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A.P. AOI JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

AUGUST 2010

No: 2

CONTENTS

AUGUST 2010

A.P. AOI JOURNAL

OF

OTORHINOLARYNGOLOGY

&

HEAD AND NECK SURGERY


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ORIGINAL ARTICLES

1. C.S.O.M- A Study with Intact Canal wall technique in the Management.

Dr. V. Anil Kumar, Dr. D. Kabir., Dr. S. Muneeruddin Ahmed, Dr. M.Mahendra Kumar

Dr. M. Sridhar Rao, Dr. Y. Praveen Kumar

2. Use of C T Scan in C.S.O.M.2. Use of C T Scan in C.S.O.M.

Dr. P. Parameshwar, Dr. S. Muneeruddin Ahmed, Dr. M. Mahendra Kumar

Dr. M. Sridhar Rao, Dr. Y. Praveen Kumar.

3. Functional Endoscopic Sinus Surgery, A review of Surgical Procedures at

ENT-II Unit, Government General Hospital, Kurnool (2006-2008).

Dr. P. Fazlur Rahman, Dr. S. Muneeruddin Ahmed, Dr. M. MahendraKumar


4.4. Multiple Complications of C.S.O.M- Temporal Lobe Abscess & SquamousCell

Carcinoma

Dr. Hareesh, Dr. S. Muneeruddin Ahmed,Dr. Hareesh, Dr. S. Muneeruddin Ahmed, Dr. M. Mahendra Kumar


5. Penetrating Foreign Body causing Head Injury- A case report.

Dr. Naveen, Dr. D. Kabir, Dr. Muneeruddin Ahmed, Dr. W. Seetharam.

__________________________________________________________________________________________________________________________________________________________________

ASSOCIATION NEWS:ASSOCIATION NEWS:

1. AOI AP BRANCH Annual Conference; September 2010; Nandyal; Kurnool

District; A. P.

[email protected]

2.2. International Otology and Skull Base Surgery Workshop; 28-29 August,International Otology and Skull Base Surgery Workshop; 28-29 August,

Visakhapatnam.Visakhapatnam.

http://www.entindia.net/2010/05/international-otology-skull-base.htmlhttp://www.entindia.net/2010/05/international-otology-skull-base.html..
http://www.entindia.net/2010/05/international-otology-skull-base.htmlhttp://www.entindia.net/2010/05/international-otology-skull-base.htmlhttp://www.entindia.net/2010/05/international-otology-skull-base.htmlhttp://www.entindia.net/2010/05/international-otology-skull-base.html


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3.3. Phonosurgery Workshop, Mumbai, Seth G.S. Medical College, K.E.M.Phonosurgery Workshop, Mumbai, Seth G.S. Medical College, K.E.M.

HospitalHospital

[email protected]@yahoomail.com

4. Sri Ramachandra Voice Update; 28Sri Ramachandra Voice Update; 28thth 2929thth August 2010-08-07August 2010-08-07

www.srmc.eduwww.srmc.edu

5.5. Nasal and Paranasal Sinuses; Anterior Skull Base surgery Workshop;4-6Nasal and Paranasal Sinuses; Anterior Skull Base surgery Workshop;4-6

February, 2011February, 2011

[email protected]@narayanj.com
mailto:[email protected]:[email protected]:[email protected]://www.srmc.edu/http://www.srmc.edu/mailto:[email protected]://www.srmc.edu/


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From: 05-08-2010,

Dr. S. Muneeruddin Ahmed, Kurnool.Editor, A.O.I. A.P. Branch,Hyderabad,Andhra Pradesh.Dear members,

I am releasing the second issue of e-journal of our branch of A.O.I. A.P, before we go forthe Annual meet. This contains 3 original papers and two case reports. I feel the debate inthe Annual General Body meet at Warangal to start an E- Journal instead of a printed

journal was good and wise because, the process of publishing an article followscomplicated meanders: the article must be carefully written; it is then submitted to the

journal which proceeds to evaluate it carefully, preferably by means of "peer" refereeswho submit a critical judgment and the respective comments. The Journal's Editor has thefinal say-so as to whether the article is published or not. Finally, the mechanism, and thecost of printing the article crowns the process.

Such a process takes more or less one year, and can be in certain cases extended to twoyears, so that, at least in the "hot" areas, the article is long past its prime when itappears, even though less so than when we deal with a published book.

I request and welcome the members to spare time to open our website

www.aoiapstate.com to go through the articles and give their opinion wherevernecessary.

I request the honorable members to send me Original papers, Case reports, News itemsand Association activities by local branches so that I can upload the same for the benefitof all the members.

I look forward to your company with your families at the Annual meet at NANDYAL in the

month of September.

Thanking You

Yours sincerely(DR.S.MUNEERUDDIN AHMED)
http://www.aoiapstate.com/http://www.aoiapstate.com/


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PRESIDENTS MESSAGE

Date: 05/08/2010.Hyderabad.

Dear friends

It gives me a great pleasure to pen few words on occasion of release of e-Journal of

AOI AP State Branch in a website www.aoiapstate.com . I congratulate the editor of e-

journal AOI AP Prof. Dr. Muneeruddin Ahmed for bringing the second e-journal

in website.

I request Honorable members to go through the e-journal in the website

www.aoiapstate.com to enrich their knowledge and also to know the day to day activities

of the Association.

I request all teaching faculty of varies Medical Colleges both Government and

Private sector and the members to utilize the e-journal by contribute scientific papers for

publication.

I also take the opportunity to thank the governing body of AOI AP State branch for

their excellent job.

Thanking you

Yours SincerelySd/-

Dr. C. RamakrishnaProf. of ENT, OMC,

Govt. ENT Hospital, koti, Hyd.President,AOI AP State Br.

Cell:9849134831
http://www.aoiapstate.com/http://www.aoiapstate.com/http://www.aoiapstate.com/http://www.aoiapstate.com/


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FROM THE DESK OF SECRETARY

Dear Colleague

On behalf of executive committee AOI AP State branch I congratulate Dr. Prof.

Muneeruddin Ahmed for being elected as 1st e-editor in chief for the Journal of AOI AP

State Branch.

I am pleased to acknowledge the release of 2nd Journal of AOI AP State in our

website. I congratulate Dr. Muneeruddin Ahmed for his efforts in bringing out the 1st

Edition of e-Journal. I request all the members both in Private Practice and teaching

hospitals to sent interesting case reports and series to the Editor Dr. Muneeruddin Ahmedand contribute the Academic excellence.

Thanking you

Sd/-Dr. N. Venkatram Reddy

Hony. SecretaryAOI AP State Br.


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FROM THE DESK OF TREASURER

Respected Members

Warm greetings to you all.

I welcome you to the A.P. Journal of the Otolaryngology and Head & Neck Surgery which

is now available online (e-journal). Thanks to our dynamic editor of the Journal Dr.

Muneeruddin Ahmed, the journal is available on our website www.aoiapstate.com and I

congratulate him on his efforts to bring out the journal in such a short span of time.

I hope all the members benefit from the journal and give their valuable feedback on the

contents of the journal.

Thanking you

Sd./-Dr. K. SREENIVAS

Hony. TreasurerAOI AP State Br.

C.S.O.M- A Study with Intact Canal wall technique in the

Management.

Dr. V. Anil Kumar, Dr. D. Kabir., Dr. S. Muneeruddin Ahmed, Dr. M.

Mahendra Kumar

http://www.aoiapstate.com/http://www.aoiapstate.com/


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INTRODUCTION

Chronic suppurative otitis media is typically a persistent disease of Middle Ear cleft,

insidious in its onset. This disease often causes severe destruction and irreversible

sequelae, involving the tympanic membrane, Ossicles and the temporal bone. Itmanifests clinically as discharge and deafness of variable severity. It can be subdivided

into active or inactive depending on whether or not there is infection. Even though

conservative treatment makes the ear temporarily dry, the susceptibility for future re-

infection persists as long as the perforation is present, especially in children. The Foci of

sepsis lies in the Adenoids, Tonsils, Sinuses and teeth. The principal aim of surgery for

chronic suppurative otitis media is first to clear the disease and only then, if possible, to

reconstruct the hearing mechanism in the middle ear. Randomized clinical trials

comparing medical and surgical intervention are not available. Hence, the treatment of

CSOM is almost exclusively based on empirical experience. Either procedure is a valid

alternative. Duration and time frame of medical treatment for patients who remainasymptomatic, still remains unclear. However, case series describing the intraoperative

findings of medically intractable cases have been published. The surgery of mastoid and

the middle ear has evolved in the present time with the use of Operating microscope and

endoscopes to its pinnacle. The post-operative complications are minimal. The post-

operative end results are convincingly encouraging. The incidence of chronic middle ear

infection is about 5% in Indian population.

AIM OF THE STUDY

In the absence of Randomized clinical studies comparing the Conservative and Surgical

treatment modalities for Chronic Suppurative Otitis Media the present study wasconducted. The purpose of the present study is to evaluate the long-term effects of

cortical mastoidectomy combined with Tympanoplasty in the treatment of C.S.O.M Tubo-

tympanic type. Final success rate, FS (dry ears for 2 years) and the optimal final

success rate, OFS (dry ears for 2 years without re-operations and without

retractions/perforations) were estimated. No serious surgical complications occurred.

