CSOM

This presentation describes chronic suppurative otitis media safe type

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Chronic suppurative otitis mediaChronic suppurative otitis media
Dr. T. Balasubramanian M.S. D.L.O.Dr. T. Balasubramanian M.S. D.L.O.

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DefinitionDefinition
CSOM is defined as a CSOM is defined as a
chronic infection of chronic infection of
middle ear mucosa middle ear mucosa
lining the middle ear lining the middle ear
cleftcleft
The duration of The duration of
infection should be infection should be
more than 3 weeksmore than 3 weeks
Middle ear cleft Middle ear cleft
includes eustachean includes eustachean
tube, middle ear tube, middle ear
proper and mastoid air proper and mastoid air
cell systemcell system

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Tubotympanic diseaseTubotympanic disease
Also known as safe Also known as safe
earear
It does not cause It does not cause
any serious any serious
complicationscomplications
Infection limited to Infection limited to
the antero inferior the antero inferior
part of middle ear part of middle ear
cleftcleft
Associated with Associated with
central perforationcentral perforation

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Why is Tubotympanic disease Why is Tubotympanic disease
safe?safe?
There is no risk of bone erosionThere is no risk of bone erosion
Not known to cause intracranial Not known to cause intracranial
complicationscomplications
Discharge from middle ear flows freely Discharge from middle ear flows freely
through the perforation in the pars tensathrough the perforation in the pars tensa
Usually the perforation of pars tensa is Usually the perforation of pars tensa is
surrounded by a rim of intact drumsurrounded by a rim of intact drum
The annulus is intact in all these casesThe annulus is intact in all these cases

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AetiologyAetiology
 Inadequately treated ASOM
 ASOM causing persistent perforation (Persistent
perforation syndrome)
 Presence of focal sepsis in Nose / throat causing EC
 Infected traumatic central perforation

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MicrobiologyMicrobiology
Gram negative bacilli has been commonly Gram negative bacilli has been commonly
isolatedisolated
Ps. aeruginosa, E. coli, and B. proteus Ps. aeruginosa, E. coli, and B. proteus
These organisms are not commonly found These organisms are not commonly found
in the respiratory tractin the respiratory tract
These organisms are commonly found in These organisms are commonly found in
the skin of external canal the skin of external canal
Always number your slides

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Clinical featuresClinical features
 Discharge is profuse and MucopurulentDischarge is profuse and Mucopurulent
 It is not foul smellingIt is not foul smelling
 Since the infected area is open at both Since the infected area is open at both
ends discharge doesn't accumulate in the ends discharge doesn't accumulate in the
middle ear cavitymiddle ear cavity
 Ossicular chain is mostly uninvolvedOssicular chain is mostly uninvolved
 Pts have conductive deafness – 30 – 40 Pts have conductive deafness – 30 – 40
dBdB
 Pain is usually due to otitis externaPain is usually due to otitis externa

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Stages of Tubotympanic Stages of Tubotympanic
diseasedisease
 Acute stage Acute stage
 Inactive stageInactive stage
 Quiescent stageQuiescent stage
 Healed stageHealed stage

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Acute stageAcute stage
 Ear is actively dischargingEar is actively discharging
 Middle ear mucosa hypertrophied Middle ear mucosa hypertrophied
and congestedand congested
 The ear discharge is MucopurulentThe ear discharge is Mucopurulent
 Discharge is not foul smellingDischarge is not foul smelling

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Inactive stageInactive stage
 Dry perforation of ear drum +Dry perforation of ear drum +
 Perforation involves the pars tensaPerforation involves the pars tensa
 Annulus is intactAnnulus is intact
 Middle ear mucosa is normal and healthyMiddle ear mucosa is normal and healthy

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Quiescent stageQuiescent stage
 Perforation of ear drum present
 Middle ear is dry
 Middle ear mucosa may be normal /
hypertrophied
 Discharge stopped just a few days back

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Healed stageHealed stage
Healing of drum by thin scarHealing of drum by thin scar
Tympanosclerotic patches may be seenTympanosclerotic patches may be seen
Ossicular chain invariably intactOssicular chain invariably intact

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Tuning fork testsTuning fork tests
 Rinne negative on the affected sideRinne negative on the affected side
 Weber lateralized to deaf earWeber lateralized to deaf ear
 ABC - Not reducedABC - Not reduced

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Pure tone audiometryPure tone audiometry
 Shows conductive hearing lossShows conductive hearing loss
 Hearing loss commonly ranges Hearing loss commonly ranges
between 30 - 40 dBbetween 30 - 40 dB
 If hearing loss exceeds 60 dB then If hearing loss exceeds 60 dB then
ossicular chain disruption should be ossicular chain disruption should be
suspectedsuspected
 Associated sensorineural loss should Associated sensorineural loss should
arouse suspicion of toxic deafnessarouse suspicion of toxic deafness

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Conservative managementConservative management
Aural toileting - in active diseaseAural toileting - in active disease
Suction clearanceSuction clearance
Syringing of affected ear using warm Syringing of affected ear using warm
saline mixed with 1.5 % acetic acidsaline mixed with 1.5 % acetic acid
Topical antibiotics administered after Topical antibiotics administered after
culture report becomes availableculture report becomes available
Ear drops is administered by Ear drops is administered by
displacement methoddisplacement method

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Role of systemic drugsRole of systemic drugs
AntibioticsAntibiotics
AntihistaminesAntihistamines
Ototoxic drugs to be avoidedOtotoxic drugs to be avoided
Nasal decongestants ? Rhinitis Nasal decongestants ? Rhinitis
medicamentosamedicamentosa

