CSOM of Middle Ear part 2

8/13/2019 CSOM of Middle Ear part 2

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C.S.O.M.:

Investigations &

Treatment

Dr. Vishal Sharma


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Investigations for T.T.D.

Examination under microscope

Ear discharge swab:for culture sensitivity

Pure tone audiometry

Patch test

X-ray mastoid: B/L 300

lateral oblique (Schuller)Done when cortical mastoidectomy is required

in ear discharge refractory to antibiotics


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Patch Test

Done when deafness = 40-50 dB

Do pure tone audiometry:for hearing threshold

Put Aluminum foil patch over T.M. perforation

Repeat pure tone audiometry:

Hearing improved =ossicular chain intact & mobile

Hearing same / worse =oss. chain broken or fixed


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Investigations for A.A.D.

Examination under microscope

Ear discharge swab:for culture sensitivity

Pure tone audiometry

X-ray mastoid: B/L 300

lateral oblique (Schuller)

CT scan:revision surgery, complications, children


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Uses of E.U.M.

Confirmation of otoscopy findings

Epithelial migration at perforation margin

Cholesteatoma & granulations

Adhesions & tympanosclerosis

Assesment of ossicular chain integrity

Collection of discharge for culture sensitivity


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Dural & sinus plates


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Cellular mastoid


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Sclerotic mastoid


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Diploetic mastoid


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Attic bone erosion


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Causes for mastoid cavity

Cholesteatoma erosion

Mastoidectomy cavity

Tubercular mastoiditis Coalescent mastoiditis

Malignancy

Eosinophilic granuloma

Mega-antrum

Large emissary vein


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C.T. scan temporal bone

Posterior canal wall erosion


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C.T. scan temporal bone

Mastoid cholesteatoma


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Treatment for

Tubo-tympanic

Disease


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Non-surgical Treatment

Precautions

Aural toilet

Antibiotics: Systemic & Topical

Antihistamines:Systemic & Topical

Nasal decongestant: Systemic & Topical

Treatment of respiratory infection & allergy

Tympanic membrane patcher


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Precautions

Encourage breast feeding with childs head

raised. Avoid bottle feeding.

Avoid forceful nose blowing

Plug E.A.C. with Vaseline smeared cotton

while bathing & avoid swimming

Avoid putting oil & self-cleaning of E.A.C.


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Done only for active stage

Dry mopping with cotton swab

Suction clearance: best method

Gentle irrigation (wet mopping)

1.5% acetic acid solution used T.I.D.

Removes accumulated debris

Acidic pH discourages bacterial growth

Aural Toilet


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Antibiotics

Topical Antibiotics:

Antibiotics:Ciprofloxacin, Gentamicin, Tobramycin

Antibiotics + Steroid: for polyps, granulations

Neosporin + Betamethasone / Hydrocortisone

Oral Antibiotics:for severe infections

Cefuroxime, Cefaclor, Cefpodoxime, Cefixime


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Antihistamines & Decongestants

Antihistamines Systemic decongestants

Chlorpheniramine Pseudoephedrine

Cetirizine

PhenylephrineFexofenadine Topical decongestants

Loratidine Oxymetazoline

Levo-cetrizine Xylometazoline

Azelastine (topical) Hypertonic saline


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Kartush T.M. Patcher

Indicated in:

Perforation in only

hearing ear

Patient refuses surgery

Patient unfit for surgery

Age < 7 years


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Surgical Treatment

Indicated in inactive or quiescent stage

Myringoplasty

Tympanoplasty

Indicated in active stage

Cortical Mastoidectomy

Aural polypectomy


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Methods to close perforation

T.M. perforation < 2 mm

Chemical cautery with silver nitrate

Fat grafting

Myringoplasty if these measures fail

T.M. perforation > 2 mm Tympanic membrane patcher

Myringoplasty


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Chemical cautery


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Approaches to

middle ear


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Wildes post-aural incision


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Lemperts end-aural incision


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Rosens permeatal incision


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Hearing Restoration

Myringoplasty:

surgical closure of tympanic membrane perforation

Ossiculoplasty:

surgical reconstruction of ossicular chain

Tympanoplasty: Surgical removal of disease + reconstruction of

hearing mechanism without mastoid surgery


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Principles of hearing restoration

Intact tympanic membrane

Intact ossicular chain

Functioning receiving & relieving windows

Acoustic separation of these windows

Functioning Eustachian tube

Absence of sensori-neural hearing loss

Absence of active infection / allergy in

middle ear cleft


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Myringoplasty


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Aims Permanently stop ear discharge: dry, safe ear

Improve hearing:provided: 1. ossicles are intact +

mobile; 2. absence of sensori-neural deafness

Prevention of:tympanosclerosis, adhesions,

vertigo, S.N.H.L. (cochlear exposure to loud sound)

Wearing of hearing aid Occupational:military, pilots

Recreation:swimming, diving


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Contraindications

Purulent ear discharge

Otitis externa Respiratory allergy

Age < 7 yr (Eustachian tube not fully developed)

Only hearing ear

Cholesteatoma


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Underlay myringoplasty


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Overlay myringoplasty


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Steps of underlay

myringoplasty


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Tympanomeatal flap raised


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Placement of graft


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Tympanomeatal flap replaced


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Tympanomeatal flap replaced


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Why temporalis fascia?

Basal metabolic rate lowest (best survival rate)

Easily harvested by post-aural incision

Its an autograft, so no rejection

Same thickness as normal tympanic membrane

Large size graft can be harvested

Good resistance to infection


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Onlay UnderlayGraft cholesteatoma No

Blunting of anterior tympano-

meatal angle

No

Lateralization of graft No

Delayed healing time (6 wk) 3-4 weeks

No middle ear inspection Possible

Difficult & takes more time Easier & quicker

Ad t f L l


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Advantages of Local

Anesthesia

Minimal bleeding

Hearing results can be tested on table

Facial palsy detected immediately

Labyrinthine stimulation detected

immediately

No complications of General anesthesia


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Tympanoplasty


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Types


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Type Pathology Graft placed on

I Ear drum perforation only Malleus handle

II Malleus handle eroded Incus

III Malleus + Incus eroded Stapes head

IV Only footplate remains: mobile Footplate

exposed

V Only stapes remains: fixed Lateral SCC

opening

VI Only footplate remains: mobile Footplate

exposed


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Malleus / Incus Autografts


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Th k Y


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Thank You

Documents

CSOM of Middle Ear part 2