Post-operatively re-mastoidectomy was performed in 0.5% and re-

Myringoplasty/tympanoplasty in 1.5%. At the long-term follow-up the FS rate was 98%

and the OFS rate was 88%.

MATERIALS AND METHODS:

The present study of THE INTACT CANAL WALL TECHNIQUE FOR CSOM was

conducted in the department of E.N.T & HEAD AND NECK SURGERY, Government General

Hospital, Kurnool medical college, Kurnool, during the period of August-2004 to August-

2006.

The total number of patients attended to the out-patient department of Government

General Hospital, Kurnool was 681546 during the period of Aug-2004 to Aug-2006. Out of


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these the number of patients attended the ENT out-patient department was 32,075. The

total number of patients with symptoms pertaining to the ear, particularly ear discharge

and hearing loss was 7025. The number of patients got admission in the ENT ward with

chronic suppurative otitis media was 450, out of these 270 patients underwent ear

surgery.

Patients were selected based on the symptoms and Otoscopic findings. Patients, only with

Tubo-tympanic variety of CSOM were included in this study and those with Attico-antral

disease and associated complications were excluded. Sixty patients with active or

inactive mucosal disease were subjected to detailed study and analysis. The patients

were admitted in the ENT ward one or two days prior to the day of surgery. In all the

selected cases with or without ear discharge and hearing loss, detailed history was taken

and examined clinically.

Name, age, sex, occupation & religion of every case were noted for statistical study.

History of trauma, sinus infection and upper respiratory tract infection either

accompanying or preceding the condition were noted. Previous treatment with antibioticsand surgery was also enquired and marked. Previous history of similar complaint and any

illness was elicited to substantiate the present condition.

After a routine general examination, a detailed local examination was carried out in every

case. Both the ears were examined thoroughly even though the patient complaints of

discharge only from one side since the condition of the opposite ear, often reflects the

valuable clues about the pathology of the affected ear. The external auditory canal was

examined for the presence of discharge, dermatitis, furunculosis, crusts, granulations and

polyps. Discharge is noted for its nature, amount, smell, colour and the presence of

Reservoir sign. For all the discharging ears aural swabs were taken and sent for culture

& sensitivity test.Aural toilet (dry mop) was done for the discharging ears and then theOtoscopic examination carried OUT.

OBSERVATION & STATISTICAL ANALYSIS

The statistical analysis in the present study is based on the observations made in the

cases of chronic suppurative otitis media (Tubo-tympanic type) being treated surgically in

the Department of ENT and HEAD & NECK Surgery, Government General Hospital, Kurnool

Medical College, Kurnool during the period of two years from August-2004 to August-

2006.

------------

Table 1 Sex Distribution (Total No. of cases: 60)

S. No: Gender No. of cases Percentage

1 Male 32 53

2 Female 28 47


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The above table shows that the male and female are almost equally affected though the

incidence is little higher in males. It signifies the increasing awareness of health among

the female population.

Table 2 Age Distribution (Total No. of cases: 60)

S. No: Age (years) No. of cases Percentage

1 11-20 10 17

2 21-30 35 58

3 31-40 10 17

4 41-50 5 8

This age distribution denotes that the disease is most frequently encountered during the

3rd decade and least frequently encountered during the 5 th decade of life. And the relative

frequency is equal in the 2nd & 4th decades of life which intends that the hearing loss is a

major concern in the productive age group (11-40) and this age group particularly is more

amenable to surgery.

Table 3 Religious Distribution (Total No. of cases: 60)

S. No: Religion No. of cases Percentage

1 Hindu 28 47

2 Muslim 26 43

3 Christian 6 10

The religious dispersion renders that while the Hindus are prevailing among others,

nevertheless the percentage of the Muslims is also comparable.

Table 4 Socio-economic status (Total No. of cases: 60)


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S. No: Status No. of cases Percentage

1 Low 40 67

2 Mid 15 25

3 High 5 8

The above strata depicts that invariably the low socio-economic group is affected more

often due to lack of awareness of disease and its prevention.

Table 5 Symptoms associated with CSOM (Total No. of cases: 60)

S. No: Symptoms No. of cases Percentage

1 Ear discharge 60 100

2 Hearing loss 50 83

3 Pain in ear 14 23

4 Tinnitus 8 13

5 Vertigo 2 3

The above data reveals that the ear discharge and the hearing loss are the striking

symptoms in the present study. A quarter among them had pain in the ear and few

among them had tinnitus and vertigo; even so, the possible intracranial and intratemporalcomplications were precluded.

Table 6 Duration of symptoms (Total No. of cases: 60)

S. No: Duration No. of cases Percentage

1 1 to 6 months 21 35

2 6 months to 1 yr 31 52

3 1 to 5 yr 5 8

4 5 to 10 years 3 5


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In this study more than 80% of the patients had the ear symptoms from one month to

one year. While 8% of the patients had given the history of 5 to 10 year duration, merely

5% had the continuance of symptoms for more than 5 years. This longer duration of the

symptoms implies the chronicity of the disease and is usually associated with either the

unsafe pathology like osteitis, bone erosion, granulations etc; or the possible sequelae

like fibrosis, fibro sclerosis and Tympanosclerosis.

Table 7 Preponderance of side of the ear (Total No. of cases: 60)

S. No: Side of the ear No. of cases Percentage

1 Right 28 47

2 Left 24 40

3 Bilateral 8 13

The above table imparts that the incidence of CSOM is almost equal at both sides

although there is some preponderance of right over left ear. The bilateral affection of the

disease is also seen but to a lesser extent.

Table 8 Type of TM perforation (Total No. of cases: 60)

S. No: Type of

perforation

No. of cases Percentage

1 Central 37 62

2 Posterior quadrant 15 25

3 Subtotal 6 10

4 Anterior marginal 2 3

It is ascertained from the above table that the predominance is seen in the central type of

tympanic membrane perforations. Twenty five percent of the study group had posterior

quadrant perforations while large central type is seen in ten percent. Only 2 cases have

anterior marginal perforations but without any evidence of in growing of epithelium.

Table 9 Cellularity of mastoid (Total No. of cases: 60)

S. No: Cellularity No. of cases Percentage


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1 Well Pneumatized 33 55

2 Acellular 15 25

3 Mixed 12 20

The above table shows that more than fifty percent of the cases have well pneumatizedmastoids where as acellular mastoids are seen in one fourth of the study group. Mixed

cellularity is seen in 12 cases.

Table 10 Type of hearing loss (HL) (Total No. of cases: 50)

S. No: Type of HL No. of cases Percentage

1 Conductive 42 84

2 Mixed 8 16Ten out of sixty cases had no complaint of hearing loss. Majority of the remaining cases

have shown the conductive type of hearing loss reflecting the pathology in the tympanic

membrane and middle ear. Mixed hearing loss is also seen in some cases, probably due

to the adverse effects on cochlear mechanics, since the protection afforded by tympanic

membrane to the round window niche is lost because of perforation.

Table 11 Degree of Hearing loss (HL) (Total No. of cases: 60)

S. No: Degree of HL (dB) No. of cases Percentage

1 0-20 (Nil significant) 10 17

2 21-40 (Mild) 36 60

3 41-55 (Moderate) 12 20

4 56-70 (Moderately

severe)

2 3

Preoperative audiological assessment by pure tone audiometry elucidates that most of

the patients (60%) have mild degree hearing loss. In ten cases the audiogram unveiled 0

to 20 dB loss, which is not significant and indeed these patients had even no complaint of

hearing loss. While moderate loss is seen in 20%, none presented with severe degree ofhearing loss (> 70 dB).

Table 12 Post-op. Hearing assessment (Total No. of cases: 57)

S. No: Hearing No. of cases Percentage


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1 Improved 44 77

2 No change 10 18

3 Declined 3 5

Postoperatively, all the cases were subjected to pure tone audiometry after 6 monthsfollow up. 3 out of 60 were not turned up and hence could not be done audiometry on to

them. The above table discloses the post-operative hearing outcomes pertaining to the

57 cases that pursued for 6 months. In this study, 77% are satisfactory with bettered

results and 18% pointed to the same as before but not as waned. Only 3 cases evinced

declined upshots on audiogram.

Table 13 Culture patterns (Total No. of cases: 60)

S. No: Bacteria No. of cases Percentage

1 Staphylococcus

aureus

22 37

2 Pseudomonas 15 25

3 Bacillus proteus 8 13

4 Streptococcus

pyogenes

4 7

5 Mixed 5 8

6 No Growth 6 10

The above table contemplates that the Staphylococcus aureus was the most common

organism isolated in my study 22(37%) followed by Pseudomonas group 15(25%), Bacillus

proteus 8(13%) and Streptococcus pyogenes 4(7%) Mixed growth is seen in 5(8%)

cultures while no growth in 6(10%) cultures. Staphylococcus aureus continues to reign

supreme as primary offender and bear the inherent trait of resistance. The similar

analysis was also attained in some previous studies made by Friedman (1957), Lin

chuang etal (2001) etc;

Table 14 Pathological findings in middle ear (Total No. of cases: 60)

S. No: Pathology No. of cases Percentage


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1 Mucosal edema 32 53

2 Polyp 7 12

3 Hypertrophied

mucosa18 30

4 Adhesions 3 5

5 Ossicular erosion 12 20

6 Tympanosclerosis 20 33

In my study, simple mucosal edema is the common pathological finding in many cases.

