c.s.o.m.: clinical features
DESCRIPTION
C.S.O.M.: Clinical Features. Dr. Vishal Sharma. Definition. Chronic (> 3 months) pyogenic infection of middle ear cleft mucosa , characterized by persistent perforation of tympanic membrane, ear discharge & decreased hearing Prevalence in Nepal: 7.2 %. Types of C.S.O.M. - PowerPoint PPT PresentationTRANSCRIPT
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C.S.O.M.: Clinical Features
Dr. Vishal Sharma
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Definition
• Chronic (> 3 months) pyogenic infection of
middle ear cleft mucosa, characterized by
persistent perforation of tympanic membrane,
ear discharge & decreased hearing
• Prevalence in Nepal: 7.2 %
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Types of C.S.O.M.Tubo-tympanic: chronic pyogenic infection of
middle ear cleft mucosa with persistent perforation
in pars tensa
Attico-antral: chronic pyogenic infection of middle
ear cleft with cholesteatoma & granulations in attic
or postero-superior quadrant of pars tensa
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Middle ear cleft
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Tubo-tympanic vs. Attico-antral
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Tympanic Membrane Perforations
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TypesPerforation of Pars Tensa
1. Central tubo-tympanic
Small Medium Large Subtotal
2. Central with ingrowing epithelium attico-antral
3. Marginal attico-antral
4. Total attico-antral
Perforation of Pars Flaccida
1. Attic attico-antral
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4 quadrants of T.M.
umbo
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Small perforation
Involves only
one quadrant
or
< 10% of pars
tensa
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Medium perforation
Involves two
quadrants
or
10 – 40 %
of
pars tensa
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Medium perforation
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Large perforationInvolves 3 or 4
quadrants with
wide T.M.
remnant
or
> 40 % of pars
tensa
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Subtotal perforation
Involves all 4
quadrants &
reaches up to
annulus
fibrosus
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In growing epithelium
T.M.
perforation
with
inward
migration of
epithelium
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Marginal perforation
Erodes
annulus
fibrosus & one
margin is
formed by
bony tympanic
annulus
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Marginal perforation
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Total perforation
Total erosion
of pars tensa
& anulus
fibrosus
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Attic perforation
Involves
pars
flaccida
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Tympanic Membrane Retractions
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Grade 1 retraction• Dull, lustreless T.M.
• Prominent annulus
• Cone of light absent
• Handle medialized
• Prominent lateral
process
• Malleolar folds
sickle shaped
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Grade 2 retraction
Eardrum
touches
incus
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Grade 3 retractionTM touches
promontory
(atelectasis)
but mobile on
Valsalva
maneuver or
Siegalization
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Grade 4 retraction
TM firmly
adherent to
promontory &
immobile on
Valsalva
maneuver or
Siegalization
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PSQ retraction pocket
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Attic retraction pocket
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Otological examination
1. Pre-auricular region: sinus, lymph node
2. Pinna: size, position, deformity, swelling
3. Post-auricular region: surgical scar, swelling,
fistula, lymph node
4. External auditory canal: meatal opening, otitis
externa, wax, fungal debris, ear discharge
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5. Tympanic membrane:
intact: colour, position, mobility, tympanosclerosis,
retraction pocket
perforated: type, site, size & margin of perforation
handle of malleus; middle ear cavity (mucosa, ear
discharge, polyp, granulations, cholesteatoma
flakes); pars flaccida
Otological examination
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Otological examination6. Mastoid cavity: size, facial ridge, discharge,
epithelialization, granulations,
polyps
7. Tragal tenderness: associated otitis externa
8. Mastoid tenderness: cymba conchae, mastoid
body + tip & posterior zygoma root
9. Fistula sign 10. Facial nerve function
11. Tuning Fork Tests
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Tubo-tympanic Disease
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Predisposing factors• Upper respiratory tract infection (recurrent)
• Upper respiratory tract allergy
• Pre-existing otitis media with effusion
• Cleft palate
• Immune deficiency: diabetes, AIDS
• Poor socio-economic status
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Bacteria responsible
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Klebsiella
• Proteus
• Streptococcus
• Bacteroides
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Routes of infection
1. Via Eustachian tube:
U.R.T.I., nose blowing,
regurgitation of milk
2. Via tympanic membrane perforation:
