CSOMATTICOANTRAL TYPE
Middle Ear Regions
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Middle ear cleft
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Atticoantral type / Unsafe type Associated with
Cholesteatoma Having bone eroding properties , causes risk of complications Involves posterosuperior part of middle ear cleft (attic, antrum, post tympanum and mastoid)
Wednesday, January 18, 2012
Dr Sajol Ashfaq
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CHOLESTEOTOMA Definition- A bag or sac of concentrically arranged keratinized stratified squomous epithelium surrounded by fibrous tissue with tendency to bone destruction. Epidermoid cyst, pearly tumor. Pathology- encysted and concentrically arranged keratin, capsule or matrix is covered by mucosa.
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Classification Congenital AcquiredPrimary acquired (retraction pocket) Secondary acquired
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Pathogenesis CongenitalArise from embryonal rests of epithelial cells Location (petrous pyramid, mastoid and middle ear cleft) Levenson criteria White mass medial to normal TM Normal pars flaccida and tensa No history of otorrhea or perforations No prior otologic procedures Prior bouts of otitis media not grounds for exclusion
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Congenital cholesteatoma
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Pathogenesis Primary acquiredEustachian tube dysfunction Poor aeration of the epitympanic space Retraction of the pars flaccida Normal migratory pattern altered Accumulation of keratin, enlargement of sac
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Primary Acquired Cholesteatomas Ultimately form due to underlying Eustachian tube dysfunction that causes retraction of pars flaccidaResults in poor aeration of epitympanic space which draws pars flaccida medially on top of malleus neck, forming retraction pocket Normal migratory pattern of the tympanic membrane epithelium altered by retraction pocket Enhances potential accumulation of keratinDr Sajol Ashfaq Wednesday, January 18, 2012
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Primary acquired cholesteatoma
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Primary Acquired CholesteatomasPars flaccida retraction Pars tensa retraction
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Secondary Acquired CholesteatomasImplantation theorySquamous epithelium implanted in the middle ear as a result of surgery, foreign body, blast injury, etc.
Metaplasia theoryTransformation of cuboidal epithelium to keratinized stratified squamous epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theorySquamous epithelium migrates along perforation edge medially along undersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theoryInflammatory reaction in Prussack s space with an intact pars flaccida (likely secondary to poor ventilation) may cause break in basal membrane allowing cord of epithelial cells to start inward proliferationDr Sajol Ashfaq Wednesday, January 18, 2012
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Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Pathophysiology, Routes of spread: Through bone. Small veins, dural sinuses. Anatomical pathways -oval and round window. Non anatomical pathway- Surgical stapedectomy. Periarterioler space of Virchow Robin.
Wednesday, January 18, 2012
Dr Sajol Ashfaq
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Cholesteatoma Spread Posterior epitympanic cholesteatoma passing
through superior incudal space and aditus ad antrum
Wednesday, January 18, 2012
Dr Sajol Ashfaq
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Cholesteatoma Spread Posterior mesotympanic cholesteatoma invading the
sinus tympani and facial recess
Wednesday, January 18, 2012
Dr Sajol Ashfaq
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Cholesteatoma Spread Anterior epitympanic cholesteatoma with extension
to geniculate ganglion
Wednesday, January 18, 2012
Dr Sajol Ashfaq
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COMPARISON OF TWO TYPES OF CSOMArea of inflammation AetiologyEustacian tube and tympanum Acute infection Non healed perforation CentralCentral- Pars tensa Attic and mastoid antrum Retraction pocket
Site of perforation Complications Colesteatoma Discharge TreatmentWednesday, January 18, 2012
Marginal-posterosuperior MarginalPars flaccida Intra and extra cranial Present Scanty, Foul smelling Surgery- MRM/RM Surgery21
Rare, usually conductive deafness Absent Copious, Mucopurulent Conservative, MyringoplastyDr Sajol Ashfaq
Complications of cholesteatoma Hearing loss Labyrinthine fistula Facial paralysis Intracranial complications
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Patient Evaluation HistoryDetailed otologic history Hearing loss Otorrhea- foul smelling Otalgia Nasal obstruction Tinnitus Vertigo
Previous history of middle ear disease Chronic otitis media Tympanic membrane perforation Prior surgeryDr Sajol Ashfaq Wednesday, January 18, 2012
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Symptoms Ear discharge- foul-smelling, scanty. Hearing loss- mostly conductive. May be normal if ossicular chain is intact or Cholesteatoma destroyed the ossicles but bridges the gap of the ossicles. Bleeding- due to granulation tissue or polyp when cleaning the ear
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Signs Perforation of TM- Attic or Posterosuperior marginal type. Sometimes perforation could not be visualised Retraction pocket- Attic/ Posterosuperior area Chlosteatoma
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Investigations X-ray mastoid towne s view CT- Temporal bone Audiogram
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Preventative Management Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistenceDr Sajol Ashfaq Wednesday, January 18, 2012
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Treatment of Atticoantral type of CSOM Without complications- modified radical
mastiodectomy with or without tympanoplasty. With complicationsIntracranial- Radical mastoidectomy. Extracranial - MRM/ combined approach Mastiodectomy.
Aim of treatment Prevent complications and associated mortality
to save life not the ear-to make the ear safeDr Sajol Ashfaq Wednesday, January 18, 2012
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MRM- eradication of disease of middle ear and mastoid antrum, malleus and incus may be removed, stapes preserved Radical- Eradication of disease + All remnants of TM, ossicles except footplate of stapes removed
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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Complications of CSOM Next class
Dr Sajol Ashfaq
Wednesday, January 18, 2012
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