CHRONIC
CHRONIC
SUPPURATIVE
SUPPURATIVE
OTITIS
OTITIS MEDIA
MEDIA
CSOM: DEFINITION
• Chronic SUPPURTAIVE
inflammation of the
middle ear cleft (middle
ear, ET and mastoid) of >
6 weeks duration, usually
following ASOM, with a
non-intact TM
• Perforation of the
pars tensa or pars
flaccida
CLASSIFICATION
• Tubotympanic disease • Atticoantral disease
CSOM:PREVALENCE
• High in ethnic groups and developing
countries
• Aboriginals of Australia 85%
• Eskimos 12%
• Native Americans 8%
• India 6-12%, higher in some areas
• United Kingdom 0.5%
CSOM:PREDISPOSING
FACTORS
PATIENT FACTORS
EUSTACHIAN TUBE DYSFUNCTION
• MALNUTRITION & IMMUNODEFICIENCY
• EARLY NASOPHARYNGEAL COLONISATION:
PNEUMOCOCCUS
• DOWN’S SYNDROME
• CLEFT PALATE
• ALLERGY
• GERD
CSOM:PREDISPOSING
FACTORS
ENVIRONMENTAL FACTORS
• PASSIVE SMOKING
• POOR HYGEINE
• OVERCROWDING
• DAY CARE
• INACCESSIBLE HEALTH CARE
CSOM:BACTERIOLOGY
• PSEUDOMONAS AERUGINOSA (18-
67%)
• KLEBSIELLA (4-43%)
• PROTEUS MIRABILIS (4-43%)
• ANAEROBES-Bacteroides (1-91%)
• STAPHYLOCOCCUS (14-33%)
• STREPTOCOCCUS
Differences
Tubotympanic Atticoantral
disease disease
Discharge Profuse, Scanty, foul-
mucoid smelling
Perforation Central Attic/ marginal
Granulations Uncommon Common
Polyp Pale Red and fleshy
Cholesteatoma Absent Common
Complications Rare Common
PTA mild- mod CHL CHL/ mixed HL
Clinical features
•
HISTORY
Ear discharge :
– non-offensive, mucoid, constant or
intermittent
– increases at the time of URI or entry of
water in the ear
– Last attack ? Active < 6 weeks
Quiescent 6 wks- 6
months
• Hearing loss : Inactive > 6 months
– Conductive type
– Round window shielding effect
Signs
• External auditory meatus : discharge
may be seen if active
• Perforation : pars tensa
– Central
• Small
• Medium
• Large
• Subtotal
CSOM:OTOSCOPY
Signs
• Middle ear mucosa
– Inactive : pale pink
– Active : red, oedematous and swollen
– Polyp may be seen – pale, fleshy
• Ossicular chain : usually intact, long
process of incus may show necrosis
Signs
• Mastoid tenderness / swelling
• Tuning fork tests :
– Rinne’s test – positive on side of affected ear
– Weber’s test- lateralised to affected ear
– ABC – not decreased
• Examination of nose, oral cavity and pharynx
Investigations
• Examination under microscope
• Pure tone audiometry :
– Degree of hearing loss
– Type of hearing loss
• Culture and sensitivity :
– Selection of proper antibiotic
• Mastoid X-ray
TREATMENT
• Aural toilet :
– Dry mopping
– Suction clearance
• Ear drops :
– Ciprofloxacin
– Norfloxacin
• Treatment of contributory causes :
– Treat infected tonsils, adenoids, sinuses
• Surgical treatment :
– Removal of polyp/ cortical mastoidectomy
Cortical mastoidectomy
Reconstructive surgery
• Once the ear is dry
• Myringoplasty
• Tympanoplasty
ATTICOANTRAL TYPE
• Involves the posterosuperior part of
the middle ear cleft
– Attic
– Antrum
– Posterior tympanum and mastoid
• Associated with cholesteatoma
• Unsafe / dangerous type
CSOM: PATHOLOGY
• Mucosal damage
• Osteitis of
ossicles, mastoid
• Inflammatory
granulation tissue
• Tympanosclerosis
• Atticoantral
• Cholesteatoma
Cholesteatoma
• ‘ skin in the wrong place’
• Keratinised squamous epithelium in the
middle ear
• Secondary acquired cholesteatoma :
• Migration of squamous epithelium
( Habermann’s theory )
• Metaplasia of the middle ear epithelium
(Sade’s theory )
• Cholesteatoma has the property of
invasion and enzymatic bone destruction
CSOM:
CHOLESTEATOMA
• Congenital – behind
an intact TM
• Acquired
Primary
Secondary
CHOLESTEATOMA-
THEORIES
• Wendt’s metaplasia theory- Metaplasia of ME &
attic epithelium due to infection
• Ruedi’s hyperplasia theory- Invasive hyperplasia
of basal layers of meatal skin adjacent to upper
margin of TM
• McGuckin’s theory – Invasive hyperkeratosis of
deep EAC skin
• Wittmaack’s theory- Retraction/collapse of TM
with invagination secondary to ET dysfunction
Symptoms
• Ear discharge :
– Scanty, foul-smelling
– May be blood stained
• Hearing loss
– Conductive loss
Features indicating
complications :
• Vertigo
• Headache
• Facial weakness
• Vomiting
• Neck rigidity
• Diplopia, ataxia
• Swelling in the region of mastoid
• Perforation : Signs
– Attic / posterior-superior marginal perforation
– May be masked by granulation/ discharge
• Retraction pocket :
– Invaginated tympanic membrane in
attic/posterior-superior region
– If deep, keratin mass can accumulate
• Cholesteatoma :
– White flakes in retraction pocket
– Seen using operating microscope
Retraction pocket
Investigations
• Examination under microscope :
– Cholesteatoma, retraction pocket, perforation
• Pure tone audiometry :
– Degree of hearing loss
– Type of hearing loss
• Culture and sensitivity :
– Selection of proper antibiotic
• Mastoid X-ray :
– Extent of bone destruction,
– Law’s view
TREATMENT
• Aural toilet :
– Dry mopping
– Suction clearance
• Surgery :
– Modified Radical Mastoidectomy
– Reconstructive surgery :
• Tympanoplasty
CSOM: TREATMENT
• MEDICAL: AURAL TOILET FOLLOWED BY
TOPICAL ANTIBIOTIC EAR DROPS-
Ciprofloxacin ear drops, Norfloxacin ear
drops
• TREAT UNDERLYING FOCUS: ADENOIDS,
SINUSITIS
• SYSTEMIC ANTIBIOTICS- ACUTE
EXACERBATION/ FOR COMPLICATIONS
CSOM : SURGERY
• MYRINGOPLASTY
• TYMPANOPLASTY
(TYPES I TO VI)
• OSSICULOPLASTY
CSOM: SURGERY
• CORTICAL MASTOIDECTOMY
• MODIFIED RADICAL MASTOIDECTOMY
• RADICAL MASTOIDECTOMY
Complications
Intratemporal Intracranial
-mastoiditis -Extradural abscess
-petrositis -Subdural abscess
-facial paralysis -Meningitis
-labyrinthitis -Brain abscess
-LST
-Otitic hydrocephalus
