CSOM of Middle ear part 1

8/13/2019 CSOM of Middle ear part 1

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C.S.O.M.:

Clinical Features

Dr. Vishal Sharma


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Definition

Chronic (> 3 months) pyogenic infection of

middle ear cleft mucosa, characterized by

persistent perforation of tympanic membrane,

ear discharge & decreased hearing

Prevalence in Nepal: 7.2 %


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Types of C.S.O.M.

Tubo-tympanic:chronic pyogenic infection of

middle ear cleft mucosa with persistent perforation

in pars tensa

Attico-antral:chronic pyogenic infection of middle

ear cleft with cholesteatoma & granulations in attic

or postero-superior quadrant of pars tensa


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Middle ear cleft


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Tubo-tympanic vs. Attico-antral


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Tympanic MembranePerforations


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Types

Perforation of Pars Tensa

1. Centraltubo-tympanic

Small Medium Large Subtotal

2. Central with ingrowing epitheliumattico-antral

3. Marginalattico-antral

4. Totalattico-antral

Perforation of Pars Flaccida

1. Attic attico-antral


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4 quadrants of T.M.

umbo


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Small perforation

Involves only

one quadrant

or

< 10% of pars

tensa


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Medium perforation

Involves two

quadrants

or

10 40 %

of

pars tensa


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Medium perforation


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Subtotal perforation

Involves all 4

quadrants &

reaches up to

annulus

fibrosus


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In growing epithelium

T.M.

perforation

with

inward

migration of

epithelium


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Marginal perforation

Erodes

annulus

fibrosus & onemargin is

formed by

bony tympanic

annulus


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Total perforation

Total erosion

of pars tensa

& anulus

fibrosus


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Attic perforation

Involves

pars

flaccida


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Tympanic Membrane

Retractions


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Grade 1 retraction Dull, lustreless T.M.

Prominent annulus

Cone of light absent

Handle medialized

Prominent lateral

process

Malleolar folds

sickle shaped


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Grade 2 retraction

Eardrum

touches

incus


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Grade 3 retractionTM touches

promontory

(atelectasis)

but mobile on

Valsalva

maneuver or

Siegalization


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PSQ retraction pocket


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Attic retraction pocket


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Otological examination

1. Pre-auricular region:sinus, lymph node

2. Pinna:size, position, deformity, swelling

3. Post-auricular region:surgical scar, swelling,

fistula, lymph node

4. External auditory canal:meatal opening, otitis

externa, wax, fungal debris, ear discharge


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5. Tympanic membrane:

intact:colour, position, mobility, tympanosclerosis,

retraction pocket

perforated:type, site, size& margin of perforation

handle of malleus; middle ear cavity(mucosa, ear

discharge, polyp, granulations, cholesteatoma

flakes); pars flaccida



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6. Mastoid cavity:size, facial ridge, discharge,

epithelialization, granulations, polyps

7. Tragal tenderness: associated otitis externa

8. Mastoid tenderness:cymba conchae, mastoid

body + tip & posterior zygoma root

9. Fistula sign 10. Facial nerve function

11. Tuning Fork Tests


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Tubo-tympanic

Disease


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Predisposing factors

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


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Bacteria responsible

Staphylococcus aureus

Pseudomonas aeruginosa

Klebsiella

Proteus

Streptococcus

Bacteroides


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Routes of infection

1. Via Eustachian tube:

U.R.T.I., nose blowing, regurgitation of milk

2. Via tympanic membrane perforation:

following A.S.O.M. or post-traumatic

3. Haematogenous (rare):

viral exanthematous fevers


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Pathological Changes

1. Eardrum: central perforation; myringosclerosis

2. Ossicles:Destruction (hyperaemic decalcification)

Tympanoslerosis

Fibrosis + Adhesions

3. Middle ear mucosa:edematous, pale pink

4. Mastoid bone:sclerosis


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Clinical Features

Ear discharge:profuse, mucoid / muco-purulent,

intermittent, odourless, not blood-stained

Hearing Loss: usually conductive (25-50 dB)

absent in small, dry perforations

round window shielding by ear

discharge leads to better hearing

Tympanic membrane:central perforation


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Stages of Tubotympanic disease

