Diseases of middle ear;csom(safe&unsafe)&cholesteatoma dr.davis thomas,22.02.2016
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CHRONIC SUPPURATIVE OTITIS MEDIA
DR. DAVIS THOMAS
OBJECTIVES:At the end of this class, you should be able
to describe:
•Lining epithelium of the middle ear cleft•Definition of CSOM and Cholesteatoma•Types of CSOM and their clinical features•Theories of Cholesteatoma•Investigations for CSOM•Treatment of CSOM
RELEVANT ANATOMY
MIDDLE EAR CLEFT
LINING EPITHELIUM OF MIDDLE EAR CLEFT
• Antero inferiorly – ciliated columnar epithelium
• Posteriorly – cuboidal type
• Epitympanum and mastoid air cells – flat nonciliated epithelium (pavement epithelium)
DEFINITION OF CSOM• Chronic suppurative otitis media is a long
standing infection of a part or
whole of the middle ear cleft characterised by
continuous or intermittent
discharge through a persistent tympanic membrane
perforation.
EPIDEMIOLOGY•Incidence is higher in developing
countries
•Predisposing factors: Poor socio-economic status, poor nutrition, lack of health education
•Affects both sexes
•All age groups
•In India overall prevalance rate is : Rural: 46 per thousand Urban : 16 per thousand
•CSOM is the single most important cause of hearing impairment in rural population
TYPES OF CSOMSafe Type Or Tubo Tympanic Disease
Unsafe Type Or Attico Antral Disease
Active (Mucosal / Squamous)
Inactive (Mucosal / Squamous )
Healed
TUBOTYMPANIC DISEASE
•Disease confined to eustachian tube , anterior and inferior part of mesotympanum and hypotympanum
•Usually starts in childhood , so safe type is common in that age group
•Presents with central perforation•No underlying osteitis or osteomyelitis
AETIOLOGY
Tubotympanic Type
• Sequelae of acute otitis media
• Ascending infections via the eustachian tube
• Nasal Allergy
• GERD
• Cranio facial abnormalities
•Autoimmune disease
BACTERIOLOGY•Pseudomonas aeruginosa •B.Proteus• Esch.coli •Staph. Aureus •Bacteroides fragilis •Anaerobic streptococci.
SYMPTOMS•Ear Discharge
•Hearing Loss
•Ear Pain
•Fever
SIGNS•Profuse mucopurulent discharge, non foul
smelling, not blood stained.•Hearing loss.•Central Perforation.•Middle ear mucosa – congested.•Polyp•Ossicular chain – erosion.•Tympanosclerosis
TYPES OF PERFORATIONCENTRAL PERFORATION:• Perforation in the pars tensa
sorrounded all around by pars tensa
MARGINAL PERFORATION:
• Perforation in the pars tensa surrounded partly by pars tensa and partly by bone
ATTIC PERFORATION:• Perforation in the pars
flaccida
ROUND WINDOW SHIELDING EFFECT
• Patient hears better in the presence of discharge rather than dry ear
• Effect is produced by discharge, by maintaining phase differential
• In dry ear, sound waves strike both the Oval and Round windows simultaneously, thus cancelling each other’s effect with no movement of perilymph, and thus, no hearing.
STAGES FEATURES
ACTIVE STAGE Discharging at the time of examination.
QUIESCENT STAGE In the recent past, discharge present but there is no discharge now.
INACTIVE STAGE No discharge for 3- 6 months.Dry ear.
HEALED STAGE TM Perforation has healed.Permanently controlled middle ear infection.