Virtually in 30% of the cases the unsafe pathology like hypertrophied mucosa and in 20%

ossicular erosion has been visualized. Furthermore about 38% revealed the pathology in

the form of adhesions and Tympanosclerosis which are infact the sequelae of CSOM.

Table 15 Intra operative findings (Total No. of cases: 60)

S. No: Intra-op findings No. of

cases

Percentage

1 Malleus erosion 12 20

2 Incus necrosis 8 13

3 Ossicular fixity 16 27

4 Hypertrophied mucosa in

middle ear18 30

5 Hypertrophied mucosa in

mastoid7 12

6 Hypertrophied mucosa in attic 9 15

7 Cholesterol fluid 5 8

8 Korner's septum 9 15

9 Narrow auditus 28 47

10 Low lying tegmen 6 10

11 Facial canal dehiscence 4 7


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12 Lateral canal dehiscence 2 3

Hypertrophied mucosa and the Narrow auditus were the most frequent intra-operative

findings in this study. Korners septum was encountered in 15% of cases. Ossicular fixity

was also observed often in this study and in many cases it is consorted with the fibrosis or

sclerosis. Ossicular erosion was the substantial pathology found in 33% of the cases,

among them the necrosis of the long process of incus constitutes 13% and it is the most

vulnerable structure to the disease process even though the malleus erosion was seen in

20% of cases in this study. Though facial canal dehiscence was observed in 7% of cases,

only one has presented with signs of facial palsy. Lateral canal dehiscence was noticed in

only 2 cases and these cases had the history of tinnitus and vertigo initially. Though not

much significant, cholesterol fluid was seen in considerable number of cases.

Table 16 Type of tympanoplasty (Total No. of cases: 60)

S. No: TympanoplastyType

No. of cases Percentage

1 Type 1 37 62

2 Type 2 12 20

3 Type 3 8 13

4 Type 4 3 5

Depending on the ossicular pathology and status all the patients underwent required

tympanoplasty. More than 60% cases needed Type1 tympanoplasty. In 20% of cases

Type 2 repair was required. 8 out of 60 cases underwent Type 3 tympanoplasty

(myringostapediopexy) where the long process of incus was either necrosed or absent but

with a mobile footplate and normal stapes superstructure. Myringoplatinopexy (Type 4)

was performed in 5% of cases where even the stapes super structure is lost but with

mobile footplate.

Table 17 Follow up statistics {for 6 months} (Total No. of cases: 60)

S. No: Follow up No. of cases Percentage

1 Regular 48 80

2 Irregular 9 15

3 Not turned up 3 5


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In view of meticulous post operative care and good success rate we advised and insisted

all the patients to have a regular follow up for 6 months. Despite that, 3 out of 60 were

not turned up. 80% of the study group had the regular follow up while 15% visited

irregularly, nevertheless all the 57 members were followed for 6 months unfeignedly.Table 18 Results of Ear surgery (After 6 months follow up)

S. No: Follow up No. of cases Percentage

1 Healed well 54 94.74

2 Recurrence 3 5.26

3 Cant be judged 3 ---

(Total No. of cases studied: 57)

(The No. of cases not turned up: 3)

The above table displays distinctly the success rate we achieved (95%) in terms of

disease clearance by intact canal wall technique-endoscope assisted and in terms of

hearing improvement. 5% of the cases showed recurrence in the form of discharging

ears, residual perforation and declined hearing. The results cannot be judged in 3 cases

as they did not comply for 6 months follow up and hence considering them as defaulters

they were not included in the statistical analysis reports of the post-operative hearingassessment and Results of surgery.

DISCUSSION

Chronic Suppurative otitis media and its complications are among the most

common conditions seen by the Otologist, Pediatrician and the general practitioner. It is a

persistent disease with irreversible complications. Early Otoscopic, bacteriological, and

radiological diagnosis with surgical intervention will assume accurate and appropriate

effective therapy.

It is observed in the present study that the incidence in the general population is

about 5% which was also observed by H. Vijayendra et al. The number of consults

(pediatric and adult patients) with diagnosis of CSOM in the ORL-Outpatient Department

of the Philippine General Hospital is 325 (5.6%) in 2002.


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It is observed in the present series that majority of the patients belonged to the

age group of 21 to 30 years i.e. 58%, followed by the age groups of 11 to 20 and 31 to 40

years both 17%. V.K. Poorie and Aarti Iyer found the incidence more common in the age

group of 0 to 10 years. This may be because this study includes those patients who

underwent surgery of mastoid, unlike their study which is a bacteriological study.

C.S.O.M is found to be more common in males. The ratio of M: F is 1.1:1 in the

present study. It was 1.4:1 in the study by V.K. Poorie. A similar study by Eugenijus

Lesinskas et al of Lithuania showed incidence in M: F as 1.4: 1. Prevalence in Britain, 0.9%

of children and 0.5% of adults have chronic suppurative otitis media with no difference

between the sexes (Paul Hewish et al).

The incidence of chronic suppurative otitis media appears to depend on race and

socioeconomic factors. In the present series the incidence in Low socio economic group is

67%, 25% in mid and 8% in High group. Poor socioeconomic status, overcrowding, poor

nutrition, poor hygiene, and infectious diseases (e.g., measles) have been found to

contribute to the development of chronic suppurative otitis media.

In the present series Ear discharge is present in all the patients (100%), Loss of

hearing in 83%, Pain in 23%, Tinnitus in 13% and vertigo in 3% of patients. The duration

of symptoms prior to reporting for treatment range from 6 months to 10 years among the

patients studied. 52% of the patients reported between 6 months to 1 year (51%). It

shows the awareness among the general population in regards to the discharge and other

symptoms of the ear.

Central perforation is noted in 62%, Posterior quadrant perforation in 25%, Sub-

Total perforation in 12% and Anterior marginal in 3% of cases.

Patients who had involvement of tympanic annulus were not taken in this study.

The assessment begins with a thorough history of the frequency, duration, and

characteristics of the discharge. Physical examination of the affected ear requires

cleansing of the external auditory canal before the tympanic membrane can be

accurately assessed. The eardrum is adequately visualized for accurate diagnosis.

All the patients are subjected to Pure tone Audiometry and found to have Purely

Conductive deafness in 84% and Mixed deafness in 16%. The loss of hearing is found to

be more in patients with Sub-Total and Posterior quadrant perforations. The pure tone

average is 21 to 40 dB loss in 60%, 41 to 55dB loss in 20%, and 0 to 10 dB loss in 17% of

patients. This shows the ossicular involvement, apart from simple perforation of thetympanic membrane, in the diseases process of CSOM. It varied from mucosal edema,

Hypertrophy, Fibrosis, Ossicular necrosis, I.S Joint Dislocation to Tympano-sclerosis on

surgical exploration. It gives baseline data regarding the pre-operative hearing status that

is important for surgical planning and for evaluating the effectiveness of Tympanoplasty

and Ossiculoplasty.It must be emphasized that PTA and ST are done only after thoroughly

cleaning the ear and in the absence of acute suppurative symptoms.


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Mucosal edema is seen in (53%), Hypertrophied mucosa (30%), Polyp (12 %),

Ossicular erosion (20%) and adhesions in (5%) of cases. A hearing loss of 30 dB or more

may represent ossicular disruption. Progressive loss with no obvious middle ear pathology

on examination may represent Tympanosclerosis or otosclerosis. (RanceW. Raney, M.D.)

All the patients are subjected to Plain X-Ray of the mastoid- Laws lateral obliqueview and it is found that (55%) of cases showed cellular mastoid, 25% showed acellular

and 20% of cases mixed variety of pneumatization. At present, there are no

internationally accepted guidelines with regards to the indications for imaging studies in

chronic suppurative otitis media. Although plain mastoid X-rays are inferior to CT scan in

terms of clarity and precision of diagnostic imaging of the middle ear and mastoid

pathology, they can be used to assess the status of mastoid aeration, especially in

situations where this finding is expected to be altered by the disease process. In the

present series CT scan is done in 58% of cases, both coronal and axial cuts with 2mm

sections are taken. It helps in assessing the middle ear structures, nature of pathology

like Cholesteatoma, soft tissue mass, bone destruction, fluid levels, coalescence of

mastoid air cells and complications.

In the present study ear swabs are taken pre-operatively and sent for culture and

sensitivity. It is found that Staph. Aureus found in (37%), Streptococci in (7%),

Pseudomonas in (25%), E.coli in (5%), Bacillus Proteus (13%) and Klebsiella in (3%) of

cases. Both local and international studies have shown that the bacteria most commonly

seen in CSOM may be aerobic (e.g. Pseudomonas aerogenes, E. coli, S. aureus,

Streptococcus pyogenes, Proteus mirabilis, Klebsiella species) or anaerobic (e.g.