following A.S.O.M. or post-traumatic
3. Haematogenous (rare):
viral exanthematous fevers
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Pathological Changes
1. Eardrum: central perforation; myringosclerosis
2. Ossicles: Destruction (hyperaemic decalcification)
Tympanoslerosis
Fibrosis + Adhesions
3. Middle ear mucosa: edematous, pale pink
4. Mastoid bone: sclerosis
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Clinical Features
Ear discharge: profuse, mucoid / muco-purulent,
intermittent, odourless, not blood-stained
Hearing Loss: usually conductive (25-50 dB)
absent in small, dry perforations
round window shielding by ear
discharge leads to better hearing
Tympanic membrane: central perforation
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Stages of Tubotympanic diseaseOtorrhoea Eardrum
perforationLast ear
discharge
Active Present Present -
Quiescent Absent Present < 6 months
Inactive Absent Present > 6 months
Healed Absent Absent -
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Attico-antral disease
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Cholesteatoma• Term used by Johannes Müller in 1858
• Three dimensional sac lined by matrix of
keratinizing stratified squamous epithelium
which rests on a thin layer of fibrous tissue
• Contains desquamated keratin debris
• Grows at the expense of surrounding bone
• Not a tumor & has no cholesterol
• Epidermosis is a better term
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Cholesteatoma
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Histopathology
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Causes of bone destruction1. Hyperaemic decalcification
2. Osteoclastic bone resorption due to:
Acid phosphatase Collagenase
Acid proteases Proteolytic enzymes
Leukotrienes Cytokines
3. Pressure necrosis: No role
4. Bacterial toxins: No role
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Congenital (McKenzie)
Primary Acquired Secondary Acquired
1. Retraction pocket 1. Squamous
metaplasia
(Wittmaack) 2. Epithelial migration
2. Basal cell hyperplasia (Habermann)
(Ruedi) Tertiary Acquired
3. Squamous metaplasia 1. Post-traumatic
(Sade) 2. Post-tympanoplasty
Types of Cholesteatoma
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Congenital cholesteatoma
Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle
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Congenital cholesteatoma
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Retraction pocket formation
Retraction pocket in pars flaccida or Postero-superior
quadrant pars tensa due to E.T. dysfunction
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Basal cell hyperplasia
Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-
epithelial tissues
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Primary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection, with no T.M. perforation
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Secondary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection via T.M. perforation
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Epithelial migration
Migration of epithelium via T.M. perforation into middle ear
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Post-traumatic cholesteatoma
Mechanisms:
1. Epithelial entrapment in fracture line
2. In growth of epithelium through fracture line
3. Traumatic implantation of epithelium into middle ear
4. Trapping of epithelium medial to E.A.C. stenosis
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Pathological Changes1. T.M. perforation: marginal or attic
2. T.M. retraction pocket: attic or P.S.Q.
3. Cholesteatoma formation
4. Ossicles: destruction
5. Middle ear mucosa: edematous, red
6. Aural polyp: red, fleshy
7. Osteitis & granulation tissue formation
8. Mastoid bone: erosion, sclerosis
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Clinical FeaturesEar discharge: scanty, purulent, continuous, foul-
smelling, blood-stained
Hearing Loss: conductive or sensori-neural
T.M. perforation: marginal or attic or total
T.M. retraction pocket: attic or P.S.Q.
Cholesteatoma flakes
Aural polyp, osteitis & granulation tissue
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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
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Otorrhoea & aural polyp
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Attic cholesteatoma
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Attic cholesteatoma
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PSQ cholesteatoma & granulation tissue
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Attico-antral Tubo-tympanic
Otorrhoea: Scanty Profuse
Continuous Intermittent
Purulent Mucoid
Blood-stained No
Foul smelling No
Attic / marginal perforation, retraction pocket
Central perforation
Cholesteatoma, granulation No
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Tuberculous Otitis Media• Painless, odorless otorrhoea refractory to antibiotics
• Multiple TM perforations large perforation
• Middle ear mucosa pale (congestion around E.T.O.)
• Pale granulations in mastoid & middle ear
• Severe deafness with bony necrosis (caries)
• Facial palsy & labyrinthitis
• Tx: Anti-TB therapy + cortical mastoidectomy
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Multiple T.M. perforations
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