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C.S.O.M.: Investigations &
TreatmentDr. Vishal Sharma
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Investigations for T.T.D.• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• Patch test
• X-ray mastoid: B/L 300 lateral oblique (Schuller) Done when cortical mastoidectomy is required in ear discharge refractory to antibiotics
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Uses of Audiometry• Presence of hearing loss
• Degree of hearing loss
• Type of hearing loss
• Hearing of other ear
• Record to compare hearing post-operatively
• Medico legal purpose
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Patch TestDone when deafness = 40-50 dB
• Do pure tone audiometry: for hearing threshold
• Put Aluminum foil patch over T.M. perforation
• Repeat pure tone audiometry:
Hearing improved = ossicular chain intact & mobile
Hearing same / worse = oss. chain broken or fixed
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Investigations for A.A.D.• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
• CT scan: revision surgery, complications, children
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Uses of E.U.M.• Confirmation of otoscopy findings
• Epithelial migration at perforation margin
• Cholesteatoma & granulations
• Adhesions & tympanosclerosis
• Assesment of ossicular chain integrity
• Collection of discharge for culture sensitivity
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Uses of X-ray mastoid1. Position of dural & sinus plates: helps in surgery
2. Type of pneumatization:
a. Cellular (80%): plenty of air cells
b. Sclerotic (20%): small antrum, air cells absent
c. Diploetic (<1%): bone marrow within few air cells
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity
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Dural & sinus plates
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Cellular mastoid
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Sclerotic mastoid
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Diploetic mastoid
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Attic bone erosion
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Causes for mastoid cavity• Cholesteatoma erosion• Mastoidectomy cavity• Tubercular mastoiditis• Coalescent mastoiditis• Malignancy• Eosinophilic granuloma• Mega-antrum• Large emissary vein
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C.T. scan temporal bone
Posterior canal wall erosion
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C.T. scan temporal bone
Mastoid cholesteatoma
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Treatment for Tubo-tympanic
Disease
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Non-surgical Treatment• Precautions• Aural toilet• Antibiotics: Systemic & Topical• Antihistamines: Systemic & Topical• Nasal decongestant: Systemic & Topical• Treatment of respiratory infection & allergy• Tympanic membrane patcher
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Precautions• Encourage breast feeding with child’s head
raised. Avoid bottle feeding.
• Avoid forceful nose blowing
• Plug E.A.C. with Vaseline smeared cotton
while bathing & avoid swimming
• Avoid putting oil & self-cleaning of E.A.C.
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Done only for active stage
– Dry mopping with cotton swab
– Suction clearance: best method
– Gentle irrigation (wet mopping)
1.5% acetic acid solution used T.I.D.
Removes accumulated debris
Acidic pH discourages bacterial growth
Aural Toilet
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AntibioticsTopical Antibiotics:
Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin
Antibiotics + Steroid: for polyps, granulations
Neosporin + Betamethasone / Hydrocortisone
Oral Antibiotics: for severe infections
Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
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Antihistamines & Decongestants Antihistamines Systemic decongestants
Chlorpheniramine Pseudoephedrine
Cetirizine Phenylephrine
Fexofenadine Topical decongestants
Loratidine Oxymetazoline
Levo-cetrizine Xylometazoline
Azelastine (topical) Hypertonic saline
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Kartush T.M. PatcherIndicated in:
• Perforation in only
hearing ear
• Patient refuses surgery
• Patient unfit for surgery
• Age < 7 years
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Surgical TreatmentIndicated in inactive or quiescent stage
• Myringoplasty
• Tympanoplasty
Indicated in active stage
• Cortical Mastoidectomy
• Aural polypectomy
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Methods to close perforationT.M. perforation < 2 mm
Chemical cautery with silver nitrate Fat grafting Myringoplasty if these measures fail
T.M. perforation > 2 mm Tympanic membrane patcher Myringoplasty
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Chemical cautery
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Approaches to middle ear
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Wilde’s post-aural incision
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Lempert’s end-aural incision
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Rosen’s permeatal incision
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Hearing RestorationMyringoplasty: • surgical closure of tympanic membrane perforation
Ossiculoplasty: • surgical reconstruction of ossicular chain
Tympanoplasty: • Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery
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Principles of hearing restoration• Intact tympanic membrane• Intact ossicular chain• Functioning receiving & relieving windows• Acoustic separation of these windows• Functioning Eustachian tube• Absence of sensori-neural hearing loss• Absence of active infection / allergy in
middle ear cleft
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Myringoplasty
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Aims• Permanently stop ear discharge: dry, safe ear• Improve hearing: provided: 1. ossicles are intact +
mobile; 2. absence of sensori-neural deafness• Prevention of: tympanosclerosis, adhesions,
vertigo, S.N.H.L. (cochlear exposure to loud sound)• Wearing of hearing aid• Occupational: military, pilots• Recreation: swimming, diving
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Contraindications• Purulent ear discharge• Otitis externa• Respiratory allergy• Age < 7 yr (Eustachian tube not fully developed)
• Only hearing ear• Cholesteatoma
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MethodsTechniques:
• Underlay: graft placed medial to fibrous annulus
• Overlay: graft placed lateral to fibrous annulus
Grafts used:
• Temporalis fascia, Tragal perichondrium, Vein
graft, Fascia lata, Dura mater
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Underlay myringoplasty
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Overlay myringoplasty
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Steps of underlay myringoplasty
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Tympanomeatal flap raised
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Placement of graft
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Tympanomeatal flap replaced
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Tympanomeatal flap replaced
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Why temporalis fascia?• Basal metabolic rate lowest (best survival rate)
• Easily harvested by post-aural incision
• Its an autograft, so no rejection
• Same thickness as normal tympanic membrane
• Large size graft can be harvested
• Good resistance to infection
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Onlay UnderlayGraft cholesteatoma No
Blunting of anterior tympano-meatal angle
No
Lateralization of graft No
Delayed healing time (6 wk) 3-4 weeks
No middle ear inspection Possible
Difficult & takes more time Easier & quicker
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Advantages of Local Anesthesia
• Minimal bleeding
• Hearing results can be tested on table
• Facial palsy detected immediately
• Labyrinthine stimulation detected
immediately
• No complications of General anesthesia
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Tympanoplasty
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Types
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Type Pathology Graft placed on
I Ear drum perforation only Malleus handle
II Malleus handle eroded Incus
III Malleus + Incus eroded Stapes head
IV Only footplate remains: mobile
Round window (Footplate exposed)
V Only stapes remains: fixed Lateral SCC opening
VI Only footplate remains: mobile
Stapes Footplate
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Malleus / Incus Autografts
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Thank You