Bacteroides, Peptostreptococcus, Proprionibacterium) However, in the prospective study

of Khanna et. al., they found that there is no definite role of culture and sensitivity in the

initial management of all cases of CSOM. This is further supported by the local studies

that show no significant change in the pathogenic organisms in patients with CSOM within

the last twenty (20) years. In addition, reliable and sensitive culture facilities are often not

available particularly in rural and far-flung areas. Poor patients may find the added

expense of the test prohibitive. Otology & Neurotology. 23(1): 18-20, January 2002. Tong,

Michael C. F.; Yue, Virgil; Ku, Peter K. M.; van Hasselt, C. Andrew

Our study has shown that ofloxacin successfully eradicates most bacterial flora

preoperatively. We cannot, however, confirm the benefits of its preoperative usage in

improving the graft success rate.

The Primary surgical treatment in all the patients is Cortical mastoidectomy intact

canal wall technique (CWU) with Tympanoplasty through a post aural route. Preoperative

broad-spectrum systemic antibiotic like Ceftriaxone sodium 1 Gram is administered to all

cases just before the surgery. In all the Patients standard Tympano meatal flaps are

raised and that includes Posterior meatal skin flap, Superior Tympano meatal flap, Inferior

Tympano-meatal flap and Posterior Tympano-meatal flap, which help to preserve the

vascularity and thus helps in rapid epithelialization of the Tympanic membrane.


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In 65% of patients anterior window is made to tuck the anterior end of the graft to

stabilize it as described by Kerr. This helps in preventing retraction of the graft and in

such cases leading to remnant perforation in the anterior part. In the present study this

technique was observed to help in preventing blunting also. It is quoted in Amer.j.otol

ISSN 0192-9763 that the flaps are introduced to improve blood supply which will bring

down the rate of canal skin break down, chronic myringitits and chronic External otitis.Handle of malleus is skeletonized.

In 15 patients 45-degree endoscope is used to determine the patency of auditus

and condition of the Ossicles. Canalplasty was done in 20 patients (33%). It helps in

visualization of the tympanic ring in its entirety, so that the graft can be placed

accurately. This has helped in rapid epithelialization of the tympanic membrane as there

is good aeration of external canal.

In all the patients underlay grafting is done. In 45% of cases the handle of malleus

is exteriorized and in remaining 55% of cases it is medialized. In all the cases the patency

of the auditus is judged by the water test i.e. water flushed through the auditus flowseasily through the middle ear and external ear. (Ugo Fisch). This precludes good

ventilation of the middle ear postoperatively and also helps in keeping the graft in situ

which is a prerequisite for rapid epithelialization.

In all the possible cases (40%) primary Ossiculoplasty is done depending upon

the ossicular status. Septal cartilage and homograft ossicles are used as prostheses for

partial ossicular replacement. In 62% of cases in the present study ossicular chain was

intact; hence Type I Tympanoplasty is done. In cases where Malleus is found eroded Type

II Tympanoplasty (20%), in cases of Incus erosion Type III Tympanoplasty is done (12%) in

this series. Where Incus, Malleus and Stapes supra structure are eroded with mobile foot

plate, Type IV Tympanoplasty (6%) is done. Single stage procedure is adopted in thepresent study. Vijayendra et al in their series performed single stage procedure in 95% of

cases.

All the patients are followed postoperatively for 4 weeks, with the patient

reporting to the out patient department. Suture removal is done after 1st week. External

canal pack removed after 3 weeks. Ear drops are allowed after 3 weeks. Where purulent

discharge is noticed microscopic examination is done to find out the cause and cleaning.

This will help in drying the canal which helps in rapid epithelialization.

Among the patients 80% of them turned up regularly for follow up. 15% of them

came irregularly and 5% did not turn up for follow up. 98% of the cases showed Finalsuccess rate and 88% showed Optimal Final success rate in this study. 2% of patients

presented with small remnant perforation anteriorly, Persistent inflammation on the

surface of tympanic membrane with intact T.M and mild retraction pocket. Vijayendra et

al showed similar result of Final success rate of 98% in their series. A study by Manning et

al. found successful closure of the tympanic membrane in 78% of Tympanoplasties

initially but only 52% had a healed graft with good postoperative middle ear function.


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CONCLUSIONS

1. The incidence of CSOM is 5% in the present study2. The patients awareness regarding the discharging ear and the importance of

undergoing surgery is increased.3. Tubo-tympanic type of CSOM is more common than Cholesteatoma.

4. The cause for persistent discharge is involvement of mastoid air cells andtemporal bone.

5. Preoperative use of antibiotic ear drops was useful in making the bacterial floranegative.

6. Presence of granulations and polyps in the middle ear precludes definitesurgery.

7. In most cases extensive Polypoidal mucosa is seen in the mastoid and auditus.Clearing the auditus to improve the ventilation of mastoid antrum is the keyfactor in early restoration of normal middle ear mucosa and successful take upof the graft.

8. In 2 to 3% of Tubo-tympanic type of CSOM Cholesteatoma and at timesTympanosclerosis is seen. Hence it is mandatory to open the mastoid in all

cases, to avoid failure in detection of Cholesteatoma.9. Use of 45 degree endoscope to visualize the auditus after cortical

mastoidectomy and to remove the disease from it was found to beadvantageous in narrow mastoid cavities and where the fibrosis around theOssicles making the auditus patency difficult.

10.Water flow test was used in all the cases and in all the cases with clear flow ofwater through auditus, the graft take up was good.

11.Meticulous graft placement will help in achieving a normal tympanic membrane.12.Per operative use of Systemic antibiotics certainly improved final result in graft

take up.13.Post operative follow up is the key to a successful result.14.Combining Mastoidectomy with Tympanoplasty is an appropriate option in

reducing the need for future surgery.15.A thorough knowledge of temporal bone and a good microscope are mandatory

in performing the surgery of middle ear and temporal bone.

USE OF CT SCAN IN CSOM

Dr. P. Parameshwar, Dr. S. Muneeruddin Ahmed, Dr. M. Mahendra Kumar


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INTRODUCTION

CSOM has been an important cause of Middle ear disease since

prehistoric times. CSOM is a long-standing infection of middle ear cleft characterized by

Chronic or intermittent otorrhoea through a persistent non-intact tympanic membrane.

(Robin Youngs)

CT scan of temporal bone is an important investigation for the

diagnosis of various diseases like

Congenital anomalies

1) Tumors2) Acute and Chronic inflammatory diseases.

CT images have to be obtained in a) axial plane

b) Coronal plane

c) Sagittal plane

The axial plane is the Natural plane for CT and the most comfortable

for the patient. It also gives the maximum information about the middle ear, and innerear, especially the coils of the cochlea.

High resolution CT is now the investigation of choice for Petrous

temporal bone disease. The role of CT in diagnoses of CSOM is to Assess:

1. Location and extension of lesion tympani.

2. Erosion of tegmen tympani or intra cranial Extension.

3. Potential or possibility of labyrinthine fistula.

4. Involvement of facial nerve canal.

5. Complications of Cholesteatoma like meningitis, sigmoid sinus

thrombosis, temporal bone abscess, etc.


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This study is conducted to find the use of preoperative CT scan in the

management of CSOM. The pre-operative CT scan findings are correlated with the

operative findings.

74 patients attending the Out Patient department of the ENT

Government General Hospital, Kurnool were included in the present study over a period

of two years. (September 2003 to September 2005).

HISTORICAL BACKGROUND

The CT system was invented in 1972 by Godfrey Newbold Hounsfieldof

EMI Central Research Laboratories (now Sensaura [1] owned by Creative Technology Ltd.)

using X-rays. Allan McLeod Cormack ofTufts University independently invented the same

process and they shared a Nobel Prize in medicine in 1979.The first scanner, known asthe EMI Scanner, took several hours to acquire the raw data and several days to produce

the images. The first EMI scanner was limited to making tomographic sections of the

brain. It required the use of a water-containing device that enclosed the patient's head.

The first CT system that could make images of any part of the body, and did not require

the "water bottle" was the ACTA scanner designed by Robert S. Ledley, DDS at

Georgetown University.

The first generation CT scanners used a pencil-thin beam of radiation

directed at one or two detectors. The images were acquired by a "translate-rotate"

method in which the x-ray source and the detector in a fixed relative position move

across the patient followed by a rotation of the x-ray source/detector combination by one

degree. Pairs of images were acquired in about 5 minutes.

The second generation of CT scanners increased the number of detectors

and changed the shape of the radiation beam. The x-ray source changed from the pencil-

thin beam to a fan shaped beam. The "translate-rotate" method was still used but there

was a significant decrease in scanning time. Rotation was increased from one degree to

thirty degrees.

The third generation of CT scanners made a dramatic change in the speed

at which images could be obtained. In the third generation a fan shaped beam of x-rays

was directed to an array of detectors that was fixed in position relative to the x-ray
http://en.wikipedia.org/wiki/1972http://en.wikipedia.org/wiki/Godfrey_Newbold_Hounsfieldhttp://en.wikipedia.org/wiki/EMIhttp://www.sensaura.com/http://en.wikipedia.org/wiki/Creative_Technologyhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Allan_McLeod_Cormackhttp://en.wikipedia.org/wiki/Tufts_Universityhttp://en.wikipedia.org/wiki/Nobel_Prizehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/1979http://en.wikipedia.org/wiki/1972http://en.wikipedia.org/wiki/Godfrey_Newbold_Hounsfieldhttp://en.wikipedia.org/wiki/EMIhttp://www.sensaura.com/http://en.wikipedia.org/wiki/Creative_Technologyhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Allan_McLeod_Cormackhttp://en.wikipedia.org/wiki/Tufts_Universityhttp://en.wikipedia.org/wiki/Nobel_Prizehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/1979


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source. The slow "translate" portion of the scan was eliminated. Scan time per slice was

reduced to 10 seconds initially.

