ENT
Case discussion
Abhilesh, 24 yr old male, is a student hailing from puducherry, presented with
Chief complaints of
Discharge in right ear × 1 year
Hard of hearing× 1 month
History of presenting illness
Patient was apparently asymptomatic 1 year ago, when he developed
Discharge in right ear which is insidious in onset, gradual in progression intermittent
in nature. The discharges yellow in colour and mucoid in nature, moderate in
quantity, non bloodstained and not foul smelling. It aggravated on URTI and relieved
on medication. last discharge was one day back.
Patient also complained of hard of hearing since 1 month in the right ear. Which is
insidious in onset and gradual in progression. There is improvement in hearing when
discharge is present. It aggravated on URTI and relieved on medication.
No History of ear pain
No History of tinnitus or vertigo
No history of fever headache or giddiness
No history of irritability or neck rigidity
No history of visual defects or diplopia
No history of ear trauma
No previous ear surgeries
No complaints of nose and throat
Past history
No history of similar complaints in the past
No history of DM/HTN/TB/Asthma
No previous ENT illness/surgeries
Personal history
Normal sleep and appetite
Normal bowel and bladder movements
No addictions
No known history of allergy
Family history
No significant family history
Examination
General examination:
Patient's consent was taken.
Patient was conscious cooperative, oriented to time place and person
Moderately built and moderately nourished
No pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy & pedal edema
Temperature - afebrile, BP - 110/68 mmHg, Pulse rate - 78 BPM, RR- 15/min
Ear examination:
Right ear Left ear
Preauricular area, pinna, Normal Normal
post auricular area
Tragal tenderness Absent Absent
Mastoid tenderness Absent Absent
External auditory canal Mucoid discharge is seen Normal
Tympanic membrane TM dull and lustreless TM is intact, pearly white
Cone of light absent in color
Medium sized perforation Cone of light is visible in
seen in antero-inferior antero-inferior quadrant.
and postero-inferior Pars flaccida is normal.
quadrants with smooth
and rounded edges.
Pars flaccida is normal.
Tuning fork tests
Rhinne's -ve (256,512), +ve (1024) positive
Weber lateralised to right ear
ABC same as examiner same as examiner
Fistula test Negative Negative
Facial nerve Normal Normal
Systemic examination:
CVS: S1 and S2 heard, no murmurs
RS: Normal vesicular breath sounds heard, no added sounds.
P/A: Soft, non tender, no organomegaly
CNS: No focal neurological deficit
Provisional diagnosis:
Right sided chronic suppurative otitis media - tubotympanic type - active stage
with right sided conductive hearing loss with no complications.
Differential diagnosis:
CSOM - TTD
CSOM - AAD
ASOM
Traumatic perforation
Foreign body impaction
The Discharging Ear
Differential diagnosis:
● Watery discharge (CSF otorrhea)
● Bloody discharge (Malignant otitis externa, bullous myringitis, CSOM with
granulation tissue, malignancy)
● Pure blood (trauma to ear)
● Mucopurulent (ASOM with perforated drum, CSOM - TTD)
● Purulent (furunculosis, diffuse otitis externa, cholesteatoma)
Cholesteatoma
Definition: A 3-dimensional epidermal sac in the middle ear cleft, lined by stratified
squamous epithelium which has lost its self-cleansing property causing accumulation
of keratin and desquamated cells inside the sac, having the property of expansion of
the sac at the expense of surrounding structures and can give rise to various
intra/extra cranial complications.
Classification of cholesteatoma:
● Congenital Cholesteatoma - embryonic epidermal cell rests.
Occur at Middle ear, Petrous apex (or) Cerebellopontine angle.
Presents as a white mass behind an intact tympanic membrane.
It may also spontaneously rupture through the TM.
Levenson Criteria for Diagnosis:
The patient should not have had previous episodes of middle ear disease.
Skin mass present behind an intact and normal TM.
Patient should not have a h/o ear trauma and/or surgery.
● Acquired cholesteatoma:
Primary acquired cholesteatoma occurs in the ear where there is no previous
history of ear discharge from the ear or tympanic membrane perforation.
