Chronic suppurative otitis mediChronic suppurative otitis media with and without cholesteatoa with and without cholesteato

mama

Hongyan Jiang MD&PhD

Otorhinolaryngology Hospital,The First Affiliated Hospital of Sun Yat-sen University

Chronic suppurative otitis media withouChronic suppurative otitis media without cholesteatomat cholesteatoma

Chronic infection of the middle ear with a non-heChronic infection of the middle ear with a non-healing perforation of the tympanic membranealing perforation of the tympanic membrane

Otorrhea (ear drainage) for 6-12 weeksOtorrhea (ear drainage) for 6-12 weeks Middle ear mucosa becomes edematous, polypoiMiddle ear mucosa becomes edematous, polypoi

d, or ulceratedd, or ulcerated The tympanic cavity usually contains granulation The tympanic cavity usually contains granulation

tissuetissue Most common infecting organisms are PseudomoMost common infecting organisms are Pseudomo

nas aeruginosa, Staphylococcus aureus, Proteus nas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroidsspecies, Klebsiella pneumoniae, and diphteroids

Annual incidence approximately 40 cases/100,00Annual incidence approximately 40 cases/100,000 population0 population

Chronic suppurative otitis media withChronic suppurative otitis media without cholesteatomaout cholesteatoma

Patients present with hearing loss and otorrheaPatients present with hearing loss and otorrhea Pain, vertigo, fevers, facial nerve palsy, mental statuPain, vertigo, fevers, facial nerve palsy, mental statu

s changes or fetid drainage signify impending intra-ts changes or fetid drainage signify impending intra-temporal or intra-cranial complicationsemporal or intra-cranial complications

Near Total TM PerforationNear Total TM Perforation

CholesteatomaCholesteatoma

CholesteatomaCholesteatoma Cholesteatomas are epidermal inclusion cysts oCholesteatomas are epidermal inclusion cysts o

f the middle ear and/or mastoid with a squamof the middle ear and/or mastoid with a squamous epithelial liningus epithelial lining

Contain Contain keratinkeratin and desquamated epithelium and desquamated epithelium Term “cholesteatoma” coined by Johannes MTerm “cholesteatoma” coined by Johannes M

uller in 1838 uller in 1838 Misnomer because the cysts don’t contain choMisnomer because the cysts don’t contain cho

lesterollesterol Can be congenital or acquiredCan be congenital or acquired Natural history is progressive growth with erosiNatural history is progressive growth with erosi

on of surrounding bone due to pressure effects on of surrounding bone due to pressure effects and osteoclast activationand osteoclast activation

CholesteatomaCholesteatoma

CholesteatomaCholesteatoma Annual incidence is unknownAnnual incidence is unknown In 1978, there were 4.2 hospital discharges per In 1978, there were 4.2 hospital discharges per

100,000 with cholesteatoma 100,000 with cholesteatoma ((Ruben RJ: Ruben RJ: The disease in society: evaluation of chronic otitis media in general and cholesteatoma in partiThe disease in society: evaluation of chronic otitis media in general and cholesteatoma in parti

cularcular. In Sadé J, editor: . In Sadé J, editor: Cholesteatoma and mastoid surgeryCholesteatoma and mastoid surgery, Amsterdam, 1982, Kugler Publishing, Amsterdam, 1982, Kugler Publishing)) Harker and coworkers estimated the incidencHarker and coworkers estimated the incidenc

e at 6/100,000e at 6/100,000(Harker LA: (Harker LA: Cholesteatoma: an incidence studyCholesteatoma: an incidence study . In McCabe BF, Sadé J, Abramson M, editors: . In McCabe BF, Sadé J, Abramson M, editors: CholesteatCholesteat

oma: first international conferenceoma: first international conference , Birmingham, Alabama, 1977, Aesculapius Publishing), Birmingham, Alabama, 1977, Aesculapius Publishing) Tos and colleagues found 3/100,000 in childreTos and colleagues found 3/100,000 in childre

n and 12.6 per 100,000 in adultsn and 12.6 per 100,000 in adults(Tos M: Incidence, etiology and pathogenesis of cholesteatoma in children, (Tos M: Incidence, etiology and pathogenesis of cholesteatoma in children, Ann Otol Rhinol LaryngolAnn Otol Rhinol Laryngol 40:1 40:1

10, 1988) 10, 1988)

Congenital cholesteatomaCongenital cholesteatoma Epidermal inclusion cysts usually present in the antEpidermal inclusion cysts usually present in the ant

erior superior quadrant of the middle ear near the erior superior quadrant of the middle ear near the Eustachian tube orificeEustachian tube orifice

