CHOLESTEATOMA AND CHRONIC SUPPURATIVE OTITIS MEDIA

CHOLESTEATOMA

Normally middle ear cleft linings: Ciliated columnar in anterior and inferior part. Cuboidal in middle part. There is nowhere lined by keratinising squamous epithelium in middle ear cleft. Presence of this epithelium in middle ear is called cholesteatoma(skin in the wrong place)

ORIGIN OF CHOLESTEATOMA1)Presence of congenital cell rests.

2)Invagination TM from attic or posterosuperior part of pars tensa in the form of retraction pockets(wittmacck’s theory).3)Basal cell hyperplasia(Rueid’s theory)

4)Epithelial invasion(Habermann’s theory)

5)Metaplasia(Sade’s theory)

CLASSIFICATION OF CHOLESTEATOMA

1.CONGENITAL

2.ACQUIRED,PRIMARY

3.ACQUIRED,SECONDARY

EUSTACHIAN TUBE OBSTRUCTION

PERSISTENT NEGATIVE PRESSURE IN MIDDLE EAR

ATTIC OR POSTERIOSUPERIOR RETRACTION POCKET

METAPLASIA OF

MIDDLE EAR

MUCOSA

PROLIFERATION OF BASAL LAYER

PRIMARY ACQUIRED CHOLESTEATOMA

SUBCLINICAL INFECTIONS OF

MIDDLE EAR

REPEATED INFECTION THROUGH

PERFORATION

METAPLASIA OF MIDDLE EAR MUCOSA

LARGE CENTRAL OR MARGINAL

PERFORATION

ACUTE NECROTIZING OTITIS MEDIA

EPITHELIAL MIGRATION THROUGH

PERFORATION

SECONDARY ACQUIRED

CHOLESTEATOMA

Expansion of cholesteatoma and destruction of bone

Once cholestetoma enters middle ear cleft , it invades surrounding structures,first by following the path of least resistance, and then by enzymatic bone destruction which is caused by collagenase , acid phosphatase and proteolytic enzymes which are liberated by osteoclasts and mononuclear inflammatory cells.

CHRONIC SUPPURATIVE OTITIS MEDIA

It is long standing infection of a part or whole of the middle ear cleft , characterised by ear discharge and permanent perforation .

Epidemiology:Higher incidence in developing countries.Both sexes and all age group s are affected.Singlemost imp. Cause of hearing loss.

TYPES OF CSOM

A)Tubotympanic : Also called safe or benign type . Involves antero inferior part with central perforation.

B)Atticoantral : Also called unsafe or dangerous type . Involves the posterosuperior part and is associated with an attic or marginal perforation . Often associated with bone eroding process.

A)TUBOTYMPANIC TYPE

Pathology:1)Perforation of pars tensa2)Middle ear mucosa3)Polyp4)Ossicular chain5)Tympanosclerosis6)Fibrosis and adhesions

Bacteriology

Pseudomonas aeruginosa , proteus , E.coli and staph aerus.

Bacteroides fragilis and streptococci.

Clinical Features:1)Ear discharge : non offensive mucoid or

mucopurulent.2)Hearing loss3)Perforation4)Middle ear mucosa:Red oedematous and swollen.

INVESTIGATIONS:

1)Examination under microscope2)Audiogram3)Culture and sensitivity of ear discharge4)Mastoid X-rays.

TREATMENT:

Aural Toilet.Ear drops.Systemic antibiotics.Precautions.Treatment of contributory causes.Surgical treatment.Reconstructive surgery.

B)ATTICOANTRAL TYPE

Pathology:CholesteatomaOsteitis and granulation tissueOssicular necrosisCholesterol granuloma

SYMPTOMS:Ear discharge.Hearing loss.Bleeding.SIGNS:Perforation.Retraction pocket.Cholesteatoma

INVESTIGATIONS:

1)Tunning fork test2)Audiogram3)X-ray mastoids and CT scan of temporal bone.4)Culture and sensitivity of ear discharge.

TREATMENT:

1)Surgical:

2)Reconstructive surgery:

3)Conservative Treatment:

TUBERCULAR OTITIS MEDIA

SYPHILITIC OTITIS MEDIA

WILL BE CONTINUED AFTER 10 MIN BREAK