Csom

chronic suppurative otitis media

1. CHRONIC SUPPURATIVE OTITIS MEDIA Dept. of ENT

2. DEFINITION OF CSOM Chronic suppurative otitis media is a long standing infection of a part or whole of the middle ear cleft characterised by continuous or intermittent discharge through a persistent tympanic membrane perforation.

3. EPIDEMIOLOGY Incidence is higher in developing countries Predisposing factors : Poor socio-economic status, poor nutrition, lack of health education Affects both sexes All age groups

4. TYPES OF CSOM Safe Type Or Tubo Tympanic Disease Unsafe Type Or Attico Antral Disease Active (Mucosal / Squamous ) Inactive (Mucosal / Squamous ) Healed

5. TYPES:

6. 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

7. 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

8. TUBOTYMPANIC DISEASE Disease confined to eustachian tube , anterior and inferior part of mesotympanum and hypotympanum Usually starts in childhood , so safe type is common in that age group Presents with central perforation No underlying osteitis or osteomyelitis

9. AETIOLOGY Tubotympanic Type Sequelae of acute otitis media Ascending infections via the eustachian tube Nasal Allergy GERD Cranio facial abnormalities Autoimmune disease

10. BACTERIOLOGY Pseudomonas aeruginosa B.Proteus Esch.coli Staph. Aureus Bacteroides fragilis Anaerobic streptococci.

11. SYMPTOMS Ear Discharge Hearing Loss Ear Pain Fever

12. SIGNS Profuse mucopurulent discharge, non foul smelling, not blood stained. Hearing loss. Central Perforation. Middle ear mucosa – congested. Polyp Ossicular chain – erosion. Tympanosclerosis

13. TYPES OF PERFORATION CENTRAL PERFORATION: Perforation in the pars tensa sorrounded all around by pars tensa MARGINAL PERFORATION : Perforation in the pars tensa surrounded partly by pars tensa and partly by bone

14. STAGES FEATURES ACTIVE STAGE Discharging at the time of examination. QUIESCENT STAGE In the recent past, discharge present but there is no discharge now. INACTIVE STAGE No discharge for 3- 6 months. Dry ear. HEALED STAGE TM Perforation has healed. Permanently controlled middle ear infection.

15. ATTICO ANTRAL DISEASE Chronic inflammatory condition of the middle ear cleft confined to posterior part of the mesotympanum , attic and antrum associated with bone eroding disease or cholesteatoma charactersied by thick, purulent, scanty, foul smelling, blood stained persistent discharge and may be associated with perforation in pars flaccida

16. CHOLESTEATOMA It is a cystic bag like structure lined by stratified squamous epithelium containing desquamated epithelial debris lying on a fibrous tissue stroma of variable thickness Skin in the wrong place Synonym: keratoma , epidermosis

17. THEORIES OF CHOLESTEATOMA FORMATION Congenital cell rests 2. Invagination theory: ( Wittmack ) Invagination of TM from attic or posterosuperior part of pars tensa

18. 3. Epithelial invasion theory ( Habermann ) Squamous epithelium from TM migrates to middle ear via TM perforation

19. 4 . Basal cell hyperplasia theory: Infection or inflammation Basal membrane breaks Squamous epithelium invade into sub epithelial tissue in pars flaccida like epithelial cones forming microcholesteatoma This enlarges and perforates secondarily through the TM

20. 5. Squamous metaplasia theory : Cuboidal epithelium can undergo metaplasia to sq.epithelium Middle ear cuboidal epithelium is pluripotent can be stimulated by inflammation to become keratinising sq.epithelium

21. TYPES OF CHOLESTEATOMA Congenital Acquired - primary - secondary

22. COMMON SITES OF CHOLESTEATOMA Most common sites of origin of acquired cholesteatomas are Posterior epitympanum Posterior mesotympanum Anterior epitympanum

23. PATHOLOGY Cholesteatoma Osteitis and granulation tisue Ossicular necrosis Cholesterol granuloma

24. ATTICO ANTRAL DISEASE SYMPTOMS Ear Discharge Hearing Loss Bleeding Ear Ache Dizziness Tinnitus Symptoms Of Complications

25. PARS TENSA CHOLESTEATOMA SIGNS Retraction Pockets Cholesteatoma Flakes Granulation Tissue Polyp Hearing Loss

26. INVESTIGATION Examination under microscope Pus for C/S Audiological Assessment X-ray both Mastoids CT Scan Temporal bone Basic Investigations X-ray PNS Diagnostic Nasal Endoscopy Eustachian Tube Function Tests

27. EXAMINATION UNDER MICROSCOPE To confirm Otoscopic findings Site & size of perforation Margin of perforation Appearance of Middle ear Presence of Polyp & granulation Tissue and its site

28. PURE TONE AUDIOGRAM Identifying the presence or absence of auditory functions Differentiating conductive from sensorineural hearing loss Degree of hearing loss

29. X-RAY BOTH MASTOIDS Pneumatisation of mastoid air cells Hazziness / clouding of air cells Low lying tegmen or anteriorly lying sinus plate

30. BASIC INVESTIGATIONS Complete hemogram : Hb , TC, DC, BT, CT, ESR B. Sugar B. Urea, S. Creatinine Urine analysis ECG X-Ray Chest PA view

31. X-RAY PNS

32. DIAGNOSTIC NASAL ENDOSCOPY

33. EUSTACHIAN TUBE FUNCTION TESTS Valsalva Test Politzer Test Catheterisation Toynbees test Tympanometry Radiological Test

34. MEDICAL TREATMENT Short term goals : Elimination of infection Control of otorrhoea Long term goals :- Improvement of hearing Eventual healing of TM Aural Toileting - Dry Mopping Wet mopping Suction irrigation under microscope Topical Antibiotics Systemic Antibiotics

35. CAUSES OF FAILURE OF MEDICAL TREATMENT Poor drainage of inflammatory exudate from the middle ear Presence of persistent osteitis with mastoid granulation Virulent & resistant organisms Reinfection via Eustachian tube – adenoid, sinuses Allergy Mastoid reservoir

36. CHEMICAL CAUTERIZATION (MEDICAL MYRINGOPLASTY) Trichloroacetic acid Principle : The epithelium covering the margin of the perforation is destroyed and exposing the fibroblasts Mild irritations induces hyperemia and secondary fibroblast proliferations Used in dry small to medium perforations Several sittings may be necessary

37. Medical Treatment For Cholesteatoma :- Topical antibiotics with aural toileting Suction clearance Application of silver nitrate to granulation tissue Antimetabolite - 5 – fluorouracil Reduces the activity of squamous epithelium & curtail the production of keratin debris Ventilation Tubes In Attic Retractions

38. SURGICAL PROCEDURES MYRINGOPLASTY An operation performed to repair or reconstruct the TM TYMPANOPLASTY An operation performed to eradicate disease in the middle ear and to reconstruct the hearing mechanisms with out mastoid surgery, with or without TM grafting. OSSICULOPLASTY An operation performed to repair or reconstruct the ossicular chain

39. MYRINGOPLASTY Prerequisites Dry ear Good cochlear reserve Normal ET function Predominantly conductive hearing loss No cholesteatoma Types Grafting techniques – onlay , underlay

40. TYMPANOPLASTY TYPE I : -intact ossicular chain. -sound protection for round window. TYPE II: -slight defect of the ossicles . -middle ear is of about normal size. TYPE III: - malleus and incus are extremely eroded - columella effect. TYPE IV: - mobile stapes foot plate. - sound pressure transformation is given up. TYPE V: - Fixed stapes foot plate. - sound pressure through fenestration.