Secondary acquired cholesteatoma always occurs in an already diseased ear
where there is a pre-existing tympanic membrane perforation.
Theories of Cholesteatoma:
● Wittmack's theory: Persistent ET obstruction causes a negative middle ear
pressure that leads to a posterosuperior retraction pocket, skin lined sac
inside the attic — leading to Cholesteatoma.
● Habermann's theory: The stratified squamous epithelium migrates from the
external canal across the edge of the marginal perforation into middle ear
cavity.
● Ruedi's theory: The basal cells of germinal layer of skin proliferate under the
influence of infection and lay down keratinizing squamous epithelium.
● Sade's theory: Long standing infection in the middle ear mucosa causes
metaplasia of the epithelial lining from simple columnar to keratinized stratified
squamous epithelium.
Tubotympanic disease Atticoantral disease
Definition: Chronic inflammation of the Definition: Chronic inflammation of the
muco-periosteal layer of the middle ear muco-periosteal layer of the middle ear
cleft characterized by ear discharge and cleft characterized by presence of skin
a permanent perforation of pars tensa. in the middle ear (cholesteatoma),
Aetiology: scanty foul smelling ear discharge and a
● sequela of acute otitis media permanent perforation of the attic (pars
● Ascen. infections from ET flaccida) or a marginal perforation.
● Persistent mucoid otorrhoea may Aetiology:
be d/t allergy to ingestants ● Same as cholesteatoma
In CSOM, the epithelium and endothelium meet each other and healing occurs at
their junction (Edges get covered by squamous epithelium) leading to creation of a
permanent perforation.
Bacteriology: pus culture reveals both aerobic and anaerobic organisms.
Pseudomonas aeruginosa is the most common organism involved. Another
common organism is Staphylococcus aureus.
Symptoms: Ear discharge
Long standing (> 3 months)
Insidious in onset, gradual in progression, constant/intermittent
Quantity of discharge:
Profuse: If discharge comes out of ear canal and stains the pillow during sleep.
Moderate: If discharge remains in the external auditory canal.
Scanty: If the tip of swab stick is stained by the discharge.
Yellow in color (greenish in Yellow in color, purulent in nature,
pseudomonas inf.), Mucoid/ Scanty in quantity (The attic and the
mucopurulent in nature, profuse in mastoid air cells are lined by flat
quantity (anterio-inferior part of the squamous pavement epithelium. The no
middle ear cleft is line by ciliated of mucous glands is very less and thus
columnar epithelium with abundant scanty discharge).
mucous glands and goblet cells)
Not foul smelling Foul smelling (because of osteitis and
Non blood stained bone erosion by cholesteatoma and
Stages of TTD. infection with anaerobic bacteria).
Active – Last discharge < 6 weeks
Quiescent – Last disch. 6 wk - 6 mon Blood tinged discharge (Granulation
Inactive – Last discharge beyond 6 mon tissue is present in middle ear cleft in
Healed – closed Tympanic membrane – Unsafe type of CSOM. They have
middle fibrous layer is lost forever; fragile capillaries. Polyps can also be
fused epithelium and endothelium. responsible for bleeding).
The discharge aggravates at time of URTI or on accidental entry of water into the
ear. discharge relieves on medication.
Symptoms: Hard of hearing
It is conductive type; severity varies but Hearing loss occurs in [Link] of
rarely exceeds 50 dB. Usually 30-40 dB. cases. Hearing loss is mostly
If ossicular chain loses continuity conductive but sensorineural element
hearing loss increases to 50-60 dB. may be added.
Reason: The Round window baffling Reason: Because of ossicular
effect is lost d/t to perforation → sound disruption.
waves simultaneously striking both oval Incus > Malleus > Stapes
and round window → destructive Incus is more prone due to poorest
interference and ↓ vibration of blood supply.
perilymph and the basilar membrane. Hearing is normal when ossicular chain
Hears better in the presence of is intact or
discharge than when the ear is dry (This when cholesteatoma, having destroyed
is due to “round window shielding the ossicles, bridges the gap caused by
effect” produced by discharge which destroyed ossicles (chol
helps to maintain phase differential). esteatoma hearer).
In long standing cases, cochlea may suffer damage due to absorption of toxins
from the oval and round windows and hearing loss becomes mixed type.
