csom (chronic suppurative otitis media)

Dr.Ramesh Parajuli

CSOM/COM: Definition

• Chronic (> 3 months) infection of middle ear cleft mucosa characterized by perforation of tympanic membrane, ear discharge (continuous or intermittent) & decreased hearing.

• Most likely a result of earlier AOM, negative

middle ear pressure or OME

• Most important cause of hearing impairment in rural population

Types of CSOM1.CSOM -Tubotympanic (Mucosal): Safe type

2.CSOM-Atticoantral (Squamous): Unsafe type

• COM T T (Mucosal):

Inactive: Central perforation of pars tensa, Dry (middle ear mucosa not inflmmed)

Active: Central perforation of pars tensa associated with discharge or granulation tissue

Stages of COM

• COM AA (Squamous): Inactive: Retraction of tympanic

membrane(pars flaccida or tensa)

Active: Attic perforation, marginal peforation associated with discharge/cholesteatoma/granulation tissue

Retraction of pars tensa Retraction of pars flaccida

cholesteatoma & granulation tissue

Predisposing factors for CSOM

• URTI

• Allergy

• Pre-existing otitis media with effusion(OME)

• Eustachian tube dysfunction

• Negative middle ear pressure

• Cleft palate

• Immune deficiency

• Poor socio-economic status

• Staphylococcus aureus

• Pseudomonas aeruginosa

• Klebsiella

• Proteus

• Streptococcus

• Bacteroides

• E.coli

Bacteriology of CSOM

Routes of infection for CSOM-TT

1.Via Eustachian tube: URTI, nose blowing, regurgitation of milk

2.Via tympanic membrane perforation:

Following AOM or post-traumatic

3.Haematogenous (rare):

Viral exanthematous fever

Clinical Features of CSOM-TT

Symptoms:Recurrent Ear discharge: profuse,mucopurulent,

intermittent, odourless, not blood-stained

Hearing Loss: usually conductive (25-50 dB)

Signs:

• Ear discharge• Perforation of pars tensa• Middle Ear Mucosa –

Oedematous• Granulation tissue/aural

polyp

Natural history of CSOM TT

I. Progression towards healing

II. Progression with continued activity •Further hearing loss•Ossicular damage•Complications•Secondary acquired cholesteatoma

Investigations for CSOM-TT

• Examination under microscope (EUM)• Ear discharge swab: for culture sensitivity• Pure tone audiometry (PTA)

(I) Medical treatment:

Active stage

Topical antibiotics with aural toilet: Ocupol-D/Betnor ear drops

Oral antibiotics: Ciprofloxacin, Amoxycillin

Inactive stage:Aural Precautions

Treatment of CSOM-TT

(II) Surgical treatment

Myringoplasty: Aims 1.To make ear dry 2.To improve hearing 3.Occupation 4.Recreation 5.To prevent

complications 6.Hearing aid

Graft materials 1.Temporalis fascia 2.Cartilage (Tragal, Conchal)3.Fat 4.Vein5.Canal skin6.Split Thickness Skin Graft 7.Composite

cartilage/perichondrium8.Pericardium, Dura

Approach

1. Postaural Approach

2. Transcanal(permeatal) Approach

3. Endaural Approach

Underlay technique

Post operative instructions

To insure proper healing, avoid the following:

Avoid Blowing nose Sneezing open mouth sneezing Exposing ear to water Flying: for 3 months Heavy weight lifting and straining Return of hearing may take up to 6 - 8

weeks PTA after 3 months

CSOM Attico-antral(Squamous)

Cholesteatoma

• Definition: Sac lined by keratinising squamous epithelium (KSE) containing desquamated epithelial debris in the middle ear cleft ,which has bone eroding property.

• Hallmark: Retention of desquamated keratin debris

• Narrow neck and inner surface of sac continuously produce keratin Desquamated dead keratin collects in & sac expands

• Misnomer: Not a tumor & has no cholesterol

Histologically made up of:1.Center: Desquamated epithelial debris(keratin)2.Matrix: Keratinizing stratified squamous epithelium(KSE)3.Perimatrix: Granulation tissue in contact with bone

perimatrix

Causes of bone erosion/destruction in cholesteatoma

1.Enzymatic theory: Osteoclastic bone resorption due to release of various enzymes: Acid phosphatase Collagenase Acid proteases Proteolytic enzymes Leukotrienes Cytokines2. Pressure necrosis3. Pyogenic osteitis

Classification Types of cholesteotoma1. Congenital 2. Acquired (I) Primary: Occurs where there is no previous

history of ear discharge (II)Secondary:Occurs in already diseased ear i.e.

CSOM-TT (III)Tertiary (Implantation): iatrogenic eg. post-

tympanoplasty

Theories of origin of cholesteatoma

1. Theory of invagination (retraction pocket) (Wittmaack’s)

2. Theory of epithelial invasion (Habermann’s)

3. Theory of basal cell hyperplasia (Ruedi’s)

4. Theory of squamous metaplasia (Sade’s)

Congenital cholesteatoma

Embryonal Squamous epithelial cell rests fails to disappear during developmentPersistence in middle ear, petrous apex, CPA angle

Clinical Features1. Ear discharge: scanty, purulent, continuous, foul- smelling,

blood-stained

2. Hearing Loss: conductive or mixed

3. TM perforation: attic or marginal; or central perforation with

inward growing epithelium towards middle ear

4. TM retraction pocket:

5. Cholesteatoma flecks

6. Aural polyp & granulation tissue

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

Aural polyp

PSQ cholesteatoma & granulation tissue

Attico-antral(squamous) Tubo-tympanic(mucosal)

Quantity/Amount of discharge:Scanty Profuse

Continuous IntermittentCharacter: Purulent Mucoid

Blood-stained No

Smell: Foul smelling Non foul smelling

Perforation: Attic or marginal Central perforation

Cholesteatoma: present Absent

Polyp & Granulation tissue: common Uncommon

Hearing loss:Mod.to Sev., mixed HL Mild to moderate,CHL

Complications: common(unsafe COM) Rare(Safe COM)Treatment: surgical i.e. MRM Medical or surgical(M’plasty)

Investigations for AA disease

1. EUM (examination under anesthesia): Confirmation of

otoscopy findings

2. Ear discharge swab: for culture sensitivity

3. PTA (pure tone audiogram):

4. X-ray mastoid: Towne’s view and lateral oblique view

5. CT scan: Revision surgery, complications, children

Examination under microscope(EUM)

X-Ray Mastoid-lateral oblique view

sinus plate

Dural plate

Attic bone erosion

Treatment for Attico-antral disease

Topical ear drops + frequent suction clearanceIndications:1. Early disease with shallow retraction pocket2. Only hearing ear with cholesteatoma3. Elderly patients4. Patients who are not fit for surgery under G.A.5. Patients who can regularly come for follow up

Medical Treatment

Canal Wall down(CWD)

• Modified Radical Mastoidectomy (MRM)

• Radical Mastoidectomy

Canal Wall up(CWU)

• Combined Approach Tympanoplasty (CAT)

• Cortical mastoidectomy

Surgical Treatment

Mac Ewen’s (suprameatal) triangle

Mac Ewen’s(suprameatal) triangle

Canal Wall Up Mastoidectomy

Canal Wall Down Mastoidectomy