The fourth generation of CT scanners achieved scan time similar to the

third generation by employing a 360 degree ring of detectors that encircled the patient.The fan shaped x-ray beam rotated around the patient directed at detectors in a non-

fixed relationship.

Modern multi-detector, multi-row CT systems can complete a scan of the

chest, for example, in less time than it takes for a single breath hold and display the

computed images in near real time. Images that used to take hours to acquire and days

to process are now accomplished in seconds. The number of cross sectional images that

can be produced has increased from about a dozen to many hundreds.

In recent years, tomography has also been introduced on the micrometer

level and is named Microtomography. But these machines are currently only fit for

smaller objects or animals, and cannot yet be used on humans.

AIM OF THE STUDY

1. Examine influence of routine Pre-operative HRCT Scan on Surgical management

Of CSOM.

2.To find subgroups of CSOM where CT is particularly useful.

: DEVELOPMENT OF TEMPORAL BONE:

Temporal bone is developed from four separate morphological

elements that fuse with each other to form total bone.

The elements are a) Tympanic bone, b) Squamous bone c) Petro- mastoid complex d)

Styloid process.
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A) TYMPANIC BONE: Develops in mesenchymal origin. With in the

mesenchyme around the External Auditory Meatus, four small centers of ossification arise

in the Ninth week of IUL. These are destined to fuse and become the tympanic Ring.

(Which is not a complete ring)? The ring develops a groove on its inner concave surface

and this becomes the tympanic sulcus. The bony ring grows in diameter and extends

laterally and inferiorly. At birth Tympanic plate is widely open and the definitive bony

canal is not formed. After birth, anterior and posterior bony prominences, which have

developed on the inner aspect of the ring, grow inwards and eventually fuse to form the

floor of the canal. There is a space in the floor surrounded by bone. This is called the

foramen of Huschke.

The completed tympanic bone makes contact with the mastoid

process and Part of squamous bone posteriorly and part of the petrous and squamousbone anteriorly. Petro-tympanic fissure allows the passage of chorda tympani nerve.

Tympanic ring deficient superiorly in the EAM and this is called Tympanic incisura.

B) SQUAMOUS PORTION: Develops from mesenchyme in origin. It is

ossified from one center that, as early as 8 weeks, which appears close to the root of the

zygoma and extends radially and also into the arch itself. The postero-inferior portion

grows down behind the tympanic ring to form the lateral wall of fetal mastoid antrum.

c) PETRO-MASTOID PORTION: It is morphologically a single

element. A cartilaginous flange grows downwards and outwards from the lateral part of

the petrosal cartilages just above the tubo-tympanic cavity, to form the roof of the middle

ear and the lateral bony wall of the Eustachian tube.

A separate flange grows outwards below the developing middle ear

cavity to form the jugular plate. Other changes gradually develop in the outer layers of

the otic capsule. Anteriorly the outer periosteal layer enlarges to form Petrous apex.

d) STYLOID PROCESS: It develops from two centers at cranial end of

second arch cartilage. The part closest to the tympanic bone is the tympano-hyal and its

ossification centers appear before birth. The distal part (Stylohyal) ossification center

appears after birth. Two-parts fuse at puberty.


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The tympanic bone unites with the squamous portion before birth. The

tympano-mastoid and tympano-Squamous suture lines are present in the external bony

meatus.

A squamo- Petrous suture line is usually visible on the outer surface of

mastoid process. With in this process antral air cells are found and a septum may be left

between deep and superficial air cells. This is called KORNERS SEPTEM and is remnant

of the petro-Squamous suture line.

DEVELOPMENT OF OSSICULAR CHAIN

The first evidence of ossicular development in the embryo occurs at

approximately 4 weeks. An Inter-bronchial bridge, which connects the upper end of the

first arch and central region of the second arch, develops. From this bridge primordial

malleus and incus develops and all of the stapes blastema derives from the Hyoid bar

except footplate.

At 11 th week, ossicular chain develops in cartilaginous model. The

bony development from cartilage is called Enchondral bony development.

The tensor tympani and stapedius muscles develop from the

mesenchyme of the first and second bronchial arches. Ossicles assume their adult

configuration by 20 weeks of IUL.

POSTNATAL DEVELOPMENT OF THE TEMPORAL BONE

Middle and inner ear structures have completed development before

birth. The mastoid and tympanic bones manifest postnatal growth and development.

In neonate, the squama is disproportionately large in comparison to

that of the adult. Mastoid process is non-existent and the tympanic bone is relatively flat

ring. The relative position of the entire temporal bone in the neonate is infero-lateral in

comparison with the temporal bone in the adult. Facial nerve in the absence of mastoid

process exists from stylomastoid foramen and is more vulnerable to injury.

After 1st year of life, the mastoid process begins development both

laterally and inferiorly with the tip deriving from the petrous portion of the mastoid. The


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tympanic ring extends laterally, completing the formation of the bony external auditory

canal, and the sheath of styloid process.

In the one-year-old infant opposing spurs of growing bone at the vertical aspect of the

bony EAC, fuse and divide the original EAC, into the adult EAC and the inferior channel,

known as FORMEN OF HUSCHKE.

With these changes in the mastoid and tympanic bones, the lateral

aspect of the temporal bone is vertically oriented and the Facial Nerve is buried beneath

the mastoid process.

:ANATOMY OF ADULT TEMPORAL BONE:

The temporal bones in the sides and base of the skull are

developmentally divisible into Squamous, Petro mastoid, Tympanic and Styloid parts.. In

structure, that temporal squama is like other cranial bones, the mastoid part is trabecular

and variably pneumatized, the petrous part is compact.

SQUAMOUS PART: The Squamous part is antero-superior in the bone, is thin and partly

translucent. Its temporal surface is smooth, slightly convex, and gives attachment for the

Temporalis muscle; its external surface is grooved vertically by the middle temporal

artery. The supra-mastoid crest curves back wards and upwards across its posterior part;

it is an attachment of temporal fascia and muscle. The junction between squamous and

mastoid parts is about 1.5 cm below this crest; traces of the squamo-mastoid suture may

persist. Between the anterior end of the crest and postero-superior quadrant of the

external acoustic meatus is the SUPRAMEATAL TRIANGLE, which has a depression

marking the mastoid antrum, medial to it at a depth of about 1.25 cm; anteriorly it

usually contains a small supra meatal spine.

The cerebral surface is concave and its depressions correspond to

convolutions of the temporal lobe, its lower border is fused to the anterior petrous

surface, but traces of a petro-squamosal suture often appear in adult bones. The superior

border is thin, beveled internally and overlaps the parietal bones inferior border at the

squamosal suture. The antero-inferior border, thin above and thick below, joins with the

greater wing of sphenoid bone.


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ZYGOMATIC PROCESS:

This part of the zygoma jets forwards from the squamas lower region.

Its triangular posterior part has a broad base directed laterally; it has superior and inferior

surfaces. The process then twists antero-medially, so that its surfaces become medial and

lateral. The posterior parts superior surface is concave and continuous with that of the

squama; anterior and posterior roots, converging into the anterior part of the process,

bound the inferior surface. The posterior root is prolonged forwards above the external

acoustic meatus, its upper border continuing into the supra-mastoid crest. The anterior

root jets almost horizontally from the squma; its inferior surface, with an antero-posterior

convexity covered by cartilage, contacts the joints articular disc, forming a short semi

cylindrical articular tubercle, the anterior limit of the mandibular fossa.

The zygomatic process anterior part is thin and flat. To its superior

border, the temporal fascia is attached; to the inferior border fibers of masseter are

attached. The convex lateral surface is subcutaneous; the medial is concave and provides

in attachment for part of masseter. The anterior end is deeply serrated and slopes

obliquely to articulate with the zygomatic bones temporal process. Anterior to the

articular tubercle a small triangular area forms part of the root of the infra temporal

fossa, separated from the squamas temporal surface by a ridge, continuous behind with

the zygomatic process anterior root.

MANDIBULAR FOSSA:

The fossa, limited in front by the articular tubercle, and has an

anterior articular area, formed by temporal squama, and a posterior non-articular area,

formed by the tympanic element. The articular surface is smooth, oval and articulates

with the temporo-mandibular disc; the non-articular area sometimes contains part of the

parotid gland.

Between the medial part of the articular fossa and the tympanic plateis the squamo-tympanic fissure in to which the antero-lateral edge of the tegmen

tympani turns down; the petro- tympanic fissure is between this plate and the tympanic

part; it leads into the tympanic cavity and contains an anterior malleolar ligament and

anterior tympanic branch of the maxillary artery. At the fissures medial end is the

anterior opening of the anterior canaliculus for the chorda tympani. Rarely a post-


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glenoid foramen exists anterior to the external acoustic meatus in the line of fusion of the

squama and tympanic part; it replaces the squamosal foramen noted above and

transmits the petro-Squamous sinus.

