1

Fifth stage ENT

Lec-18

4/4/2016 د.سعد

Chronic Suppurative Otitis Media (CSOM)

CSOM is a long-standing infection of a part or whole of the middle ear cleft characterized by painless

ear discharge and a permanent perforation with hearing loss. A perforation becomes permanent

when its edges are covered by squamous epithelium and it does not heal spontaneously.

Classification of chronic suppurative otitis media

1.

Classification based on

anatomical

considerations

a. Tubotympanic disease =’ safe’ disease;

perforation is central and non-marginal. b.Atticoantral disease=’unsafe’ disease: perforation

is marginal or in attic: cholesteatoma.

2.

Classification based on

pathological

consideration

A. Healed otitis media: adhesive otitis media,

tympanosclerosis.

B. Inactive mucosal chronic otitis media:

permanent perforation.

C. Active mucosal chronic otitis media: chronic

suppurative otitis media, aural polyp.

D. Active squamous epithelial chronic otitis

media: cholesteatoma with discharge.

E. Inactive squamous epithelial chronic otitis

media: retraction pocket.

2

Tubotympanic Disease

Also called the safe or benign type; it involves the anteroinferior part of the middle ear cleft, i.e.

Eustachian tube and mesotympanum and is associated with central perforation. There is no risk of

serious complication.

Aetiology

It is virtually always a complication of AOM where there is persisting perforation of the TM. It

therefore usually starts in infancy and early childhood. Reinfection either through the nasopharynx

(tonsillitis, adenoid hypertrophy and sinusitis) or through the perforation allows active infection to

persist or to recur.

3

Bacteriology

There is high incidence of gram negative infection like proteus and pseudomonas aeroginosa.

Anaerobic infection can be found as well.

Pathology

The main pathological condition is a central perforation of the TM resulting from AOM. Repeated

infection may cause polyp formation which consists of oedematous middle ear mucosa prolapsing

through the perforation.

Clinical picture

1. Mucoid or mucopurulent discharge which may be intermittent or persistent.

2. CHL Its degree varies with the size and position of the perforation.

Examination

1. Otoscopy: a. Central TM perforation in the pars tensa.

b. Middle ear mucosa It is seen when the perforation is large. Normally, it is pale pink and moist;

when inflamed it looks red, oedematus and swollen. Occasionally, a polyp may be seen.

2. Tuning fork tests: CHL.

Investigations

1. PTA: CHL. 2. X-ray and CT scan shows sclerosis with clouding of the mastoid air cells. 3. Swab of the aural discharge for c/s.

Treatment

1. Elimination of URTI: Treatment of sinusitis, adenoidectomy and tonsillectomy. 2. Medical Treatment

a) Aural toilet: suction clearance and mopping with cotton-wool wicks at home. The patient should be warned not to get water into the ear when washing or swimming.

b) Local antibiotic /steroid drops e.g. Ciprofloxacin, Neomycin or Gentamycin. These drops are instilled after mopping the ear and the head should be on the side so that the affected ear is upper most. After that the tragus is pressed inwards to assist the drops to pass into the middle ear.

c) Systemic antibiotics has little role in treatment.

4

3. Surgical treatment a) Removal of polyps and granulation tissue. b) Myringoplasty: repair of TM perforation by temporalis fascia is indicated when there is

recurring discharge or there is disabling deafness.

Atticoantral Disease

In this type of infection the bone of the attic, mastoid antrum and air cells are involved as well as

the mucosa of the middle ear cleft. It is therefore referred to as atticoantral disease. As erosion of

bone may extend to adjacent vital structures there is always a danger of serious complications; both

intra- and extracranial. This type of infection is usually associated with cholesteatoma.

Cholesteatoma

Definition: Cholesteatoma is a sac of keratinizing squamous epithelium containing keratinous debris

and surrounded by granulation tissue (i.e. it is a skin in a wrong place). The surface layers of epithelium

keep producing keratin and this result in the appearance of a thin-walled sac containing cheesy

material. The granulation tissue on the outside of the sac produces lysozymes and this gradually

erodes the ossicles, ear drum and mastoid bone.

The suffix “oma” may suggest that it is a tumour, this is not the case, though if untreated it will

continue to expand and destroy surrounding structure.

Theories of origin of cholesteatoma

I Congenial: This is unrelated to CSOM as it arises from embryonic epithelial tissue and occurs in the temporal bone and in the middle ear.

II Acquired

5

1. Invagination theory: Cholesteatoma starts as a retraction pocket of the TM due to ET obstruction. The TM tends to be retracted in attic region where the pars flaccida is thin. If the retraction pocket is more marked, a cholesteatoma sac may be formed inside the middle ear.

2. Emigration theory: cholesteatoma arise from extension of squamous epithelium into the middle ear through a marginal TM peroration.

3. Metaplasia theory: Squamous metaplasia of the middle ear mucosa in response to chronic infection.

Clinical picture

The onset of symptom is insidious so that the patient may be unaware of the starting point.

1. Persistent or recurrent purulent aural discharge. The discharge however, is purulent rather than mucopurulent and is frequently scanty and foul smelling.

2. CHL: Usually marked hearing loss because of involvement of the ossicular chain. 3. Bleeding from the ear if granulation tissue is present. 4. Headache, vertigo and facial paralysis all indicate complications.

