CSOM

CHRONIC OTITIS MEDIA
Classification of Chronic Otitis Media

Chronic Non Suppurative Otitis Media
Otitis media with effusion OME Adhesive otitis media
Chronic Suppurative Otitis Media CSOM

Tubotympanic (Safe) Atticoantral (Unsafe)
OTITIS MEDIA WITH EFFUSION
DEFINITION
Presence of non-purulent fluid within the middle ear cleft
SYNONYMS
Secretory otitis media Middle ear effusion Sero-mucinous otitis media Catarrhal otitis media Glue ear Serous otitis media Non-suppurative otitis media
PREVALENCE
Between 20% and 50% of children do have OME at some time between 3 and 10 years of age Two peaks at 2 and 5 years of age
RISK FACTORS
Race Age Gender Season Nasopharyngeal anatomical abnormalities Cleft palate Smoking ? Allergy
HISTOPATHOLOGY
Changes in the mucosa
Vasodilatation & mononuclear cell infiltration Metaplasia of the epithelium to ciliated columnar Mucus secreting gland formation
Formation of fluid in the middle ear

Transudate Exudate Secretion
ETIOPATHOLOGY
Eustachian tube dysfunction
Chronic inflammation
ETIOLOGY
Eustachian tube dysfunction
Poor muscular function Adenoids Barotrauma Others
Infections
Unresolved AOM Adenoiditis and other URTIs
SYMPTOMS
Hearing impairment Otalgia Fluid sensation
Diagnosis
DIAGNOSIS
DIAGNOSIS
Otoscopy Tuning fork tests
DIAGNOSIS
Otoscopy Tuning fork tests PTA
DIAGNOSIS
Otoscopy Tuning fork tests PTA Tympanometry
DIAGNOSIS
Otoscopy Tuning fork tests PTA Tympanometry Myringotomy
TREATMENT
Treatment of the cause if feasible Observation Medical treatment
Antibiotics Decongestants, ?Auto-inflation ?Steroids
Surgical
Myringotomy Ventilation tubes (grommets)
COMPLICATIONS OF VENTILATION TUBES INSERTION

Infection Blockage Extrusion Tympanosclerosis Perforation
Iatrogenic Cholesteatoma
FACTORS AFFECTING TREATMENT

Age Duration Unilateral or bilateral Degree of hearing impairment Previous treatment Associated conditions Tympanic membrane changes Others
SEQUELAE
Spontaneous resolution
50% resolve within 3 months. Only 5% persists for more than 12 months
Tympanosclerosis Scarring, retraction and atelectasis Cholesteatoma
Conclusion
OME is very common in children Etiology is associated with ET dysfunction and or chronic infection In adults: Nasopharyngeal pathology should be considered Most cases resolve spontaneously Conservative treatment is of doubtful value VT insertion restore hearing in the selected cases


Tubo-tympanic (Safe) Attico-antral (Unsafe)
Chronic Adhesive Otitis Media

Formation of adhesion in the middle ear after reactivation and subsequent healing of either CSOM or OME
Clinical Features
History of CSOM or OME Deafness is usually the only symptoms TM shows various structural changes
Treatment
Observation Surgical treatment Hearing aid


Tubo-tympanic (Safe) Attico-antral (Unsafe)
CHRONIC SUPPURATIVE OTITIS MEDIA
ETIOLOGY
Environmental Genetic Previous OM Upper respiratory tract infections Eustachian tube dysfunction
CLINICO-PATHOLOGICAL TYPES
Tubo-tympanic
Attico-antral
PATHOLOGY
Signs of suppurative infection
Discharge & perforation Chronic inflammatory reaction in the mucosa and the bone (ostietis)
Signs of healing attempts

