csom
TRANSCRIPT
CHRONIC CHRONIC SUPPURATIVE OTITIS SUPPURATIVE OTITIS
MEDIAMEDIA
CHRONIC CHRONIC SUPPURATIVE OTITIS SUPPURATIVE OTITIS
MEDIAMEDIA
CSOM: DEFINITION• Chronic SUPPURTAIVE
inflammation of the middle ear cleft (middle ear, ET and mastoid) of > 6 weeks duration, usually following ASOM, with a non-intact TM
• Perforation of the pars tensa or pars flaccida
CLASSIFICATION• Tubotympanic
disease• Atticoantral disease
CSOM:PREVALENCE• High in ethnic groups and developing
countries• Aboriginals of Australia 85%• Eskimos 12%• Native Americans 8%• India 6-12%, higher in some areas• United Kingdom 0.5%
CSOM:PREDISPOSING FACTORS
PATIENT FACTORS EUSTACHIAN TUBE DYSFUNCTION
• MALNUTRITION & IMMUNODEFICIENCY• EARLY NASOPHARYNGEAL COLONISATION:
PNEUMOCOCCUS• DOWN’S SYNDROME• CLEFT PALATE• ALLERGY• GERD
CSOM:PREDISPOSING FACTORS
ENVIRONMENTAL FACTORS• PASSIVE SMOKING• POOR HYGEINE• OVERCROWDING• DAY CARE• INACCESSIBLE HEALTH CARE
CSOM:BACTERIOLOGY• PSEUDOMONAS AERUGINOSA (18-
67%)• KLEBSIELLA (4-43%)• PROTEUS MIRABILIS (4-43%)• ANAEROBES-Bacteroides (1-91%)• STAPHYLOCOCCUS (14-33%)• STREPTOCOCCUS
Differences Tubotympanic disease
Atticoantral disease
Discharge Profuse, mucoid
Scanty, foul-smelling
Perforation Central Attic/ marginal
Granulations Uncommon Common
Polyp Pale Red and fleshy
Cholesteatoma
Absent Common
Complications Rare Common
PTA mild- mod CHL
CHL/ mixed HL
Clinical featuresHISTORY
• Ear discharge : – non-offensive, mucoid, constant or
intermittent – increases at the time of URI or entry of
water in the ear– Last attack ?
• Hearing loss :
– Conductive type– Round window shielding effect
Active < 6 weeks
Quiescent 6 wks- 6 months
Inactive > 6 months
Signs • External auditory meatus :
discharge may be seen if active• Perforation : pars tensa
– Central• Small• Medium• Large • Subtotal
CSOM:OTOSCOPY
Signs • Middle ear mucosa
– Inactive : pale pink– Active : red, oedematous and swollen– Polyp may be seen – pale, fleshy
• Ossicular chain : usually intact, long process of incus may show necrosis
Signs • Mastoid tenderness / swelling• Tuning fork tests :
– Rinne’s test – positive on side of affected ear– Weber’s test- lateralised to affected ear– ABC – not decreased
• Examination of nose, oral cavity and pharynx
Investigations • Examination under microscope• Pure tone audiometry :
– Degree of hearing loss– Type of hearing loss
• Culture and sensitivity :– Selection of proper antibiotic
• Mastoid X-ray
TREATMENT• Aural toilet :
– Dry mopping– Suction clearance
• Ear drops :– Ciprofloxacin– Norfloxacin
• Treatment of contributory causes :– Treat infected tonsils, adenoids, sinuses
• Surgical treatment :– Removal of polyp/ cortical mastoidectomy
Cortical mastoidectomy
Reconstructive surgery• Once the ear is
dry• Myringoplasty • Tympanoplasty
ATTICOANTRAL TYPE• Involves the posterosuperior part
of the middle ear cleft– Attic– Antrum– Posterior tympanum and mastoid
• Associated with cholesteatoma• Unsafe / dangerous type
CSOM: PATHOLOGY• Mucosal damage• Osteitis of
ossicles, mastoid• Inflammatory
granulation tissue• Tympanosclerosis• Atticoantral• Cholesteatoma
Cholesteatoma • ‘ skin in the wrong place’• Keratinised squamous epithelium in
the middle ear• Secondary acquired cholesteatoma :
• Migration of squamous epithelium ( Habermann’s theory )
• Metaplasia of the middle ear epithelium (Sade’s theory )
• Cholesteatoma has the property of invasion and enzymatic bone destruction
CSOM: CHOLESTEATOMA
• Congenital – behind an intact TM
• Acquired Primary
Secondary
CHOLESTEATOMA-THEORIES
• Wendt’s metaplasia theory- Metaplasia of ME & attic epithelium due to infection
• Ruedi’s hyperplasia theory- Invasive hyperplasia of basal layers of meatal skin adjacent to upper margin of TM
• McGuckin’s theory – Invasive hyperkeratosis of deep EAC skin
• Wittmaack’s theory- Retraction/collapse of TM with invagination secondary to ET dysfunction
Symptoms • Ear discharge :
– Scanty, foul-smelling– May be blood stained
• Hearing loss– Conductive loss
Features indicating complications :
• Vertigo• Headache• Facial weakness• Vomiting • Neck rigidity • Diplopia, ataxia• Swelling in the region of mastoid
Signs • Perforation : – Attic / posterior-superior marginal
perforation– May be masked by granulation/ discharge
• Retraction pocket :– Invaginated tympanic membrane in
attic/posterior-superior region– If deep, keratin mass can accumulate
• Cholesteatoma : – White flakes in retraction pocket– Seen using operating microscope
Retraction pocket
Investigations • Examination under microscope :
– Cholesteatoma, retraction pocket, perforation
• Pure tone audiometry : – Degree of hearing loss– Type of hearing loss
• Culture and sensitivity :– Selection of proper antibiotic
• Mastoid X-ray :– Extent of bone destruction,– Law’s view
TREATMENT• Aural toilet :
– Dry mopping– Suction clearance
• Surgery :– Modified Radical Mastoidectomy– Reconstructive surgery :
• Tympanoplasty
CSOM: TREATMENT• MEDICAL: AURAL TOILET FOLLOWED BY
TOPICAL ANTIBIOTIC EAR DROPS- Ciprofloxacin ear drops, Norfloxacin ear drops
• TREAT UNDERLYING FOCUS: ADENOIDS, SINUSITIS
• SYSTEMIC ANTIBIOTICS- ACUTE EXACERBATION/ FOR COMPLICATIONS
CSOM : SURGERY
• MYRINGOPLASTY
• TYMPANOPLASTY (TYPES I TO VI)
• OSSICULOPLASTY
CSOM: SURGERY
• CORTICAL MASTOIDECTOMY • MODIFIED RADICAL MASTOIDECTOMY• RADICAL MASTOIDECTOMY
Complications
Intratemporal Intracranial
-mastoiditis -Extradural abscess
-petrositis -Subdural abscess
-facial paralysis -Meningitis
-labyrinthitis -Brain abscess
-LST
-Otitic hydrocephalus