PETROMASTOID PART: It is morphologically one element, for convenience described in

mastoid and Petrous parts

MASTOID PART: This is the posterior region of the temporal bone, and has an outer

surface roughened by attachments of the occipital belly of occipito frontalis and

auricularis posterior. Frequently near its posterior border is a Mastoid Foramen traversed

by a vein from the sigmoid sinus and a small dural branch of the occipital artery. The

mastoid part projects down as the conical Mastoid Process. To its lateral surface

sternocleidomastoid, splenius capitis and longisimus capitis are attached and, medially to

this a shallow occipital groove contains the occipital artery. The Internal Mastoid surface

bears a deep, curved sigmoid sulcus for the sigmoid sinus and posteriorly the mastoid

foramen. The mastoids superior border articulates with the mastoid angle of the parietal

bone. Its serrated posterior border articulates with the inferior border of the occipital

bone. The mastoid element is fused with the descending process of the Squamous part,

below it appears in the posterior wall of the tympanic cavity.

PETROUS PART: This is wedged between the sphenoid and occipital bones in the cranial

base; it has a base, apex, three surfaces and three margins. The acoustic labyrinth is within it.

I. THE BASE: Is an artificial concept corresponds to the suture between

the Petrous and the Squamous elements, though this disappears soon after

birth. The base is arbitrary but indicated by partial separation due to the

mastoid antrum.


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THE APEX: It is blunt and irregular, is angled between the posterior border of the greater

wing of the sphenoid and the basi occipital bone, it contains the carotid canals

anterior opening and limits postero-laterally the foramen lacerum.

THE ANTERIOR SURFACE: It partly floors the middle cranial fossa and is continuous with

the cerebral surface of the squamous part. Behind the apex is a Trigeminal

Impression for the Trigeminal Ganglion. A ridge separates the Trigeminal Impression

from another hollow behind, which partly roofs the internal acoustic meatus and

cochlea. This in turn is limited behind by the Arcuate Eminence and raised by the

anterior semicircular canal. Between the Squamous part and the Arcuate Eminence

there is a hollow described medially, the surface is formed by the Tegmen Antri. This

thin plate of bone roofs the mastoid antrum. Anteriorly the tegmen bears a narrow

groove, passing postero laterally to enter bone anterior to the arucate eminence by a

hiatus for the greater petrosal nerve, passing forwards to the foramen lacerum. A

smaller more lateral hiatus transmits the lesser petrosal nerve from the tympanic

plexus.

II. THE POSTERIOR SURFACE: Is an anterior part of the posterior cranial fossa.

Near its center is the internal acoustic meatus, behind witch a small slit,

almost hidden by a thin plate of bone, leads to the Vestibular aqueduct

containing the saccus and ductus endolymphaticus together with a small

artery and vein.

III. THE INFERIOR SURFACE: It is irregular and forms part of the exterior of the

cranial base. Near the Petrous apex, a quadrilateral area is partly for

attachment of levator palatini muscle and the cartilaginous auditory tube.

Behind this is the large, circular opening of the Carotid canal, behind which is

the Jugular fossa, which contains the superior jugular bulb.

Antero-medial to this, below the internal acoustic meatus, triangular

depression for the Inferior glossopharyngeal ganglion, at its apex is a

small opening in to the cochlear canaliculus, occupied by the

perilymphatic duct, a tube of dura mater and a vein from the cochlea to

the internal jugular vein. On the ridge between the carotid canal and

jugular fossa is a Canaliculus for the tympanic nerve from the

glossopharyngeal nerve.


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IV. THE SUPERIOR BORDER: Is the longest, is grooved by the superior petrosal

sinus, that tentorium cerebelli being attached to the grooves except at its

medial end, where the trigeminal roots cross it.

V. THE POSTERIOR BORDER: It bears medially a sulcus for the inferior petrosal

sinus. Behind this, the Jugular fossa forms the occipital jugular notch and the

jugular foramen, and is notched by the glossopharyngeal nerve.

VI. THE ANTERIOR BORDER: Is joined laterally to the temporal squama, medially it

articulates with the sphenoids greater wing. At the junction of the Petrous and

Squamous parts two canals exist, one above the other, separated by a thin

osseous plate. Both lead to the tympanic cavity, the upper containing the

Tensor Tympani Tendon and the lower containing the auditory tube.

TYMPANIC PART:

The tympanic part of the temporal bone is a curved plate below the

squama, anterior to the mastoid process. Internally it fuses with the Petrous part. Behind

it fuses with the squama and mastoid process and is the anterior limit of the tympano

mastoid fissure. Its concave posterior surface forms the anterior wall, floor and part of the

posterior wall of the external acoustic meatus. Medially on this surface is a narrow

Tympanic Sulcus for attachment of the tympanic membrane.

The anterior surface forms the posterior wall of the mandibular fossa.

Its rough lateral border forms most of the margin of the external acoustic meatus and is

continuous with its cartilaginous part. Laterally the upper border is fused with back of the

post glenoid tubercle medially it is the posterior edge of the petro tympanic fissure. The

inferiorly it forms the root, and Sheath of the styloid process. Between the styloid,process and mastoid process the Stylomastoid foramen.

STYLOID PROCESS:

This is slender, pointed, about 2.5 cm in length, project antero-

inferiorly. Its proximal part (tympanohyal) is ensheathed by the tympanic plate; its distal


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part (Stylohyal) is attached to the muscles and ligaments. The process is covered laterally

by the parotid gland, the facial nerve crosses its base, the external carotid artery its tip.

Medially the process is separated from the beginning of the internal jugular vein by the

attachment of stylo pharyngeus muscle.

: ANATOMY OF THE EAR: Ear is anatomicallydivided into three parts:

i) External ear ii) Middle ear cleft iii) Internal ear.

EXTERNAL EAR: External ear is again divided into two parts; Pinna and External auditory

canal.

MIDDLE EAR CLEFT it contains three parts

a) Tympanum or tympanic cavity or Middle ear proper.

b) Mastoid antrum with air cells.

c) Eustachian tube.

a) Tympanic cavity: Is again divided into three parts.

i) Attic or epi-tympanum

ii) Meso-tympanum

iii) Hypo tympanum.

Relations: Superiorly separated from brain with its covering by thin plate of bone

called tegmen.

Inferiorly separated from jugular bulb by thin plate of bone.

Anteriorly- opens through the Eustachian tube.

Posteriorly Mastoid antrum and aditus. Medially Membranous labyrinth in bony

labyrinth.

Laterally Tympanic membrane.

The roof of the tympanic cavity: The tegmen tympani is the bony roof of the

tympanic cavity, and separates it from the dura of the middle cranial fossa. It is formed in

part by the petrous and part by the Squamous bone.


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The lateral wall of the Tympanic cavity:

The lateral wall of the tympanic cavity is partly bony and

membranous. The membranous part is formed by tympanic membrane which lies

in the middle, and remaining portion of the lateral wall of the tympanic cavity

(lateral epitympanic wall) is wedge-shaped in section and its lower bony portion is

called the outer attic wall or SCUTUM. It is thin and its lateral surface forms the

superior portion of the deep part of the external meatus.

The floor of the tympanic cavity:

The floor of the tympanic cavity consists of a thin plate of bone, which

separates the tympanic cavity from the dome of the Jugular bulb. Occasionally, the floor

is deficient and the jugular bulb is then covered only by fibrous tissue and a mucous

membrane.

The anterior wall of the tympanic cavity:

The anterior wall of the tympanic cavity is rather narrow as the medial

and lateral walls converge. A thin plate of bone covering the Carotid artery as it enters

the skull and before it turns anteriorly. It presents four openings a) The small orifice of the

canal of Huguier which contains chorda tympani nerve, b)the canal for the tensor tympani

muscle, c) the glasserian fissure containing tympanic artery and anterior ligament of

malleus.

The medial wall of the tympanic cavity:

The medial wall separates the tympanic cavity from the inner ear. It is

marked by a rounded elevation called promontory.. The promontory is corresponding to

the part of the basal coil of the cochlea. Behind and above the promontory is the Fenestra

Vestibuli (Oval window) that connects the tympanic cavity with the vestibule and is closed

by foot plate of stapes. The Fenestra Cochleae (Round window), which is closed by the

secondary tympanic membrane (Round window membrane), lies below and behind the

fenestra vestibuli from which it is separated by a posterior extension of the promontory,

called the SUBICULUM.. The niches of two windows communicate posteriorly with a deep

recess called Sinus Tympani. Lateral to this sinus and separated from it by the facial canal

and pyramid is facial recess.


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The facial canal runs above the promontory and fenestra vestibuli in

an antero-posterior direction and is marked anteriorly by the Processes Cochleariformis.

Behind the fenestra vestibuli, the facial canal starts to turn inferiorly and descent in the

posterior wall of the tympanic cavity and leaves the temporal bone through the

stylomastoid foramen. The dome of the lateral semicircular canal extends a little lateral

to the facial canal and is the major feature of the epitympanum.

The posterior wall of the tympanic cavity:

The posterior wall has an opening in its upper part the aditus, leads

back from the posterior epitympanum into the mastoid antrum. Below the aditus is a

small depression, the Fossa Incudis, which houses the short process of the incus and the

ligament connecting the two. Below the Fossa Incudis and medial to the opening of the

chorda tympani nerve is the pyramid, which contains the stapedius muscle, the tendon of

which passes forward to insert into the stapes. Between the pyramid and the tympanic

annulus is the facial recess. The facial recess is, therefore, bounded medially by the facial

nerve and laterally by the tympanic annulus.