Michaels found epidermoid formation in 37 of 68 teMichaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestatiomporal bones of fetuses at 10 to 33 weeks' gestation. n. (Michaels L: An epidermoid formation in the developing middle ear; possible source of c(Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986)holesteatoma, Otolaryngol 15:169, 1986)

Diagnosed as a pearly white mass behind an intact Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have tympanic membrane in a child who does not have a history of chronic ear diseasea history of chronic ear disease

Acquired CholesteaAcquired Cholesteatomatoma

PathogenesisPathogenesis

InvaginationInvagination((Pocket rePocket retractiontraction ) )

Basal cell hyperplasiaBasal cell hyperplasia Migration (through a Migration (through a

perforation)perforation) Squamous metaplasiSquamous metaplasi

aa

Primary acquired cholesteatomaPrimary acquired cholesteatoma Retraction pocket cholesteatoma usually witRetraction pocket cholesteatoma usually wit

hin the pars flaccida or posterior superior tyhin the pars flaccida or posterior superior tympanic membrane (invagination Theory)mpanic membrane (invagination Theory)

Secondary to ETDSecondary to ETD Keratin debris collects within a retraction poKeratin debris collects within a retraction po

cketcket

Normal TM Mucoid effusion and primaryacquired cholesteatoma

Mesotympanic cholesteatoma

Primary acquired cholesteatomaPrimary acquired cholesteatoma

Secondary Acquired CholesteatomaSecondary Acquired Cholesteatoma Migration Theory – most accepted Migration Theory – most accepted Originates from a tympanic membrane perforationOriginates from a tympanic membrane perforation As the edges of the TM try to heal, the squamous epAs the edges of the TM try to heal, the squamous ep

ithelium migrates into the middle earithelium migrates into the middle ear

COM with and without cholesteatomaCOM with and without cholesteatomaDiagnosisDiagnosis

COM with and without cholesteatomaCOM with and without cholesteatomaDiagnosisDiagnosis

Axial Section Coronal Section

History, History, physical examinationphysical examination, high , high resolution resolution CT scanCT scan of the temporal bone of the temporal bone

Cholesteatoma ImagingCholesteatoma Imaging

Cholesteatoma ImagingCholesteatoma Imaging

COM with and without CholesteatomCOM with and without Cholesteatomaa

TreatmentTreatment

Chronic suppurative otitis media Chronic suppurative otitis media withoutwithout cholesteatoma cholesteatoma

Ototopical antibioticsOtotopical antibiotics Surgical repair of the TM perforationSurgical repair of the TM perforation Repair of the ossicular chain if necessaryRepair of the ossicular chain if necessary

Ototopical MedicationsOtotopical Medications

Antibiotic only otic dropsAntibiotic only otic drops Floxin (Floxin (ofloxacinofloxacin))

Antibiotic with steroid otic dropsAntibiotic with steroid otic drops Ciprodex (Ciprodex (ciprofloxin and dexamethasoneciprofloxin and dexamethasone))

Cipro HC (Cipro HC (ciprofloxin and hydrocortisoneciprofloxin and hydrocortisone))Cortisporin (Cortisporin (neomycin, polymyxin, and neomycin, polymyxin, and hydrocortishydrocortis

one) one) Ophthalmic antibiotic preparationsOphthalmic antibiotic preparations

Tobradex (Tobradex (tobramycin and dexamethasonetobramycin and dexamethasone))

The concentration of antibiotic in ototopical drops is 100-1000x grThe concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically.eater than what can be achieved systemically.

TympanoplastyTympanoplasty Paper patch myringoplastyPaper patch myringoplasty Fat myringoplastyFat myringoplasty Underlay tympanoplasty (medial graft technique)Underlay tympanoplasty (medial graft technique)

Underlay TympanoplastyUnderlay Tympanoplasty

Ossicular Chain ReconstructionOssicular Chain Reconstruction

Chronic suppurative otitis media Chronic suppurative otitis media withwith cholesteatoma cholesteatoma

Ototopical antibioticsOtotopical antibiotics Surgical repair of the TM perforationSurgical repair of the TM perforation Repair of the ossicular chain if necessaryRepair of the ossicular chain if necessary Often requires mastoidectomyOften requires mastoidectomy

MastoidectomyMastoidectomy Intact (bony ear) canal wall mastoidectIntact (bony ear) canal wall mastoidect

omyomy Canal wall down mastoidectomyCanal wall down mastoidectomy

Radical MastoidectomyRadical Mastoidectomy Modified Radical MastoidectomyModified Radical Mastoidectomy

