chronic suppurative otitis media
TRANSCRIPT
CHRONIC SUPPURATIVE OTITIS MEDIA
Introduction
• CSOM is a long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation.
Epidemiology
• Higher in developing countries because of poor socioeconomic standards, poor nutrition and lack of health education.
• Both sexes and all age groups.
TYPES
Tubotympanic or safe
• Profuse, mucoid, odourless discharge
• Central perforation• Granulations uncommon• Pale polyp• Cholesteatoma absent• Complications rare• Mild to moderate conductive
deafness
Atticoantral or unsafe
• Scanty, purulent, foul-smelling discharge
• Attic or marginal perforation• Granulations common• Red and fleshy polyp• Cholesteatoma present• Complications common• Conductive or mixed deafness
Tubotympanic type
Aetiology
• It is the sequelae of acute otitis media usually following exanthematous fever and leaving behind a large central perforation.
• Ascending infections via the eustachian tube.• Persistent mucoid otorrhea is sometimes the result of
allergy to ingestants such as milk, eggs, fish, etc.
Central perforation
Pathology
• Perforation of pars tensa• Middle ear mucosa- normal when disease is quiscent or
inactive. Oedematous and velvety when disease is active.• Polyp• Ossicular chain• Tympanosclerosis• Fibrosis and adhesions
Bacteriology
• Pus culture in both types of aerobic and anaerobic CSOM may show multiple organisms.
• Common aerobic organisms are Ps. Aeruginosa, Proteus, E. coli and Staph. Aureus, while anaerobes include Bacteroides fragilis and anaerobic Streptococci.
Alternative classification
Tubotympanic
• Active- perforation of pars tensa, inflammation of mucosa and mucopurulent discharge.
• Inactive- permanent perforation of pars tensa but middle ear mucosa is not inflamed and there is no discharge.
Atticoantral
• Active- presence of cholesteatoma of posterosuperior region of pars tensa or in pars flaccida.
• Inactive- retraction pockets in pars tensa or pars flaccida.
Clinical features
• Ear discharge- non-offensive, mucoid or mucopurulent, constant or intermittent.
• Hearing loss- conductive type
Round window phenomenon• Perforation• Middle ear mucosa- normally, it is pale pink and moist;
when inflamed it looks red, oedematous and swollen.
Investigations
• Examination under microscope• Audiogram• Culture and sensitivity of ear discharge• Mastoid X- rays/ CT scan temporal bone
Treatment
• Aural toilet• Ear drops• Systemic antibiotics• Precautions• Treatment of contributory causes- tonsils, adenoids,
maxillary antra and nasal allergy• Surgical treatment• Reconstructive surgery
Atticoantral type
• Aetiology- cholesteatoma• Patology
1. Cholesteatoma
2. Osteitis and granulation tissue
3. Ossicular necrosis
4. Cholesterol granuloma
Cholesteatoma
Symptoms and signs
Symptoms
• Ear discharge- usually scanty, but always foul smelling due to bone destruction
• Hearing loss• Bleeding
Signs
• Perforation• Retraction pocket• Cholesteatoma
Investigations
• Examination under microscope• Tuning fork tests and audiogram• X- ray mastoids/ CT scan temporal bone• Culture and sensitivity of ear discharge
Features indicating complications of CSOM
• Pain• Vertigo• Persistent headache• Facial weakness• A listless child refusing to take feeds and easily going to
sleep• Fever, nausea and vomiting• Irritability and neck rigidity• Diplopia• Ataxia• Abscess around ear
Treatment
• Surgical treatment
1. Canal wall down procedure
2. Canal wall up procedure• Reconstructive surgery• Conservative treatment
Comparison of procedures
Canal wall up procedure Canal wall down procedure
Meatus Normal appearance Widely open meatus communicating with mastoid
Dependence Does not require routine cleaning Dependence on doctor for cleaning mastoid cavity once or twice a year
Recurrence or residual disease High rate of recurrent or residual cholesteatoma
Low rate of recurrence or residual disease and thus a safe procedure
Second look surgery Requires second look surgery after 6 months or so to rule out cholesteatoma
Not required
Patients limitations No limitation. Patient allowed swimming.
Swimming can lead to infection of mastoid cavity and it is thus curtailed
Auditory rehabilitation Easy to wear a hearing aid if needed
Problems in fitting a hearing aid due to large meatus and mastoid cavity which sometimes gets infected