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PRESENTER
M.ISMAIL.DARS
MOIZ
EPIDEMIOLOGY
Incidence is higher in developing
countries
Affects both sexes and all age
groups
Most important cause of hearing
impairment in rural population
TYPES
Clinically it is divided into
two types
1.Tubotympanic
2.Atticoantral
TUBOTYMPANIC
It involves anteroinferior part of middle
ear cleft (eustachian tube,
mesotympanum) and is associated with a
central perforation
Safe/benign type
No risk of serious complications
Atticoantarl
It involves posterosuperior part of
the cleft (attic ,antrum,mastoid)
Associated with an attic or marginal
perforation
It is often associated with bone
eroding process such as
cholesteatoma,granulations or osteitis
Risk of complications is high
Unsafe/dangerous type
property
Tubotympanic
Atticoantral
Discharge
Profuse,mucoid,
odourless
Scanty,purulent,
foul smelling
Perforation
Central
Marginal
Granulations Uncommon
Common
Polyp
Pale
Cholesteato
ma
Absent
Present
Complicatio
ns
Rare
Common
Audiogram
Mild to
moderate
conductive
deafness
Conductive or mixed
deafness
1.TUBOTYMPANIC
1.AETIOLOGY
The disease starts in childhood and is
common in that age group
Sequela of acute otitis media usually
following exanthematous fever and leaving
behind a large central perforation
Ascending infections via eustachian
tube causes persistent and recurring
otorrhoea
Allergy to ingestants (milk,egg) causes
persistent mucoid otorrhoea
2.PATHOLOGICAL CHANGES
Perforation of pars tensa-it is a central
perforation, size and position varies
Middle ear mucosa-disease is
quiescent/inactive- normal mucosa
disease active- oedematous and velvety
mucosa
Polyp-pale to pink
Ossicular chain- intact , mobile but shows
some degree of necrosis( long process of incus)
Tympanosclerosis-hyalinization and
subsequent calcification of subepithelial
connective tissue.. Causes conductive deafness
Fibrosis and adhesions- result of healing
process
impair mobility of ossicular chain/block
eustachian
tube
3.BACTERIOLOGY
Pus culture in both aerobic and anaerobic types of
csom show multiple organisms
Aerobes
Anaerobes
Pseudomonas
aeruginosa
Bacteroides fragilis
Proteus
Anaerobic streptococci
Escherichia coli
Staphylococcus aureus
Tubotympanic
Atticoantral
Active-perforation of pars
tensa with inflammation of
mucosa and mucopurulent
discharge
Active-presence of
cholesteatoma in posterosuperior
part of pars tensa/in pars
flaccida. Erodes bone ,form
granulation tissue,has purulent
offensive discharge
Inactive- permanent
perforation of pars tensa but
middle ear mucosa isnt
inflamed & theres no
discharge.
Inactive-retraction in pars
tensa/pars flaccida,no discharge
Clinical features
Ear discharge-nonoffensive , mucoid/mucopurulent
,constant/intermittent.
Appears at the time of URT infection or on accidental
entry of
water into ear
Hearing loss-conductive type (rarely exceeds 50dB)
Perforation- always central ! May lie
ant./post./inferior to handle of malleus. Can be
small/med./large
Middle ear mucosa- seen when perforation is large.
normally-pale pink & moist
inflamed-red , edematous
occasionally polyp is seen
INVESTIGATIONS
Examination under microscope
Audiogram
Culture and sensitivity of ear
discharge
Mastoid xrays/ct scan temporal
bone
TREATMENT
Aural toilet- dry mopping with absorbent cotton buds
suction clearance under microscope
2.Atticoantral
1.Aetiology
It is seen in sclerotic
mastoid
cholesteatoma
2.Pathology
It is associated with the following
pathological processes
Cholesteatoma-skin in wrong place
It is presence of keratinized squamous
epithelium in the middle ear or mastoid
Osteitis and granulation tissueinvolves outer attic wall and
posteriosuperior margin of tympanic ring
Ossicular necrosis- hearing loss
Cholesterol granuloma- mass of
granulation tissue with foreign body giant
cells surrounding the cholesterol crystals
3.Symptoms
Ear discharge- scanty but foul
smelling due to bone destruction,
purulent
Hearing loss- hearing is normal
when ossicular chains are intact or
when cholesteatoma (cholesteatoma
hearer) conductive/mixed deafness
Bleeding from granulation/polyp
4.Signs
Perforation- attic/posterosuperior marginal type
Retraction pocket an invagination of tympanic
membrane is seen in attic/posterosuperior area of
pars tensa.
Stages:a) Stage 1 tympanic membrane is retracted
but doesnt contact incus (MILD RETARCTION)
b) STAGE 2- tympanic memb. Is retracted deep
& it contacts the incus; middle ear mucosa isnt
affected.
c) Stage3 middle ear atelectasis : middle ear
comes to lie on promontory & ossicles
d) Stage 4- adhesive otitis medi : TM is very thin;
wraps promontory & ossicles; no middle ear
space; mucosal lining of middle ear is absent;
retraction pockets formed; erosion of long process
of incus stapes superstructure
5.INVESTIGATIONS
Examination under microscope- imp.
Part of clinical assessment of any type
of CSOM
Tuning fork test and audiogram
Xray mastoids/CT scan of temporal
bone for extent of bone destruction
and degree of mastoid pneumatization
Culture and sensitivity of ear discharge
6.Features indicating
complications in CSOM
Pain- uncommon in uncomplicated CSOM.
Persence of pain indicates
extardural,perisinis or brain abscess
Vertigo-indicates erosion of lateral
semicircular canal , may progress to
labyrinthis/meningitis
Persistent headache-suggestive of
intracranial complications
Facial weakness- erosion of facial canal
7.Treatment
I. Surgical- mainstay treatment
(!)primary aim- remove the disease & render the ear safe
(!!)2nd aim- to preserve/reconstruct hearing
II.Reconstructive surgery
hearing can be restored by myringoplasty or
tympanoplasty
III.Conservative treatment-
done
when cholesteatoma is small and easily
accessible to suction clearance under
operating microscope
Thank you