MastoidectomyMastoidectomy

Tympanoplasty with mastoidectomy aTympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicund hydroxyapatite bone cement ossicu

lar reconstructionlar reconstruction

SurgicalSurgical development development

radical mastoidectomy (canal wall-down ,CWD)

modified radical mastoidectomy

close mastoidectomy(canal wall-UP ,CWU)

modified close mastoidectomy

Mastoid obliteration

soft/hard canal-wall reconstruction

endoscopic middle ear surgery

endoscope-assisted surgery of middle ear

a:atticotomy; b:bridge;o:otosclerosis drilling; e:thin posterior bony ear canal wall; cm: cortical mastoidectomy ; aa :anterior attic, hc:horizontal semicircular canal; ib: incus body; mh: malleus head; m: malleus; f: facial canal; r: round window; c: chorda; s :tympanic sinus

Tos 改良完壁式乳突根治

Tos modified close mastoidectomy

HongKong Flap

Hung T,et al. Laryngoscope 2007;117:1403-1407

Postauricular periosteal-pericranial flap

Ramsey MJ,et al. Otol Neurotol. 2004 Nov;25(6):873-8

Middle temporal artery flapMiddle temporal artery flap

Singh V, et al. Otolaryngology–Head and Neck Surgery (2007) 137, 433-438

Soft canal-wall reconstruction

Takahashi H ， et al. Eur Arch Otorhinolaryngol (2007) 264:867

endoscopic middle ear surgery

SurgicalSurgical development development

radical mastoidectomy (canal wall-down ,CWD)

classic radical mastoidectomy

modified radical mastoidectomy

close mastoidectomy(canal wall-UP ,CWU)

modified close mastoidectomy

Mastoid obliteration

soft/hard canal-wall reconstruction

endoscopic middle ear surgery

endoscope-assisted surgery of middle ear

COM with and without CholesteatomCOM with and without Cholesteatomaa

ComplicationsComplications

Complications of Otitis MediaComplications of Otitis Media Acute mastoiditisAcute mastoiditis Sub-periosteal absceSub-periosteal absce

ssss CholesteatomaCholesteatoma LabyrinthitisLabyrinthitis Facial paralysisFacial paralysis MeningitisMeningitis Epidural/subdural abEpidural/subdural ab

scessscess Brain abscessBrain abscess Sigmoid sinus thromSigmoid sinus throm

bosisbosis Otitic HydrocephalusOtitic Hydrocephalus

Due to antibiotics, the incidence of complicationDue to antibiotics, the incidence of complications has greatly declined.s has greatly declined.

Complications are usually associated with some Complications are usually associated with some degree of bone destruction, granulation tissue fodegree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.rmation, or the presence of a cholesteatoma.

Complications arise most commonly by infection Complications arise most commonly by infection spreading by direct extension from the middle espreading by direct extension from the middle ear or mastoid cavity to adjacent structures.ar or mastoid cavity to adjacent structures.

Complications of Otitis MediaComplications of Otitis Media

Acute mastoiditis with sub-periosteal aAcute mastoiditis with sub-periosteal abscessbscess

Brain Brain AbscessAbscess

Complications of Otitis MediaComplications of Otitis Media Patients appear more ill than expected Patients appear more ill than expected

fever, new onset vertigo, sensorineural hearing loss, fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic earfetid drainage, facial nerve weakness, proptotic ear

lethargy and mental status changes lethargy and mental status changes CT and MRI are indicated CT and MRI are indicated

CT is superior for evaluating the bony details of the CT is superior for evaluating the bony details of the middle ear and mastoid spacemiddle ear and mastoid space

MRI is more sensitive for diagnosing suspected intraMRI is more sensitive for diagnosing suspected intracranial complications.cranial complications.

Broad spectrum antibiotics and surgery are reqBroad spectrum antibiotics and surgery are requireduired

SummarySummary Eustachian tube dysfunction is central to the dEustachian tube dysfunction is central to the d

evelopment of ear diseaseevelopment of ear disease Chronic otitis media without cholesteatoma is Chronic otitis media without cholesteatoma is

defined as prolonged otorrhea thru a non-healdefined as prolonged otorrhea thru a non-healing TM perforationing TM perforation

Cholesteatomas are bone destructive epitheliCholesteatomas are bone destructive epithelial cysts that require surgical removalal cysts that require surgical removal

The temporal bone is a complex anatomic regiThe temporal bone is a complex anatomic region with close proximity to a variety of critical son with close proximity to a variety of critical structures. These structures are at risk during btructures. These structures are at risk during both acute and chronic otitis mediaoth acute and chronic otitis media