on Valsalva maneuver or Siegelization

13. 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

14. Bacteria responsible Staphylococcus aureus Pseudomonas aeruginosa Klebsiella Proteus Streptococcus Bacteroides

15. Routes of infection Via Eustachian tube U.R.T.I ., nose blowing, regurgitation of milk 2. Via tympanic membrane perforation F ollowing A.S.O.M . or post-traumatic 3. Haematogenous (rare): exanthematous fever

16. Pathological Changes Eardrum C entral perforation; myringosclerosis 2. Ossicles Destruction (hyperemic decalcification) Tympanosclerosis, Fibrosis + Adhesions 3. Middle ear mucosa: edematous , pale, congested 4. Mastoid bone: sclerosis

17. Clinical Features Ear discharge: intermittent, profuse , mucoid to muco-purulent, whitish, odorless, not blood-stained Hearing Loss: U sually conductive (25-50 dB) but might be normal in small , dry perforations R ound window shielding by ear discharge leads to better hearing in acute exacerbations Tympanic membrane: central perforation

18. Stages of Tubotympanic disease Stage Otorrhoea Eardrum perforation Last ear discharge Active Present Present - Quiescent Absent Present < 6 months Inactive Absent Present > 6 months Healed Absent Absent -

19. Investigations for CSOM TTD Examination under microscope Ear discharge swab: for culture sensitivity Pure tone audiometry Patch test X-ray mastoid: B/L 30 lateral oblique (Schuller) (Done when cortical mastoidectomy is required in CSOM TT not responding to antibiotics)

20. 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

21. 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

22. 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

23. Treatment of CSOM Tubo-tympanic Disease

24. Non-surgical Treatment Precautions Aural toilet Antibiotics : Systemic & Topical Antihistamines : Systemic & Topical Nasal decongestants : Systemic & Topical Treatment of respiratory infection & allergy Tympanic membrane patcher

25. 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

26. 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

27. Antibiotics Topical Antibiotics: Ciprofloxacin , Gentamicin, Tobramycin Antibiotics + Steroid: for polyps, granulations Neosporin + Betamethasone / Hydrocortisone Oral Antibiotics: for severe infections Cefuroxime , Cefaclor, Cefpodoxime, Cefixime

28. Antihistamines and Decongestants Antihistamines Chlorpheniramine Cetirizine Fexofenadine Loratadine Levocetrizine Azelastine ( topical ) Systemic D econgestants Pseudoephedrine Phenylephrine Topical Decongestants Oxymetazoline Xylometazoline Hypertonic saline

29. Kartush T.M. Patcher Indicated in: Perforation in only hearing ear Patient refuses surgery Patient unfit for surgery Age < 7 years

30. Surgical Treatment Indicated in inactive or quiescent stage Myringoplasty Tympanoplasty Indicated in active stage Cortical Mastoidectomy Aural polypectomy

31. 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

32. Chemical cautery

33. Surgical Approaches to the middle ear

34. Wilde’s post-aural incision

35. Lempert’s end-aural incision

36. Rosen’s permeatal incision

37. Hearing Restoration Myringoplasty S urgical closure of tympanic membrane perforation Ossiculoplasty S urgical reconstruction of ossicular chain Tympanoplasty Surgical removal of disease + reconstruction of hearing mechanism without mastoid surgery

38. 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

39. Myringoplasty Surgical closure of perforation of pars tensa of Tympanic membrane without ossicular reconstruction

40. 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

41. Contraindications Purulent ear discharge Otitis externa Respiratory allergy Age < 7 yr (Eustachian tube not fully developed) Only hearing ear Cholesteatoma

42. Methods Techniques 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

43. Overlay M yringoplasty

44. Underlay M yringoplasty

45. Steps of underlay Myringoplasty

46. Tympanomeatal flap raised

47. Placement of graft

48. Tympanomeatal flap replaced

49. 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

50. Onlay Underlay Graft 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

51. 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

52. Tympanoplasty

53. Types

54. 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 )

55. Ossiculoplasty Ossicular graft material Autograft O ssicles : incus/malleus Cartilage : Tragal/ conchal Bone : spine of H enle/mastoid Homograft: ossicles/cartilage/bone Biomaterials: plas tic(polyethylene)/ceramic/ teflon/gold (Biomaterials available as PORP and TORP)