The contents of the tympanic cavity:

The tympanic cavity contains a chain of three small movable bones

called malleus, incus, and stapes two muscles the tensor tympani and stapedius, the

chorda tympani nerve and the tympanic plexus of nerves.

The ossicles are interconnected by the joints and ligaments to form

continuous rather flexible chain between the drum and the oval window. The handle of

malleus is woven as it were into the fibrous layer of the tympanic membrane. The foot

plate of stapes is fixed in the oval window by means of an annular ligament. The incus

lies between the malleus and stapes. The whole system is kept in place by ligaments

fastening the malleus and incus to the wall of the tympanic cavity.

The Stapedius Muscle arises from the walls of the conical cavity within

the pyramid and from the apex of the pyramid and inserts into the stapes. A small

branch of the facial nerve supplies the muscle.

The Tensor Tympani Muscle is a ling slender muscle arising from the

walls of the bony canal lying above the Eustachian tube. Parts of the muscle also arise


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from the cartilaginous portion of the Eustachian tube and the greater wing of the

sphenoid. This enters the spoon shaped Processes Cochleariformis where a transverse

tendon holds it down as it turns through a right angle to pass laterally and insert into the

medial aspect of the upper end of the malleus handle. The muscle is supplied from the

mandibular nerve by way of a branch, from the medial pterygoid nerve, which passes

through the otic ganglion without synapse.

The Chorda Tympani Nerve is a branch of the facial nerve

enters the tympanic cavity from the posterior canaliculus. It runs across the medial

surface of the tympanic membrane between the mucosal and fibrous layers and

passes medial to the upper portion of the handle of the malleus above the tendon of

tensor tympani to continue forwards and leave by way of the anterior canaliculus,

which subsequently joins the petro tympanic fissure.

The tympanic plexus is formed by the tympanic branch of the

glossopharyngeal nerve and by carotico tympanic nerves, which arise from the

sympathetic plexus around the internal carotid artery. The nerves form a plexus on

the promontory are:

1. Branches to the mucous membrane lining the tympanic cavity, Eustachian

tubeand mastoid antrum and air cells.

2. A branch joining the greater superficial petrosal nerve.

3. The lesser superficial petrosal nerve, which contains all the parasympathetic

fibers of IX th nerve.

The Aditus to the Mastoid Antrum

This is a large irregular opening leading from the posterior

epitympanum into the air-filled spaces of the mastoid antrum. On the medial wall is the

prominence of the lateral semicircular canal. Below and slightly medial to this is the bony

canal of the facial nerve. The short process of the incus is closely related to these two

structures.

The Mastoid Antrum

The mastoid antrum is an air filled sinus within the petrous part of the

temporal bone. It communicates with the middle ear by way of the aditus and has


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mastoid air cells arising from its walls. The medial wall of the antrum is related to the

posterior semicircular canal and more deeply and inferiorly is the endolymphatic sac and

the dura of the posterior cranial fossa. The roof forms part of the floor of the middle

cranial fossa and separates the antrum from the temporal lobe of the brain. Mainly the

bony covering of the sigmoid sinus forms the posterior wall. The lateral wall is part of the

squamous portion of the temporal bone. The lateral wall in the adult corresponds to the

supra meatal (Mac Ewans) triangle on the outer surface of the skull. The floor of the

mastoid antrum is related to the digastric muscle laterally and the sigmoid sinus medially,

although in a poorly aerated mastoid bone these structures may be 1 cm away from the

inferior antral wall. The anterior wall of the antrum has the aditus in its upper part, while

lower down, the facial nerve passes in its descent to the stylomastoid foramen.

PHYSIOLOGY OF HEARINGSound is conducted from external auditory canal through canal

through the tympanic membrane and ossicles to the cochlea. From there impulses pass

through auditory nerve to central auditory cortex where the message is perceived. It has

two components.

i) Sound conducting mechanism (transmission).

It includes External auditory meatus to cochlear fluids.

ii) The perceptive neural mechanism (Transduction).

Generation and Conduction of electrical impulses to higher centers of Brain

Conducting mechanism:

i) Pinna: It increases pressure at tympanic membrane. It changes the sound

pressure depending on the direction of sound source, there for aiding to

localize the sound.

ii) External auditory canal: Resonance of external auditory canal changes the

sound pressure in a frequency selective way. The resonance adds 10-12 dB at

the tympanic membrane (Shaw 1974).

iii) Middle Ear: Middle ear couples sound energy to cochlea. It serves to match

the impedance of air to the much higher impedance of cochlear fluids. Provides

protection to cochlea and serves sound pressure only at one window to produce


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differential pressure that causes movement of cochlear fluids. Impedance

Matching mechanism: It has three components.

a) Area ratio: The ratio of areas of tympanic membrane and footplate of stapes

is higher. The pressure therefore increases in inverse proportion to the

areas. It is called hydraulic ratio.

b) Ossicular lever ratio. Handle of malleus being longer than long process of

incus, the displacement at stapes is decreased but force is increased. It is at

the ratio of 1:3:1,

c) The tympanic membrane reduces the movement of handle of malleus as it

buckles while moving to and for so that the force at footplate of increased

with decreased displacement.

The transformer action of middle ear including the effect of the

external ear will enhance the amount of incident energy that is transmitted to inner ear

from 1% to 50%. The calculations lead to the assumption that area ratio would increases

the pressure 35 times, the lever ratio by 1.15 times and buckling factor by 2 times, By

multiplying these together a total pressure increase of 80.5 times, corresponding to a 38

dB increase in pressure, is obtained. Nedzelnitsky (1980) calculated it as 30dB..

Influence of Middle ear muscles:

The tensor tympani muscle inserts on the top of manubrium of the

malleus and contraction pulls the malleus medially and anteriorly. Stapedius muscle

inserts on the posterior aspect of neck of stapes on contraction pulls stapes posteriorly.

The contraction of stapedius causes rocking of foot plate against oval window there by

increasing the inward tension on the posterior edge of annular ligament and the outward

tension on the anterior edge. Both muscles on contraction increase the stiffness of

ossicular chain. Pang and Peake (1986) showed that strangest stapedius contraction

could reduce transmission by up to 30dB at frequencies less than 1-2 K Hg. It may also

serve to damp out unwanted resonances in the middle ear system at higher frequencies.

Borg (1973) showed that reflex arc of these muscle has only few neurons, only 3-4

synapses for stapedius ending in facial nerve and 4 synapses for tensor tympani ending in

trigeminal nerve. These few synapses lead to very fast reaction times with a latency

period around 25ms (Metz 1951, Vander Berg et al, 1990).

Mastoid Air Cell System:


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The mastoid air cells arise as diverticula from the Antrum. The

mastoids have been classified According to Anatomic Structure in to three types:

a) Pneumatic or cellular Type

b) Acellular or Ivory type

c) Diploeic or Mixed type

a) Cellular type is one, which is completely honey-combed with out spaces. It is

respectively noted that a temporal bone with well-pneumatized mastoid process

will be pneumatic throughout the petrous portion also. This type is much more

common then other types.

b) Acellular type in one in which there are no air spaces, marrow is fully filled with

compact bone.

c) Mixed type is one in which the marrow is still exists with in the bony structure.The Diploeic mastoid in an Adult is apparently rare.

Normally the both mastoids are symmetrical but Asymmetry may

occurs as a result of unilateral disturbance of cell formation during growth, the mastoid

showing deficient cell formation being smaller than its opposite side mastoid. The air

cells are connected with the middle ear cleft.. They are lined by a very thin flattened

epithelium and communicate with Antrum and tympanum. In a perfectly pneumatized

mastoid bone they are regular and laid down in a definite arrangement.

Classification of air cells:

NEW MANS CLASSIFICATION:

This classification is useful and practical for surgical point of view. In

this

1. Zygomatic cells: These cells extending into posterior root of Zygomatic

Process.

2. Tegmen cells: Cells spreading all over the plate of the bone and supporting the duramater of middle cranial fossa.

3. Angle cells: Cells at the angle formed by the junction of the superior and posterior

wall of the mastoid cavity.


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4. Marginal cells: Cells posterior to the plate of bone over the sigmoid sinus and some

times extending into the occipital bone.

5. Plate cells: Cells overlying sigmoid sinus plate.

6. Peri antral cells: Cells in relation with the mastoid antrum.

7. Petro-facial cells: Cells extending round the facial nerve are tunneling beneath it, to

communicate with middle ear.

8. Peri-labyrinthine cells: Cells extending at times into the petrous apex.

9. Tip cells: Lateral and medial groups divided by the mastoid notch, occasionally

extending into the styloid process.

10. Peri-tubal cells: Cells around the tube and the floor of the tympanum, which may also

extend towards the Petrous apex.

MECHANISM OF PNEUMATISATION OF MASTOID BONE:

Pneumatization is a process of air cell formation and is a continuation

of the developmental process. The cavity and lining epithelium of the middle ear cleft,

Eustachian Tube, tympanum, antrum and mastoid air cells arise from the first and second

pharyngeal pouches.

