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Chronic suppurative otitis Chronic suppurative otitis mediamedia
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 proper and mastoid air cell systemair cell system
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Tubotympanic diseaseTubotympanic disease
Also known as Also known as safe earsafe ear
It does not cause It does not cause any serious any serious complicationscomplications
Infection limited Infection limited to the antero to the antero inferior part of inferior part of middle ear cleftmiddle ear cleft
Associated with Associated with central central perforationperforation
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Why is Tubotympanic Why is Tubotympanic disease safe?disease 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 through the perforation in the pars tensatensa
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 Gram negative bacilli has been commonly isolatedcommonly isolated
Ps. aeruginosa, E. coli, and B. proteus Ps. aeruginosa, E. coli, and B. proteus These organisms are not commonly These organisms are not commonly
found in the respiratory tractfound in the respiratory tract These organisms are commonly These organisms are commonly
found in the skin of external canal found in 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 ends discharge doesn't accumulate in the middle ear cavitythe middle ear cavity
Ossicular chain is mostly uninvolvedOssicular chain is mostly uninvolved Pts have conductive deafness – 30 – Pts have conductive deafness – 30 –
40 dB40 dB 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 Middle ear mucosa
hypertrophied and congestedhypertrophied and congested The ear discharge is The ear discharge is
MucopurulentMucopurulent 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 Middle ear mucosa is normal and
healthyhealthy
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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 Tympanosclerotic patches may be
seenseen Ossicular chain invariably intactOssicular chain invariably intact
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Tuning fork testsTuning fork tests
Rinne negative on the affected Rinne negative on the affected sideside
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 ossicular chain disruption should be suspectedbe suspected
Associated sensorineural loss Associated sensorineural loss should arouse suspicion of toxic should arouse suspicion of toxic deafnessdeafness
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Conservative Conservative managementmanagement
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 Topical antibiotics administered
after culture report becomes after culture report becomes availableavailable
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 Pre-existing sinus infections to
be treated aggressivelybe treated aggressively Presence of focal sepsis in the Presence of focal sepsis in the
throat should also be managedthroat should also be managed
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Surgical managementSurgical management
Surgery towards eradication of Surgery towards eradication of focal sepsisfocal sepsis
Surgery aimed towards Surgery aimed towards eradication of middle ear disease eradication of middle ear disease (Mastoidectomy)(Mastoidectomy)
Surgery aimed at reconstruction Surgery aimed at reconstruction of sound conduction mechanism of sound conduction mechanism (Myringoplasty and (Myringoplasty and tympanoplasty)tympanoplasty)
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TympanoplastyTympanoplasty
Tympanoplasty is defined as the Tympanoplasty is defined as the surgical procedure which enables surgical procedure which enables reconstruction of middle ear cavity reconstruction of middle ear cavity and ossicular system. It also and ossicular system. It also involves reconstruction of the involves reconstruction of the perforated ear drumperforated ear drum
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Components of Components of tympanoplastytympanoplasty
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 Should be performed before grafting anterior perforationsgrafting anterior perforations
This procedure facilitates better This procedure facilitates better healinghealing
External canal can be cleansed External canal can be cleansed without any difficultywithout any difficulty
Useful when performing second Useful when performing second stage ossiculoplastystage ossiculoplasty
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MeatoplastyMeatoplasty
This procedure is performed to This procedure is performed to enlarge the lateral cartilagenous enlarge the lateral cartilagenous portion of the external canalportion of the external canal
This enlargement should be in This enlargement should be in proportion to the size of the bony proportion to the size of the bony portion of the external canalportion of the external 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 X-ray / CT scan of temporal
bonesbones Tests for anesthetic fitnessTests for anesthetic fitness
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Trans canal surgical Trans canal surgical approachapproach
Performed through Performed through ear speculum ear speculum inserted into the inserted into the ear canalear canal
Ear canal should Ear canal should be widebe wide
There should not be There should not be any bony overhang any bony overhang obscuring the obscuring the edges of edges of perforationperforation
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End aural approachEnd aural approach
Incision is made Incision is made between tragus and between tragus and helixhelix
End aural speculum is End aural speculum is usedused
Posterior bony Posterior bony overhang can easily be overhang can easily be drilled outdrilled out
Better for anterior Better for anterior visualization of the ear visualization of the ear drumdrum
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Endaural view of ear Endaural view of ear drumdrum
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Post aural approachPost aural approach
Used in cases of Used in cases of narrow external narrow external canalcanal
Used to close Used to close anterior ear drum anterior ear drum perforationsperforations
William Wild’s William Wild’s post aural incision post aural incision is usedis 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 Its thickness more or less resembles
that of normal ear drumthat of normal ear drum It can be harvested through the It can be harvested through the
same post aural incisionsame post 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 Types of grafting techniquestechniques
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 tympanic membrane remnant and boneand bone
To facilitate this process a To facilitate this process a tympanomeatal flap will have to tympanomeatal flap will have to be elevatedbe elevated
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Overlay techniqueOverlay technique
The graft is placed over the The graft is placed over the bony tympanic sulcusbony tympanic 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 The overlaid graft is supported by the remnant ear drum if by the remnant ear drum if presentpresent
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Underlay techniqueUnderlay technique
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