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PrecautionsPrecautions
 The ear must be kept dryThe ear must be kept dry
 Pre-existing sinus infections to be Pre-existing sinus infections to be
treated aggressivelytreated aggressively
 Presence of focal sepsis in the throat Presence of focal sepsis in the throat
should also be managedshould also be managed

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Surgical managementSurgical management
 Surgery towards eradication of focal Surgery towards eradication of focal
sepsissepsis
 Surgery aimed towards eradication of Surgery aimed towards eradication of
middle ear disease (Mastoidectomy)middle ear disease (Mastoidectomy)
 Surgery aimed at reconstruction of Surgery aimed at reconstruction of
sound conduction mechanism sound conduction mechanism
(Myringoplasty and tympanoplasty)(Myringoplasty and tympanoplasty)

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TympanoplastyTympanoplasty
Tympanoplasty is defined as the surgical Tympanoplasty is defined as the surgical
procedure which enables reconstruction of procedure which enables reconstruction of
middle ear cavity and ossicular system. It middle ear cavity and ossicular system. It
also involves reconstruction of the also involves reconstruction of the
perforated ear drumperforated ear drum

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Components of tympanoplastyComponents of tympanoplasty
 CanalplastyCanalplasty
 MeatoplastyMeatoplasty
 MyringoplastyMyringoplasty
 OssiculoplastyOssiculoplasty

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CanalplastyCanalplasty
 This procedure is used to widen the This procedure is used to widen the
external canalexternal canal
 Should be performed before grafting Should be performed before grafting
anterior perforationsanterior perforations
 This procedure facilitates better healingThis procedure facilitates better healing
 External canal can be cleansed without External canal can be cleansed without
any difficultyany difficulty
 Useful when performing second stage Useful when performing second stage
ossiculoplastyossiculoplasty

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MeatoplastyMeatoplasty
 This procedure is performed to enlarge This procedure is performed to enlarge
the lateral cartilagenous portion of the the lateral cartilagenous portion of the
external canalexternal canal
 This enlargement should be in proportion This enlargement should be in proportion
to the size of the bony portion of the to the size of the bony portion of the
external canalexternal canal

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OssiculoplastyOssiculoplasty
 Used to reconstruct the damaged Used to reconstruct the damaged
ossicles of middle ear cavityossicles of middle ear cavity
 Long process of incus is found to be Long process of incus is found to be
commonly erodedcommonly eroded
 TORPTORP
 PORPPORP

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Aims of tympanoplastyAims of tympanoplasty
 Disease eradicationDisease eradication
 Restoration of middle ear aerationRestoration of middle ear aeration
 Reconstruction of sound conduction Reconstruction of sound conduction
mechanismmechanism
 Creation of self cleansing dry cavityCreation of self cleansing dry cavity

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Preop investigationsPreop investigations
 Tubal function testsTubal function tests
 Audiometric evaluationAudiometric evaluation
 X-ray / CT scan of temporal bonesX-ray / CT scan of temporal bones
 Tests for anesthetic fitnessTests for anesthetic fitness

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Trans canal surgical approachTrans canal surgical approach
Performed through ear Performed through ear
speculum inserted into speculum inserted into
the ear canalthe ear canal
 Ear canal should be Ear canal should be
widewide
There should not be There should not be
any bony overhang any bony overhang
obscuring the edges of obscuring the edges of
perforationperforation

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End aural approachEnd aural approach
 Incision is made Incision is made
between tragus and helixbetween tragus and helix
 End aural speculum is End aural speculum is
usedused
 Posterior bony overhang Posterior bony overhang
can easily be drilled outcan easily be drilled out
Better for anterior Better for anterior
visualization of the ear visualization of the ear
drumdrum

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Endaural view of ear drumEndaural view of ear drum

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Post aural approachPost aural approach
 Used in cases of Used in cases of
narrow external canalnarrow external canal
 Used to close Used to close
anterior ear drum anterior ear drum
perforationsperforations
 William Wild’s post William Wild’s post
aural incision is usedaural incision is used

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Ideal Tympanic membrane Ideal Tympanic membrane
graftsgrafts
 Temporalis fasciaTemporalis fascia
 DuraDura
 PeriosteumPeriosteum

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Why temporalis fascia is Why temporalis fascia is
favoured?favoured?
 It has a low basal metabolic rateIt has a low basal metabolic rate
 Its thickness more or less resembles that Its thickness more or less resembles that
of normal ear drumof normal ear drum
 It can be harvested through the same It can be harvested through the same
post aural incisionpost aural incision
 It is available in plentyIt is available in plenty
 It has a good take rateIt has a good take rate

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Types of grafting techniquesTypes of grafting techniques
 Overlay techniqueOverlay technique
 Underlay techniqueUnderlay technique
 Interlay techniqueInterlay technique

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Underlay techniqueUnderlay technique
Commonly used techniqueCommonly used technique
 The graft is placed under the The graft is placed under the
tympanic membrane remnant and tympanic membrane remnant and
bonebone
 To facilitate this process a To facilitate this process a
tympanomeatal flap will have to be tympanomeatal flap will have to be
elevatedelevated

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Overlay techniqueOverlay technique
The graft is placed over the bony The graft is placed over the bony
tympanic sulcustympanic sulcus
A bony ledge is created for this A bony ledge is created for this
purpose if the sulcus is absentpurpose if the sulcus is absent
The overlaid graft is supported by The overlaid graft is supported by
the remnant ear drum if presentthe remnant ear drum if present

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Underlay techniqueUnderlay technique

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