ATTICO ANTRAL DISEASE•Chronic inflammatory condition of the
middle ear cleft confined to posterior part of the mesotympanum , attic and antrum associated with bone eroding disease or cholesteatoma charactersied by thick, purulent, scanty, foul smelling, blood stained persistent discharge and may be associated with perforation in pars flaccida
CHOLESTEATOMA•It is a cystic bag like structure lined by
stratified squamous epithelium containing desquamated epithelial debris lying on a fibrous tissue stroma of variable thickness
•Skin in the wrong place
•Synonym: keratoma, epidermosis
THEORIES OF CHOLESTEATOMA FORMATION
1. Congenital cell rests
2. Invagination theory: (Wittmack) • Invagination of TM
from attic or posterosuperior part of pars tensa
3. Epithelial invasion theory
(Habermann)
Squamous epithelium from TM migrates to middle ear via TM perforation
4. Basal cell hyperplasia theory:
• Infection or inflammation
• Basal membrane breaks
• Squamous epithelium invade into sub epithelial tissue in pars flaccida like epithelial cones forming microcholesteatoma
• This enlarges and perforates secondarily through the TM
5. Squamous metaplasia theory: •Cuboidal epithelium can undergo
metaplasia to sq.epithelium
•Middle ear cuboidal epithelium is pluripotent can be stimulated by inflammation to become keratinising sq.epithelium
TYPES OF CHOLESTEATOMA•Congenital
•Acquired
- primary
- secondary
COMMON SITES OF CHOLESTEATOMA• Most common sites of origin of acquired
cholesteatomas are
1. Posterior epitympanum2. Posterior mesotympanum3. Anterior epitympanum
PATHOLOGY1. Cholesteatoma2. Osteitis and granulation tisue3. Ossicular necrosis4. Cholesterol granuloma
ATTICO ANTRAL DISEASE SYMPTOMS•Ear Discharge•Hearing Loss•Bleeding •Ear Ache •Dizziness•Tinnitus•Symptoms Of Complications
PARS TENSA CHOLESTEATOMA SIGNS•Retraction Pockets•Cholesteatoma Flakes•Granulation Tissue•Polyp•Hearing Loss
•Single layer of cuboidal epithelium•Crowded structures•Improper drainage
•Bony necrosis by cholesteatoma•Gram negative infection of keratin debris•Cholesteatoma itself foul smelling
WHY IS ATTICOANTRAL DISEASE UNSAFE?
WHY IS CHOLESTEATOMA FOUL SMELLING?
INVESTIGATION• Examination under microscope • Pus for C/S• Audiological Assessment• X-ray both Mastoids• CT Scan Temporal bone • Basic Investigations • X-ray PNS• Diagnostic Nasal Endoscopy • Eustachian Tube Function Tests
EXAMINATION UNDER MICROSCOPE
• To confirm Otoscopic findings
• Site & size of perforation
• Margin of perforation
• Appearance of Middle ear
• Presence of Polyp & granulation Tissue and its site
PURE TONE AUDIOGRAM • Identifying the
presence or absence of auditory functions
• Differentiating conductive from sensorineural hearing loss
• Degree of hearing loss
X-RAY BOTH MASTOIDS • Pneumatisation of
mastoid air cells
• Hazziness / clouding of air cells
• Low lying tegmen or anteriorly lying sinus plate
BASIC INVESTIGATIONS • Complete hemogram : Hb, TC, DC, BT, CT,
ESR
• B. Sugar
• B. Urea, S. Creatinine
• Urine analysis
• ECG
• X-Ray Chest PA view
X-RAY PNS
DIAGNOSTIC NASAL ENDOSCOPY
EUSTACHIAN TUBE FUNCTION TESTS
• Valsalva Test
• Politzer Test
• Catheterisation
• Toynbees test
• Tympanometry
• Radiological Test
MEDICAL TREATMENT• Short term goals : Elimination of infection
Control of otorrhoea• Long term goals :- Improvement of hearing Eventual healing of TM• Aural Toileting - Dry Mopping
Wet mopping Suction irrigation under
microscope• Topical Antibiotics • Systemic Antibiotics
CAUSES OF FAILURE OF MEDICAL TREATMENT
• Poor drainage of inflammatory exudate from the middle
ear
• Presence of persistent osteitis with mastoid granulation
• Virulent & resistant organisms
• Reinfection via Eustachian tube – adenoid, sinuses
• Allergy
• Mastoid reservoir
CHEMICAL CAUTERIZATION(MEDICAL MYRINGOPLASTY)
•Trichloroacetic acid•Principle : The epithelium covering the
margin of the perforation is destroyed and exposing the fibroblasts• Mild irritations induces hyperemia and
secondary fibroblast proliferations
•Used in dry small to medium perforations•Several sittings may be necessary
•Medical Treatment For Cholesteatoma :-• Topical antibiotics with aural toileting• Suction clearance• Application of silver nitrate to granulation tissue• Antimetabolite - 5 – fluorouracil• Reduces the activity of squamous epithelium & curtail the production of keratin debris
•Ventilation Tubes In Attic Retractions
SURGICAL PROCEDURES MYRINGOPLASTY • An operation performed to repair or reconstruct
the TM
TYMPANOPLASTY• An operation performed to eradicate disease in
the middle ear and to reconstruct the hearing mechanisms with out mastoid surgery, with or without TM grafting.
