*ATTICO-ANTRAL CSOM

*INTRODUCTIONAlso called Unsafe or Dangerous type.Involves postero-superior part of middle ear cleft.Associated with cholesteotoma.

TYPES*

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CHOLESTEOTOMAMISNOMER:Neither it contains cholesterol crystals Nor it is benign neoplasia to merit suffix oma based on its structure may be named KeratomaEpidermosis

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*CHOLESTEOTOMASac covered by stratified squamous epithelium containing keratin pearls with granulation tissue on its advancing edge.Consists of two partsMatrix- Keratinizing squamous epithelium resting on thin fibrous tissuecentral white mass- keratin debris produced by matrixSkin in the wrong place.

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*THEORIES OF ORIGINCongenital cell rests Negative pressure.(Wittmaacks theory) Basal cells Hyperplasia(Ruedis theory) Invasion.(Habermanns theory) Metaplasia.(Sades theory)

RETRACTION POCKET*

RETRACTION POCKET*

BASAL CELL HYPERPLASIA*

BASAL CELL HYPERPLASIA*

EPITHELIA INVASION*

EPITHELIA INVASION*

*TYPES OF CHOLESTEOTOMACONGENITALArises from embryonic epithelial cell rest.TM intact.Occurs inMiddle earPetrous apexCP angleJugular fossaACQUIREDPRIMARY: No H/O previous otitis media or perforation.SECONDARY: H/O otitis media with perforation.

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EXPANSION OF CHOLESTEOTOMAInvades surrounding structures.Bone destruction by various enzymes.CollagenasesAcid phosphataseProteolytic enzymesCause destruction of ear ossicles, erosion of bony labyrinth, canal of facial nerve, sinus plate, tegmen tympani.Causes serious complication.*

*BACTERIOLOGYAEROBESPs.aeruginosa.B.proteus.E.coli.Staph.aureus.ANAEROBESBacteroides.Streptococci.

*PATHOLOGY OF AA CSOMCholesteotoma.Osteitis and granulation tissue.Ossicular necrosis.Cholesterol granuloma.

SYMPTOMSDISCHARGE:ScantyPurulent Foul-smellingBlood-stainedContinuousnot associated with URTI.

HEARING LOSS:Mostly conductiveMay be sensorineural.Sometimes normal as cholesteotoma bridges gap caused by destroyed ossicles (Cholesteotoma hearer)*

*SIGNSPERFORATION: Attic or postero-superior.DISCHARGE: Purulent, foul-smelling, blood-stained.CHOLESTEOTOMA.RETRATION POCKETS.TUNING FORK TESTS: Show conductive or sensorineural hearing loss.

EXAMINATION UNDER MICROSCOPE*

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*SADE CLASSIFICATION OF PARS TENSA RETRACTIONGRADE I: Normal position of TM.GRADE II: TM touches long process of incus.GRADE III: TM touches promontory.GRADE IV: TM adheres to promontory.

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*TOS CLASSIFICATION OF ATTIC RETRACTIONGRADE I: Minimal retraction.GRADE II: Pars flaccida in contact with neck of malleus.GRADE III: Limited outer attic wall erosion.GRADE IV: Severe outer attic wall erosion.

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*INVESTIGATIONS C/S of ear discharge.X-ray mastoids.CT Scan.MRI Scan

RADIOLOGY

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X-RAYSX-RAY MASTOIDD/D OF MASTOID CAVITYCholesteatomaLarge antrum Post-op cavity Eosinophilic granulomaTB mastoiditis*

CT SCAN

CT SCAN

CT SCAN

MRI T1-weighted images

MRI T2-weighted image

*FEATURES INDICATING COMPLICATIONSPain.Vertigo.Persistent headache.Facial weakness.Listless child refuses to feed.Fever, nausea, vomiting.Irritability and neck stiffness.Diplopia. Ataxia.Abscess round the ear.

*COMPLICATIONSEXTRA-CRANIALMastoiditis.Abscesses.Petrositis.Facial paralysis.Labyrinthitis.

INTRA-CRANIALExtradural abscess.Subdural abscess.Brain abscess.Meningitis.Lateral sinus thrombophlebitis.Otitic hydrocephalus.

*SURGICAL MANAGEMENTCANAL WALL DOWN PROCEDURES.Atticotomy.Radical Mastoidectomy.Modified Radical Mastoidectomy.CANAL WALL UP PROCEDURES.Cortical Mastoidectomy.Combined Approach Tympanoplasty.

*ATTICOTOMY A canal wall down procedure performed to remove all or part of outer attic wall and adjacent deep posterior meatal wall to expose the attic and when necessary the aditus and antrum in order to gain access to these sites and their contents and/or remove disease limited to these sites.

*RADICAL MASTOIDECTOMYA canal wall down procedure in which we remove all disease from mastoid and middle ear by lowering bridge making it a single cavity, remove all ossicles except foot-plate of stapes, remove remains of tympanic membrane, obliterate the eustachian tube, and exteriorized this cavity to EAM by doing meatoplasty.

*MODIFIED RADICAL MASTOIDECTOMYA canal wall down procedure in which we remove disease from mastoid and middle ear by lowering bridge making it a single cavity, remove only diseased ossicles, donot remove remains of tympanic membrane, donot obliterate the eustachian tube, and exteriorized this cavity to EAM by doing meatoplasty.

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*CORTICAL MASTOIDECTOMYA canal wall up procedure performed to remove disease from mastoid antrum and air cell system and aditus & antrum, with preservation of an intact posterior bony external auditory canal wall, without disturbing the existing middle ear contents.

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*COMBINED APPROACH TYMPANOPLASTYOperation performed to remove disease from middle ear and mastoid by way of Mastoid.Posterior Tympanotomy.Transcanal route.followed by reconstruction of middle ear transformer mechanism.

*TYMPANOPLASTYAn operation performed to eradicate disease in the middle ear and to reconstruct the hearing mechanism, without mastoid surgery, with or without tympanic membrane grafting.

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