2. CSOM is a long standing
infection of a part or
whole of middle ear cleft
characterized byEar discharge
And a permanent
perforation
3. EPIDEMIOLOGY
Incidence is higher in developing
countries
Affects both sexes and all age
groups
Most important cause of hearing
impairment in rural population
5. TUBOTYMPANIC
It involves anteroinferior part of middle ear
cleft (eustachian tube, mesotympanum)
and is associated with a central perforation
Safe/benign type
No risk of serious complications
6. Atticoantarl
It involves posterosuperior part of the
cleft (attic ,antrum,mastoid)
Associated with an attic or marginal
perforation
It is often associated with bone eroding
process such as
cholesteatoma,granulations or osteitis
Risk of complications is high
Unsafe/dangerous type
8. 1.TUBOTYMPANIC
1.AETIOLOGY
The disease starts in childhood and is common
in that age group
Sequela of acute otitis media usually
following exanthematous fever and leaving
behind a large central perforation
Ascending infections via eustachian tube
causes persistent and recurring otorrhoea
Allergy to ingestants (milk,egg) causes
persistent mucoid otorrhoea
9. 2.PATHOLOGICAL CHANGES
Perforation of pars tensa-it is a central
perforation, size and position varies
Middle ear mucosa-disease is quiescent/inactivenormal mucosa
disease active- oedematous and velvety mucosa
Polyp-pale to pink
Ossicular chain- intact , mobile but shows some
degree of necrosis( long process of incus)
Tympanosclerosis-hyalinization and subsequent
calcification of subepithelial connective tissue..
Causes conductive deafness
Fibrosis and adhesions- result of healing process
impair mobility of ossicular chain/block eustachian
tube
10. 3.BACTERIOLOGY
Pus culture in both aerobic and anaerobic types of csom show
multiple organisms
Aerobes
Anaerobes
Pseudomonas
aeruginosa
Bacteroides fragilis
Proteus
Anaerobic streptococci
Escherichia coli
Staphylococcus aureus
11. 4.Alternative classification of Chronic otitis media
Mucosal disease-tubotympanic disease:
Squamous disease-atticoantral disease;
12. Tubotympanic
Atticoantral
Mucosal disease with no
evidence of invasion of
squamous epi.
Squamous disease of middle ear
Active-perforation of pars tensa Active-presence of
with inflammation of mucosa
cholesteatoma in posterosuperior
and mucopurulent discharge
part of pars tensa/in pars flaccida.
Erodes bone ,form granulation
tissue,has purulent offensive
discharge
Inactive- permanent
perforation of pars tensa but
middle ear mucosa isn’t
inflamed & there’s no
discharge.
Healed-tm is healed (by 2
layers)is atrophic,easily
retracted if –ve pressure in
middle ear
Inactive-retraction in pars
tensa/pars flaccida,no discharge
13. Clinical features
Ear discharge-nonoffensive , mucoid/mucopurulent
,constant/intermittent.
Appears at the time of URT infection or on accidental entry
of
water into ear
Hearing loss-conductive type (rarely exceeds 50dB)
Perforation- always central ! May lie ant./post./inferior to
handle of malleus. Can be small/med./large
Middle ear mucosa- seen when perforation is large.
normally-pale pink & moist
inflamed-red , edematous
occasionally polyp is seen
17. TREATMENT
Aural toilet- dry mopping with absorbent cotton buds
suction clearance under microscope
irrigation with sterile normal saline
Ear drops- antibiotic ear drops containing
neomycin,polymyxin,or gentamycin are used).Often
combined with steroids
Systemic antibiotics- in case of acute exacerbation
Precautions- keep water out of ear during bathing.(rubber
inserts) hard nose blowing should be avoided
Surgical treatment
Reconstructive surgery
19. 2.Pathology
It is associated with the following
pathological processes
Cholesteatoma-”skin in wrong place”
It is presence of keratinized squamous
epithelium in the middle ear or mastoid
Osteitis and granulation tissue-involves
outer attic wall and posteriosuperior
margin of tympanic ring
Ossicular necrosis- hearing loss
Cholesterol granuloma- mass of
granulation tissue with foreign body giant
cells surrounding the cholesterol crystals
20. 3.Symptoms
Ear discharge- scanty but foul
smelling due to bone destruction,
purulent
Hearing loss- hearing is normal when
ossicular chains are intact or when
cholesteatoma (cholesteatoma
hearer) conductive/mixed deafness
Bleeding – from granulation/polyp
21. 4.Signs
Perforation- attic/posterosuperior marginal type
Retraction pocket – an invagination of tympanic
membrane is seen in attic/posterosuperior area of
pars tensa.
Stages:a) Stage 1 – tympanic membrane is retracted but
doesn’t contact incus (MILD RETARCTION)
b) STAGE 2- tympanic memb. Is retracted deep & it
contacts the incus; middle ear mucosa isn’t
affected.
c) Stage3 – middle ear atelectasis : middle ear comes
to lie on promontory & ossicles
d) Stage 4- adhesive otitis medi : TM is very thin; wraps
promontory & ossicles; no middle ear space;
mucosal lining of middle ear is absent; retraction
pockets formed; erosion of long process of incus
stapes superstructure
22. 3. Cholesteatoma – pearly white flakes of
cholesteatoma can be sucked from retraction
pockets
23. 5.INVESTIGATIONS
Examination under microscope- imp. Part
of clinical assessment of any type of
CSOM
Tuning fork test and audiogram
Xray mastoids/CT scan of temporal bone
– for extent of bone destruction and
degree of mastoid pneumatization
Culture and sensitivity of ear discharge
24. 6.Features indicating complications
in CSOM
Pain- uncommon in uncomplicated CSOM.
Persence of pain indicates extardural,perisinis
or brain abscess
Vertigo-indicates erosion of lateral
semicircular canal , may progress to
labyrinthis/meningitis
Persistent headache-suggestive of
intracranial complications
Facial weakness- erosion of facial canal
25. A listless child refusing to take feeds and
easily going to sleep (extradural abscess)
Fever ,nausea & vomiting- intacranial
infection
Irritability and neck rigidity-meningitis
Diplopia (Gradenigo syndrome)petrositis
Ataxia (labyrinthitis or cerebellar abscess)
Abscess around ear (mastoiditis)
26. 7.Treatment
I. Surgical- mainstay treatment
(!)primary aim- remove the disease & render the ear safe
(!!)2nd aim- to preserve/reconstruct hearing
Two types of surgical are done to deal with cholesteatoma:
1. Canal wall down procedure- they leave the mastoid cavity
open in external auditory canal so that the diseased area is
fully exteriorized.
*atticotomy
*modified radical mastoidectomy
*radical mastoidectomy
2. Canal wall up procedures- disease is removed by
combined approach through mastoid and meatus but
retaining the posterior bony meatal wall intact thus avoiding
an open mastoid cavity
27.
28. II. Reconstructive surgery
hearing can be restored by myringoplasty or
tympanoplasty
III. Conservative treatment- done when
cholesteatoma is small and easily accessible to
suction clearance under operating
microscope