OSSICULOPLASTY• An operation performed to repair or reconstruct
the ossicular chain
MYRINGOPLASTY•Prerequisites
▫Dry ear▫Good cochlear reserve▫Normal ET function▫Predominantly conductive hearing loss▫No cholesteatoma
•Types ▫Grafting techniques – onlay, underlay
TYMPANOPLASTY• TYPE I :
-intact ossicular chain. -sound protection for round window.
• TYPE II:-slight defect of the ossicles.-middle ear is of about normal size.
• TYPE III: - malleus and incus are extremely eroded
- columella effect.
• TYPE IV: - mobile stapes foot plate.
- sound pressure transformation is given up.
• TYPE V: - Fixed stapes foot plate.
- sound pressure through fenestration.
CLOSED OR CANAL WALL UP PROCEDURES
• CORTICAL MASTOIDECTOMY
An operation performed to remove disease from the mastoid antrum and air cell system with preservation of an intact posterior meatal wall without disturbing the middle ear contents.
• COMBINED APPROACH TYMPANOPLASTY (Tympanoplasty with CWU Mastoidectomy)
An operation performed to remove disease from the middle ear and mastoid by way of a) the mastoid, b) posterior tympanotomy, c) transcanal route, followed by reconstruction of middle ear transformer mechanism
OPEN OR CANAL WALL DOWN PROCEDURES
• RADICAL MASTOIDECTOMYAn operation performed to eradicate all middle ear and mastoid disease, in which the mastoid antrum and air cell system, aditus, attic and middle ear are converted into a common cavity, exteriorized to the external meatus. During the procedure, the TM, malleus, incus are removed leaving only stapes footplate
• MODIFIED RADICAL MASTOIDECTOMYIt is a modification of Radical mastoidectomy which is performed to eradicate the disease in mastoid, aditis, attic and the whole area exteriorized into the meatus by removing the bridge and reducing the facial ridge while preserving the middle ear contents.
MODIFIED RADICAL MASTOIDECTOMY
•Indications• Cholesteatoma involving mastoid air cells• Cholesteatoma in only hearing ear• Recurrence of cholesteatoma after closed cavity procedure• Unreconstructable posterior canal wall• Otologic or CNS complications • Poor ET function
RADICAL MASTOIDECTOMYINDICATIONS:
•Unresectable cholesteatoma extending down to eustachian tube or into petrous apex
•Promontory cochlear fistula•Perilabyrinthine cholesteatoma that
cannot be removed and must be cleaned or inspected periodically
•Temporal bone neoplasm
Canal wall up procedure
Canal wall down procedure
Meatus Normal Widely open communicating with mastoid
Dependence Does not require routine cleaning
Requires regular cleaning
Recurrence or residual disease
High rate of recur / residual disease
Low rate
Second look surgery After 6 months Not required
Patients limitations Nil Swimming curtailed
Auditory rehabilitation
Hearing aid Difficult to fit hearing aid
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