Examination

1. Otoscopy: Attic (unsafe perforation) situated in the pars flaccida. Cholesteatoma may be seen a grayish substance projecting from an attic perforations. Granulation tissue may be seen as well occupying such perforation.

2. Tuning fork test: CHL.

3. Fistula sign: cholesteatoma can cause erosion of the lateral semicircular canal leading to fistula. If such fistula is present, any change in pressure in the middle ear e.g. by Siegle`s pneumatic speculum

will probably produce vertigo and nystagmus. If the test is positive, it is an indication of urgent surgery because of the risk of labyrinthitis.

Investigations

1. PTA: CHL. 2. X-ray and CT scan of mastoid; Cholesteatoma appear as an area of translucency with a clearly out

lined bony margin. 3. Swab of the aural discharge for c/s.

6

Treatment

1. Conservative: it’s used when no complications are suspected and if the cholesteatoma is small and accessible. It includes removal of cholesteatoma and granulation tissue by fine crocodile forceps and suction clearance under magnification. Other measures like ear drops and dry ear precaution are also recommended.

2. Surgical: In most cholesteatoma surgical treatment is required.

Complications of Otitis Media

Occurs when the infective process spreads beyond the confines of the middle ear.

Routes of infection

a) Medially to the labyrinth, through the oval window, round window, or by erosion of the LCC.

b) Superiorly to the middle cranial fossa through the tegmen tympani.

c) Posteriorly to the posterior cranial fossa. d) Inferiorly through the floor of the

tympanum producing a septic thrombosis the bulb of the internal jugular vein.

Extracranial complications of otitis media

1. Mastoiditis.

2. Labyrinthitis.

3. Petrositis.

4. Facial nerve paralysis.

Intracranial complications of otitis media

1. Extradural abscess. 2. Subdural abscess. 3. Lateral (sigmoid) sinus thrombosis. 4. Meningitis.

Primarily the objective of surgical treatment is

Eradication of potentially dangerous disease by

mastoidectomy.

Reconstruction of hearing mechanism ( tympanoplasty): i.e. Reconstruction of TM (Myringoplasty) + Reconstruction of the sound

conducting ossicular chain (Ossiculoplasty).

7

5. Brain abscess. 6. Otitic hydrocephalus.

Features indicating complication in COSM

1. Pain (Extradural or brain abscess and OE ) 2. Vertigo ( erosion of lateral semicircular canal and labyrinthitis) 3. Persistent headache ( Intracranial complication) 4. Facial weakness ( erosion of facial canal ) 5. A listless child refusing to take feeds and easily going to sleep ( extradural abscess) 6. Fever, nausea and vomiting ( Intracranial infection) 7. Irritability and neck rigidity ( Meningitis) 8. Diplopia ( petrositis with involvement of CN VI ) 9. Ataxia ( Labyrithitis and cerebellar abscess) 10. Abscess round the ear ( Mastoiditis)

8

Acute Mastoiditis

Inflammation of mucosal lining of antrum and mastoid air cell system is an invariable accompaniment

of acute otitis media and forms part of it. The term "mastoiditis" is used when infection spreads from

the mucosa, lining the mastoid air cells, to involve bony walls of the mastoid air cell system. The

production of pus under tension and with the hyperaemic decalcification and osteoclastic resorption of

bone will cause destruction and coalescence of mastoid air cells, converting them into a single irregular

cavity filled with pus (Empyema of mastoid). Pus may break through the mastoid cortex leading to

subperiosteal abscess which may even burst on the surface leading to a discharging fistula.

Aetiology

1. It can complicate AOM if it has been either untreated or given incorrect or inadequate antibiotic therapy.

2. Acute mastoiditis can be superimposed on a chronic atticoantral disease in which the cholesteatoma has invaded the mastoid bone.

Clinical picture

It is more common in children than adults and is often seen in mastoid with well developed air

system.

1. The patient generally looks ill with fever and tachycardia. 2. Earache followed by aural discharge with relief of pain. This is followed by cessation of discharge

and recurrence of pain with pyrexia. 3. If the disease continues uncontrolled the pus may break through the superficial cortex and forms

postauricular abscess.

Examination

1. Retroauricular swelling and tenderness over the mastoid area with fluctuation if postauricular abscess forms.

9

2. Soft tissue oedema with displacement of the auricle downwards and outwards. The postauricular sulcus tends to be retained.

3. Narrowing of the EAM due to sagging of the posterosuperior meatal wall.

Differential diagnosis

Frunculosis. Infected sebaceous cyst.

Mastoiditis Furuncle

1. Preceding history of OM No such history

2. Deafness is present No deafness until the canal is occluded

3. TM shows signs of OM TM is normal

4. Tenderness on pressure over the

mastoid

Tenderness on moving the auricle

5. Postauricular sulcus tends to

remain

Postauricular sulcus tends to be

obliterated with forward displacement.

6. Radiographic changes in mastoid No radiographic changes in mastoid

Investigations

X-ray and CT scan shows opacity of the mastoid air cells.

Treatment

Medical 1. Admission to hospital 2. Antibiotic (in full dose): Intravenous antibiotic therapy according to c/s if there is discharge. If not

IV penicillin for 48 h whether there is an abscess or merely periosteal thickening, then followed by oral antibiotic for a week. Surgical

Indications:

1. The skin remains red over a fluctuant area. 2. Pyrexia and tenderness continue. And this includes abscess drainage with or without cortical mastoidectomy with c/s of the aspirate

followed by a course of appropriate antibiotic for a week.