Otorrhoea Eardrumperforation

Last eardischarge

Active Present Present -

Quiescent Absent Present < 6 months

Inactive Absent Present > 6 months

Healed Absent Absent -


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Attico-antral

disease


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Cholesteatoma

Term used by Johannes Mllerin 1858

Three dimensional sac lined by matrix of

keratinizing stratified squamous epithelium

which rests on a thin layer of fibrous tissue

Contains desquamated keratin debris

Grows at the expense of surrounding bone Not a tumor & has no cholesterol

Epidermosisis a better term


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Cholesteatoma


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Histopathology


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Causes of bone destruction

1. Hyperaemic decalcification

2. Osteoclastic bone resorption due to:

Acid phosphatase

CollagenaseAcid proteases Proteolytic enzymes

Leukotrienes Cytokines

3. Pressure necrosis:No role

4. Bacterial toxins:No role


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Congenital (McKenzie)Primary Acquired Secondary Acquired

1. Retraction pocket 1. Squamous metaplasia

(Wittmaack) 2. Epithelial migration

2. Basal cell hyperplasia (Habermann)

(Ruedi) Tertiary Acquired

3. Squamous metaplasia 1. Post-traumatic

(Sade) 2. Post-tympanoplasty

Types of Cholesteatoma


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Congenital cholesteatoma

Persistence of congenital cell rests in middle ear,

petrous apex, cerebello-pontine angle


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Retraction pocket formation

Retraction pocket in pars flaccida or Postero-superior

quadrant pars tensa due to E.T. dysfunction


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Basal cell hyperplasia

Hyperplasia of basal cells in epithelial layer of

T.M. & their invasion of sub-epithelial tissues


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Primary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection, with no T.M. perforation


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Secondary squamous metaplasia

Transformation of middle ear mucosa into squamous

epithelium due to infection via T.M. perforation


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Epithelial migration

Migration of epithelium via T.M. perforation into middle ear


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Post-traumatic cholesteatoma

Mechanisms:

1. Epithelial entrapment in fracture line

2. In growth of epithelium through fracture line

3. Traumatic implantation of epithelium into middle ear

4. Trapping of epithelium medial to E.A.C. stenosis


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Pathological Changes

1. T.M. perforation:marginal or attic

2. T.M. retraction pocket:attic or P.S.Q.

3. Cholesteatoma formation

4. Ossicles:destruction

5. Middle ear mucosa:edematous, red

6. Aural polyp:red, fleshy

7. Osteitis & granulation tissue formation

8. Mastoid bone:erosion, sclerosis


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Clinical Features

Ear discharge:scanty, purulent, continuous, foul-

smelling, blood-stained

Hearing Loss:conductive or sensori-neural

T.M. perforation:marginal or attic or total

T.M. retraction pocket:attic or P.S.Q.

Cholesteatoma flakes

Aural polyp, osteitis & granulation tissue


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Features of Complications Severe otalgia, painful swelling around ear

Vertigo, nausea, vomiting

Headache + blurred vision + projectile vomiting

Fever + neck rigidity + irritability / drowsiness

Facial asymmetry

Gradenigo syndrome (apex petrositis)

Ataxia


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Attic cholesteatoma


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Attic cholesteatoma

PSQ h l t t &


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PSQ cholesteatoma &

granulation tissue

Atti t l T b t i


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Attico-antral Tubo-tympanic

Otorrhoea:Scanty Profuse

Continuous Intermittent

Purulent Mucoid

Blood-stained No

Foul smelling No

Attic / marginal perforation,

retraction pocket

Central perforation

Cholesteatoma, granulation No


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Tuberculous Otitis Media

Painless, odorless otorrhoea refractory to antibiotics

Multiple TM perforations large perforation

Middle ear mucosa pale (congestion around E.T.O.) Pale granulations in mastoid & middle ear

Severe deafness with bony necrosis (caries)

Facial palsy & labyrinthitis

Tx:Anti-TB therapy + cortical mastoidectomy


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Multiple T.M. perforations

Thank You


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Thank You

Date post:	04-Jun-2018
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CSOM of Middle ear part 1

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