CHRONIC CHRONIC SUPPURATIVE OTITIS SUPPURATIVE OTITIS

MEDIAMEDIA

CHRONIC CHRONIC SUPPURATIVE OTITIS SUPPURATIVE OTITIS

MEDIAMEDIA

CSOM: DEFINITION• Chronic SUPPURTAIVE

inflammation of the middle ear cleft (middle ear, ET and mastoid) of > 6 weeks duration, usually following ASOM, with a non-intact TM

• Perforation of the pars tensa or pars flaccida

CLASSIFICATION• Tubotympanic

disease• Atticoantral disease

CSOM:PREVALENCE• High in ethnic groups and developing

countries• Aboriginals of Australia 85%• Eskimos 12%• Native Americans 8%• India 6-12%, higher in some areas• United Kingdom 0.5%

CSOM:PREDISPOSING FACTORS

PATIENT FACTORS EUSTACHIAN TUBE DYSFUNCTION

• MALNUTRITION & IMMUNODEFICIENCY• EARLY NASOPHARYNGEAL COLONISATION:

PNEUMOCOCCUS• DOWN’S SYNDROME• CLEFT PALATE• ALLERGY• GERD

CSOM:PREDISPOSING FACTORS

ENVIRONMENTAL FACTORS• PASSIVE SMOKING• POOR HYGEINE• OVERCROWDING• DAY CARE• INACCESSIBLE HEALTH CARE

CSOM:BACTERIOLOGY• PSEUDOMONAS AERUGINOSA (18-

67%)• KLEBSIELLA (4-43%)• PROTEUS MIRABILIS (4-43%)• ANAEROBES-Bacteroides (1-91%)• STAPHYLOCOCCUS (14-33%)• STREPTOCOCCUS

Differences Tubotympanic disease

Atticoantral disease

Discharge Profuse, mucoid

Scanty, foul-smelling

Perforation Central Attic/ marginal

Granulations Uncommon Common

Polyp Pale Red and fleshy

Cholesteatoma

Absent Common

Complications Rare Common

PTA mild- mod CHL

CHL/ mixed HL

Clinical featuresHISTORY

• Ear discharge : – non-offensive, mucoid, constant or

intermittent – increases at the time of URI or entry of

water in the ear– Last attack ?

• Hearing loss :

– Conductive type– Round window shielding effect

Active < 6 weeks

Quiescent 6 wks- 6 months

Inactive > 6 months

Signs • External auditory meatus :

discharge may be seen if active• Perforation : pars tensa

– Central• Small• Medium• Large • Subtotal

CSOM:OTOSCOPY

Signs • Middle ear mucosa

– Inactive : pale pink– Active : red, oedematous and swollen– Polyp may be seen – pale, fleshy

• Ossicular chain : usually intact, long process of incus may show necrosis

Signs • Mastoid tenderness / swelling• Tuning fork tests :

– Rinne’s test – positive on side of affected ear– Weber’s test- lateralised to affected ear– ABC – not decreased

• Examination of nose, oral cavity and pharynx

Investigations • Examination under microscope• Pure tone audiometry :

– Degree of hearing loss– Type of hearing loss

• Culture and sensitivity :– Selection of proper antibiotic

• Mastoid X-ray

TREATMENT• Aural toilet :

– Dry mopping– Suction clearance

• Ear drops :– Ciprofloxacin– Norfloxacin

• Treatment of contributory causes :– Treat infected tonsils, adenoids, sinuses

• Surgical treatment :– Removal of polyp/ cortical mastoidectomy

Cortical mastoidectomy

Reconstructive surgery• Once the ear is

dry• Myringoplasty • Tympanoplasty

ATTICOANTRAL TYPE• Involves the posterosuperior part

of the middle ear cleft– Attic– Antrum– Posterior tympanum and mastoid

• Associated with cholesteatoma• Unsafe / dangerous type

CSOM: PATHOLOGY• Mucosal damage• Osteitis of

ossicles, mastoid• Inflammatory

granulation tissue• Tympanosclerosis• Atticoantral• Cholesteatoma

Cholesteatoma • ‘ skin in the wrong place’• Keratinised squamous epithelium in

the middle ear• Secondary acquired cholesteatoma :

• Migration of squamous epithelium ( Habermann’s theory )

• Metaplasia of the middle ear epithelium (Sade’s theory )

• Cholesteatoma has the property of invasion and enzymatic bone destruction

CSOM: CHOLESTEATOMA

• Congenital – behind an intact TM

• Acquired Primary

Secondary

CHOLESTEATOMA-THEORIES

• Wendt’s metaplasia theory- Metaplasia of ME & attic epithelium due to infection

• Ruedi’s hyperplasia theory- Invasive hyperplasia of basal layers of meatal skin adjacent to upper margin of TM

• McGuckin’s theory – Invasive hyperkeratosis of deep EAC skin

• Wittmaack’s theory- Retraction/collapse of TM with invagination secondary to ET dysfunction

Symptoms • Ear discharge :

– Scanty, foul-smelling– May be blood stained

• Hearing loss– Conductive loss

Features indicating complications :

• Vertigo• Headache• Facial weakness• Vomiting • Neck rigidity • Diplopia, ataxia• Swelling in the region of mastoid

Signs • Perforation : – Attic / posterior-superior marginal

perforation– May be masked by granulation/ discharge

• Retraction pocket :– Invaginated tympanic membrane in

attic/posterior-superior region– If deep, keratin mass can accumulate

• Cholesteatoma : – White flakes in retraction pocket– Seen using operating microscope

Retraction pocket

Investigations • Examination under microscope :

– Cholesteatoma, retraction pocket, perforation

• Pure tone audiometry : – Degree of hearing loss– Type of hearing loss

• Culture and sensitivity :– Selection of proper antibiotic

• Mastoid X-ray :– Extent of bone destruction,– Law’s view

TREATMENT• Aural toilet :

– Dry mopping– Suction clearance

• Surgery :– Modified Radical Mastoidectomy– Reconstructive surgery :

• Tympanoplasty

CSOM: TREATMENT• MEDICAL: AURAL TOILET FOLLOWED BY

TOPICAL ANTIBIOTIC EAR DROPS- Ciprofloxacin ear drops, Norfloxacin ear drops

• TREAT UNDERLYING FOCUS: ADENOIDS, SINUSITIS

• SYSTEMIC ANTIBIOTICS- ACUTE EXACERBATION/ FOR COMPLICATIONS

CSOM : SURGERY

• MYRINGOPLASTY

• TYMPANOPLASTY (TYPES I TO VI)

• OSSICULOPLASTY

CSOM: SURGERY

• CORTICAL MASTOIDECTOMY • MODIFIED RADICAL MASTOIDECTOMY• RADICAL MASTOIDECTOMY

Complications

Intratemporal Intracranial

-mastoiditis -Extradural abscess

-petrositis -Subdural abscess

-facial paralysis -Meningitis

-labyrinthitis -Brain abscess

-LST

-Otitic hydrocephalus