Csom 1

brief description about safe CSOM,
unsafe csom and its management

1. CHRONIC SUPPURATIVE OTITIS MEDIA -1 (TUBOTYMPANIC TYPE) Dr Chandra Bhan Assistant professor 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 / Squamou s ) Inactive (Mucosal / Squamous ) Healed

5. TYP E S:

6. P roperty 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 anteroinferior middle ear cleft i.e. 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. Why is TUBOTYMPANIC disease safe? There is no risk of bone erosion Not known to cause intracranial complications Discharge from middle ear flows freely through the perforation in the pars tensa Usually the perforation of pars tensa is surrounded by a rim of intact drum The annulus is intact in all these cases

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

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

12. SYMPTOMS Ear Discharge Hearing Loss Ear Pain - due to otitis externa

13. SIG N S Profuse , intermittent, mucoid or mucopurulent discharge, non foul smelling, not blood stained. Mostly conductive h earing loss but in long standing cases, cochlea may suffer damage due to absorption of toxins from the oval and round windows and hearing loss becomes mixed type.

14. Pars tensa /Central Perforation. Middle ear mucosa –pale and pink in inactive case, congested and oedematous in active cases. Polyp-pale Ossicular chain intact (necrosis in long standing cases) Tympanosclerosis Fibrosis and adhesion in middle ear

15. Round window shielding effect Sometimes, the patient reports of a paradoxical effect, i.e. hears better in the presence of discharge than when the ear is dry. This is due to discharge which helps to maintain phase differential by closing the perforation. In the dry ear with perforation, sound waves strike both the oval and round windows simultaneously, thus cancelling each other’s effect.

16. TYPES OF PERFORATION CENTRAL PE R FORATION: Perforation in the pars tensa sorrounded all around by pars tensa Annulus intact MARGINAL PERFORA T IO N : Perforation in the pars tensa surrounded partly by pars tensa and partly by bone Annulus damaged

17. 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.

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

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

20. TUNING FORK TESTS Rinne negative on the affected side Weber lateralized to deaf ear ABC - Not reduced

21. PURE TONE AUDIOGRAM Differentiating conductive from sensorineural hearing loss Type and Degree of hearing loss .

22. Shows conductive hearing loss Hearing loss commonly ranges between 30 - 40 dB If hearing loss exceeds 60 dB then ossicular chain disruption should be suspected Associated sensorineural loss should arouse suspicion of toxic deafness

23. X-RAY BOTH MASTOIDS Pneumatisation of mastoid air cells . Hazziness / clouding of air cells . Usually no evidence of bone destruction. Low lying tegmen or anteriorly lying sinus plate assessment.

24. ROUTINE INVESTIGATIONS Complete hemogram : CBC, GBP, BT, CT, ESR , LFT, ELECTROLYTE. B. Sugar B. Urea, S. Creatinine Urine analysis ECG X-Ray Chest PA view

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

26. 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 - by displacement method Systemic Antibiotics - in acute exacerbation.

27. 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 .

28. 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

29. 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

30. MYRINGOPLASTY Prerequisites ▫ Dry ear ▫ Good cochlear reserve ▫ Normal ET function ▫ well functioning round window membrane. Types ▫ Grafting techniques – onlay, underlay

31. Thank you