Symptoms: Ear pain
Acute exacerbation (or) Pus causing Mastoiditis, Petrositis (or) Sigmoid sinus
otitis externa thrombosis
Sign and symptoms of complications of CSOM and their causes
Examination: Otoscopy
Discharge is present in the external Foul smelling discharge in the external
auditory canal which is usually mucoidal auditory canal. Granulation tissue in
and non-foul smelling. posterosuperior part of deep meatus.
Tympanic membrane: A central Tympanic membrane shows attic,
perforation occurs in the pars tensa marginal or total perforation
without any involvement of the margin Occasionally granulation tissue or polyp
of the drum. Size of the perforation will may be seen coming out of perforation.
range from small to large perforation in Whitish cholesteatoma flakes can be
the pars tensa. seen through perforation.
Investigations
Examination under microscope – confirm the findings, ear suctioning, check the
ossicular status. It may reveal the presence of cholesteatoma, its site & extent,
bone destruction, granuloma, condition of ossicles & pockets of discharge.
Ear swab for culture and sensitivity - Done only in cases of active discharge.
Tuning fork tests and Pure tone audiogram:
● Tells about degree and type of hearing loss
● Serves as a documentary evidence
● Helps to monitor progression of disease or recovery.
X-Ray mastoid – Law’s view (tells whether mastoidectomy is needed or not)
High-resolution computed tomography (HRCT) and magnetic resonance imaging
(MRI) are recommended for revision mastoid operations.
Treatment
The aim is to control infection and Surgical treatment is the mainstay of
eliminate ear discharge and at a later treatment. Primary aim is to remove the
stage to correct the hearing loss by disease and render the ear safe, and
surgical means. second in priority is to preserve or
Medical treatment: reconstruct hearing but never at the
Aural toilet: Removal of discharge and cost of the primary aim.
debris from the EAC can be done by dry Antibiotics: Discharge in unsafe
mopping with absorbent cotton buds & CSOM is mainly because of bony
suction clearance under microscope. erosion so medical management with
Ear drops: Antibiotic/steroid drops 3–4 local and systemic antibiotics is
times a day in wet & running ears have indicated only in superimposed acute
local antimicrobial & anti-inflammatory infection or in infection causing extra or
effects. intracranial complications assisted by
Antibiotic of choice: Fluoroquinolones erosion due to cholesteatoma
(CIPROFLOXACIN) ear drops 5-7 days; Conservative treatment: Though has a
Antibiotic ear drops should not be given limited role it should be considered in
persistently. It will lead to death of the critically ill patient and only-hearing
normal flora and predisposes to fungal ear, where risk of surgery may not
infection. outweigh benefits.
Systemic Antibiotics: They are useful when cholesteatoma is small and easily
in acute exacerbation of chronically accessible to suction clearance under
infected ear, otherwise role of systemic operating microscope. Repeated
antibiotics in the treatment of CSOM is suction clearance and periodic
limited. checkups are essential.
Treatment of Contributory causes: Surgical treatment:
Attention should be paid to treat Canal wall up or down surgery with or
concomitantly infected tonsils, without tympanoplasty
adenoids, maxillary antra and nasal Factors determining extent and type of
allergy. surgery:
Patient’s instructions: Hearing status of both the ears.
Water should not enter in the ear while Extent of cholesteatoma.
bathing, swimming and hair-wash. Mastoid pneumatization.
The ear plugs and rubber inserts may Function of ET.
be employed. Presence of complications.
Avoid hard nose-blowing as it can push Patient factors: Age, occupation and
the infection from nasopharynx to general medical status.
middle ear.
Avoid self-cleaning of the ear.
Stop the ear drops once the ear
becomes dry.
Take treatment of upper respiratory
infections at the earliest.
Surgical treatment:
Removal of ear polyp or granulations:
They facilitate ear toilet and treatment
with local antibiotics.
(An ear polyp is never avulsed because
it may be attached to the stapes, facial
nerve and horizontal semicircular canal)
Tympanoplasty: In a dry ear,
myringoplasty/tympanoplasty restore
hearing and check repeated infection
from the external ear canal.