In the fetus, the process of pneumatization first occurs with in the

mesenchyme, which is the jelly like tissue grows between the ectoderm and endodermal

epithelium. The jelly like tissue contains few star like and spindle shaped cells provided

with long processes.. After few weeks, this jelly like mesenchyme begins to penetrate the

bone and it erodes the bone and opens into its marrow spaces. This marks the onset of

pneumatization process, which subsequently following an essentially similar mechanism

continues after birth until the fourth fifth year of life.

At eight week, stage the connective tissue of the middle ear is very

cellular. Gradually it becomes much looser and less cellular and, by 16 the week much

less cellular than Adjacent tissue. This process continues and the connective tissue of the

middle ear takes on the character of a very loose somewhat vacuolated and mucoid

tissue. At 18- 21 weeks, the otic capsule has attained the maximum size. The region of

tympanum proper and Epitympanum are well defined. By 30 weeks, the pneumatization


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of the tympanum proper is almost complete and the pneumatization of the epitympanum

is virtually completed in the last four weeks of fetal life.

The antrum, a lateral extension of the epi tympanum and begins to

form at about the 22 week. At 34 weeks, antrum is very large and half of it is

pneumatized then pneumatization goes very rapidly. By the time of birth, resorption of

mesenchyme has progressed so that only in certain regions such as aditus and antrum,

the niches of two windows, the sinus tympani, cells are still plugged with soft tissue and it

is covered by delicate epithelium. Resorption process is practically completed in the

middle ear by 6th month and in mastoid antrum by the end of 1 st year of life. In the 1st

month of infancy, irregular trabeculae of bone may grow out through the mesenchyme

from the osseous periphery of the mastoid antrum towards the pneumatized lumen of

antrum.

Like all other bones of skull at birth, the mastoid process is

composed of spongy bone and has between its bony trabecular spaces, which are filled

with a fatty bone marrow. From the antrum, highly myxomatous type of connective tissue

grows into the marrow spaces in the adjoining mastoid process. Form this time

pneumatization of the mastoid slowly progressive and continuous.

As the child grows so too this embryonic sub epithelial connective

tissue begins to assume its adult form. As the mastoid tip descends, it produces moremarrow spaces and the Diploeic bone at the upper level recedes or descends allowing

more airspace formation. With the concomitant enlargement of mastoid air spaces in the

antrum and in tip in this manner, these may now occur as a contiguity of the mucosa of

the mastoid with the dura dipping in from the sub arcuate fossa. In a child of 16 months

old, the antral cavity extends to a depth of 1 cm below the tegmen tympani.

WITTMAACKhas summarized the normal process of pneumatization in three stages:

1. The in growth of sub epithelial connective tissue into the marrow spaces.

2. The contraction of the sub-Epithelial tissue.

3. The sinking of the epithelial covering only the tip cells vary in this normal

process of pneumatization.


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According to WITTMAACKS view the pneumatic tissue disappear

finally during the 5th year life, i.e. - at the end of the so-called 3 rd and last pneumatic

phase.

When the pneumatization process does not takes place, may be due

to any reason, the important being intrauterine infection, the bone becomes acellular.

In cases where there is bone marrow persisting without any

attempt to pneumatization, it becomes Diploeic bone.

In well-pneumatized bone, air cells may extend into petrous apex,

tympanic cavity, Eustachian opening, to carotid canal, and into the base of the zygoma.

Air cells in the lateral part of the pertrous pyramid are inward extensions of the

epitympanic cells.

PATHOLOGY OF CSOM

Definition:

(1) Senturia et al (1980) defined according to duration, as pus forming infection in

the middle ear for greater than 3 months duration.

(2) Simple working definition by Robin Youngs is Chronic or intermittent otorrhoea

through a persistent non-intact tympanic membrane.

Chronic suppurative otitis media is divided into two basic types

(1) Safe or Tubo- tympanic type

(2) Unsafe or dangerous or Attico antral type

Histopathology: A single layer of cuboidal or columnar epithelium with cilia lines normal

middle ear. Goblet cells are a feature of hypo tympanum and the region below the

level of horizontal part of facial nerve where as region above and behind this, the lining

cells are flat and devoid of glandular structures. The changes in safe variety of chronic

suppurative otitis media are:

(i) Chronic inflammatory infiltrate with lymphocytes plasma cells and histiocytes

associated with increased capillary permeability of lamina propria of middle ear

mucosa with mucosal oedema.

(ii) Epithelium becomes glandular with increase in the number of goblet cells and

ciliated cells. This change in character of epithelium takes place more in the


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mastoid air cells and upper posterior middle ear cavity. This newly formed

respiratory type epithelium with glands and its secretion is an important part in the

discharge seen in CSOM.

(iii) In early stages of healing after destruction inflammatory granulation tissue

develops, which sometimes is florid forming an aural polyp is usually covered by

ciliated columnar epithelium but occasionally metaplastic change can take place

with Squamous epithelium. Another chromic inflammatory change in middle ear is

cholesterol granuloma.

(iv) The last stages of disease are characterized by a decrease in vascularity and

fibrosis. These changes are particularly seen in mastoid air cells characterized by

sclerosis and new bone formation. Tympano sclerosis is a special form of fibrosis seen in

chronic suppurative otitis media.

Ossicular changes: Main ossicular lesion is bony resorption.

Long process of incus and stapes supra structure is the parts of chain most frequently

affected and could be due to their delicate structure than their tenuous blood supply.

Osteoclasts are responsible for bone resorption in association with various enzymes.

Fibrous Sclerosis: It causes adhesions between tympanic membrane, ossicles and the

middle ear mucosa.

Cholesterol Granuloma: It is a histological entity occurring independent of whether the

ear is active or inactive there are cholesterol crystals surrounded by giant cellinflammatory reaction on histological sections. In 1982 Sade and Teitz argued that in the

middle ear effusion, secretions contain cholesterol and gross hemorrhage is not the

feature of otitis media. Otoscopic appearance of blue drum, preoperative thick yellow

fluid is in the middle ear and mastoid can be a cholesterol granuloma.

Labyrinthitis: Inflammation around round window membrane can lead to irritative

Labyrinthitis, producing vestibular symptoms. Plantenga and Browning in 1979 showed

that endolymphatic hydrops could occur in otitis media. This is supported by paparella,

schacherer and Giycoolea, (1985).

Sensorineural hearing impairment: The reasons for sensory hearing loss in CSOM

may be the disease process it self affect cochlea or the toxic products of inflammation

may enter into inner ear causing cochlear damage.


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Tympanosclerosis: It is present in twenty five percent cases of chronic otitis media

irrespective of type. Schuknecht in 1974 explained that Tympanosclerosis is a result of

continued inflammation in the middle ear cleft and pathologically it is the end point of

healing process in which collagen in fibrous tissue hyalinises, losses its structure

becoming fused into a homogenous mass. They are after calcification and ossification can

occur to variable extent. Tympanosclerosis most frequently affects the tympanic

membrane but the ossicular ligaments, inter osseous joints, muscle tendons and sub-

mucosal space can also be affected. In 1970, Igarashi stated that it causes varying

degrees of immobility of ossicular chain. Clinical reports of surgical findings suggest that

tympano sclerosis is rare in active ears (Gristwood and Venables 1982) and particularly in

ears with Cholesteatoma (Plester, 1971). In Ambegoaker, Brown and Richards 1978; TOS,

Bonding and Poulsen, 1983, studies when they followed the ears of children with

Tympanosclerosis secondary to childhood otitis media for many years, it is shown to

disappear in a proportion.

: CLINICAL ASPECTS OF CSOM:

Prevalence:

The incidence of chronic suppurative otitis media is 16% out of this

11.9% healed, 2.6% inactive, and 1.5% active cases as studied by the British Medical

Research Council- National study of hearing.

Disease equally affects both males land females:

Etiology:

1) Environmental: Chronic suppurative otitis media is more prevalent in lower

socioeconomic group.

2) Genetic: Harrell, Pennington and Morrison, 1982, stated that incidence of CSOM more

in white Americans when compared to American Negroes But this was simple due to

different patterns of attendance for treatment.

3) Previous otitis media: Like acute otitis media and otitis media with effusion predispose

to chronic suppurative otitis media E.g.: Acute necrotizing streptococcal otitis media

and acute exanthemata.


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4) Abnormal Eustachian tube function: In children with cleft plate and Downs

syndrome. Patulous Eustachian tube allows reflux of nasopharyngeal contents.

5) Poor mastoid pneumatization: Strong evidence is found in the study of temporal bone

histopathology which shows new bone formation and sclerosis to be an important part

of overall disease process.

6) Iatrogenic: Insertion of ventilation tubes found to be the cause for chronic suppurative

otitis media. 50% percent of patients will suffer at least one episode of persistent

discharge.

7) A defect in tympanic membrane: may be due to trauma, foreign bodies in the eternal

auditory canal, or iatrogenic while removing them etc.

8) Upper respiratory tract infections: upper air way viral infection would also affect

middle ear making it less resistant to bacterial overgrowth. Chronic sinusitis, chronic

tonsillitis and adenoiditis can predispose.

9) Autoimmunity: More common in individuals with auto immune diseases like rheumatoid

arthritis as stated by camilleri et al, 1992

10) Allergy: It is postulated to be important factor but remains to be proved.

Symptomatology:

Discharge: It can be continuous or intermittent.. A recent increase in theamount

aoi apstate august10

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