CSOM in Children Challenges in Management

Prahlada N.BMBBS, MS, MBA, MHA

Karnataka ENT Hospital & Research Center,Chitradurga, Karnataka, India

Oration delivered during SAARC ENT Congress 2014, Held at Colombo, Srilanka

Challenges

• Socio-economic

• Anatomical

• Pathological

• Clinical

• Surgical

Socio-economic factors

• Male gender

• Low socio-economic status

• Early onset of AOM (6 months – 24 months)

• Sibling history

• Formula feeding in infancy

Socio-economic factors

• Day care attendance

• Ethinicity (Natives, Aborigines)

• Passive smoking

• Pacifier use

• Seasonal changes

Anatomical challenges

• Natural • Eustachian tube

• Congenital• Craniofacial anomaly

• Acquired • Adenoids• Nasopharyngeal mass• Infectious or inflammatory

Eustachian tube

Anatomic features of the Eustachian Tube

Compared with the Adult’s the infant’s is

Length of tube Shorter Sadler-Kimes et al., 1989

Angle of tube to horizontal plane 10’ vs 45’ Proctor 1967

Angle of tensor veli palatine muscle to cartilage

Variable vs stable Swarts and Rood 1993

Cartilage cell density Greater Yamaguchi et al 1990

Elastic at hinge portion of Cartilage Less Mastume et al 1993

Oatmann fat pad Heavily wider Aoki et al, 1994

C.Bluestone

Eustachian tube

Clinical challenges

• Making the diagnosis in children is often a difficult task:• In-ability to express• Paucity of symptoms. • Difficulty in examination. • Small, tortuous ear canals.

• Previous antibiotic use

• Previous oitits media

• Failure to follow-up

Pathological challenges

• Middle ear pathology

• Associated pathology• Congenital • Acquired

Pathological challenges – Middle ear

• More prevalent in children than in adults

• The more forceful nature of otitis media

• More aggressive and persistent otitis media

• A higher rate of complications of this disease

• High rate of Persistent ME inflammation after TN repair.

Pathological challenges – Middle ear

• High Rate of Failure of tympanic membrane repair

• May also reflect the higher prevalence of pars tensa atrophy

• The patterns of cholesteatoma development are different.

• The pattern of cholesteatoma spread is also different.

• High recurrence rate of cholesteatoma after ICW mastoidectomy.

• Surgeon faces a more difficult task

Pathological challenges - Associated

• Congential

• Specific ethnic groups

• Cleft palate

• Craniofacial syndroms – Down, Crouzon, Apert’s. Turner’s & Pierre Robin.

• Immune disorders – Severe combined Inmmune dieficeincy, X-linked agammaglobulinemia and others.

• Ciliary dyskinesias – Kartagener’s syndrome & Cystic fibrosis

Pathological challenges - Associated

•Acquired• Allergy• Acquired immunodeficiency syndrome• Nasal pathology• Sinus pathology• Throat pathology• Gastroesophageal reflux disease• Biofilm formation in the middle ear

and mastoid

Pathology – common entities

• CSOM with Perforation

• TM Atrophy with Pars Tensa retraction

• Attic retraction

• Cholesteatoma

CSOM with Perforation

Tympanic Membrane Atrophyand Retraction Pockets: Pars Tensa

Attic retraction

Cholesteatoma

Summary

• COM is more aggressive and persistent.

• Management difficult in children.

• common in low socio-economic state population.

• The success rate for surgical closure of perforations rises with the age of the child, between 6 and 13 years.

• Pars tensa atrophy is commoner in children than in adults.

Summary

• Cholesteatoma tends to be more aggressive.

• Surgical techniques may need to be different .

• Surgical reconstruction of the ossicular chain worthwhile .

• Complications of CSOM do occur in children.

Thank you