Granulation tissue & polyps Fibrosis & tympanosclerosis
Cholesteatoma (attico-antral type)
CHOLESTEATOMA
DEFINITION
The presence of a desquamating stratified squamous epithelium in the middle ear
PATHOGENESIS OF CHOLESTEATOMA
Implantation (congenital or acquired) Metaplasia Epithelial migration
CLASSIFICATION OF CHOLESTEATOMA
Congenital Acquired
Primary Secondary
Effect of Cholesteatoma
Keratin encourages persistence of the infection Matrix causes bone erosion
Clinical Features of CSOM
CLINICO-PATHOLOGICAL TYPES
Tubo-tympanic
Attico-antral (cholesteatoma)
SYMPTOMS OF CSOM
Otorrhea
Intermittent, profuse & odorless in TT type Persistent, scanty & malodorous in AA type
Deafness Tinnitus N.B. Any other symptom means complication
OTOSCOPIC EXAMINATION
Discharge
Present in TT type if active but may be absent Usually is present in AA type
Perforation
Central: in TT type Marginal or attic in AA type with cholesteatoma
PERFORATION IN TT CSOM
PERFORATION IN AA CSOM
OTOSCOPIC EXAMINATION
Discharge
Present in TT type if active but may be absent Usually is present in AA type
Perforation
Central: in TT type Marginal or attic in AA type with cholesteatoma
Polyps, granulation tissue, tympanosclerosis
Bacteriology
B A P S P K e r o b s e t a r o le u e s d a c t e A r io l o n a e g y r o b e s ea s c u p t ia
o m o n a s p h y lo c o c c u t e u s b s i e ll a a n d
a e a r c u t ge ir n o oi d s B s P a e u p r t eo uc so c P e p t o s t r e E s c h e r ic h
INVESTIGATIONS
Audiometry Bacteriology Imaging
Congenital Cholesteatoma
Cloudy middle ear in CSOM
Cholesteatoma with attic erosion
TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA

Depends on the type and presentation
Active TT type
Inactive TT type
Attico-antral type (usually active)
Conservative treatment
Active TT type
Inactive TT type
Conservative Treatment Treat any predisposing factor Keep the ear dry TYMPANOPLASTY Ear toilet Antibiotics Removal of polyps and granulations
TYMPANOPLASTY
An operation performed to eradicate disease in the middle ear cavity and to reconstruct the hearing mechanism
MYRINGOPLASTY
An operation performed tympanic membrane to repair the
AIMS OF TYMPANOPLASTY
To close the perforation To prevent re-infection To improve hearing
TREATMENT OF ATTICOANTRAL CSOM

Removal of cholesteatoma by mastoid operation
RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane, malleus and incus are removed leaving only the stapes in situ.
MODIFIED RADICAL MASTOIDECTOMY

An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane and ossicles remnants are retained
AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY

Safety Dry ear Preserve hearing
Conclusion
In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing. In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear

CSOM

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CHRONIC OTITIS MEDIA

Classification of Chronic Otitis Media

Chronic Suppurative Otitis Media CSOM

OTITIS MEDIA WITH EFFUSION

Formation of fluid in the middle ear

COMPLICATIONS OF VENTILATION TUBES INSERTION

FACTORS AFFECTING TREATMENT

Tympanosclerosis Scarring, retraction and atelectasis Cholesteatoma

Classification of Chronic Otitis Media

Chronic Suppurative Otitis Media CSOM

Chronic Adhesive Otitis Media

Classification of Chronic Otitis Media

Chronic Suppurative Otitis Media CSOM

CHRONIC SUPPURATIVE OTITIS MEDIA

Signs of healing attempts

Cholesteatoma (attico-antral type)

Clinical Features of CSOM

Deafness Tinnitus N.B. Any other symptom means complication

Polyps, granulation tissue, tympanosclerosis

Cloudy middle ear in CSOM

Cholesteatoma with attic erosion

TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA

Attico-antral type (usually active)

TREATMENT OF ATTICOANTRAL CSOM

MODIFIED RADICAL MASTOIDECTOMY

AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY

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