Chronic Otitis Media

Prepaired by: Dr.Hiwa As’ad M.B.Ch.B. F.I.C.M.S.(ENT)

C.A.B.S.(ENT H&N Surgery)

Chronic Otitis MediaChronic Otitis Media

Introduction:Introduction: Def: Def: It is an inflammation of middle ear

space with a long standing infection. Chronic ear infections are much less

common than acute ear infections. its incidence is less common than in the pre- antibiotic era.

Chronic middle ear infection may be more destructive than an acute middle ear

infection, because its effects are prolonged or repeated.

It may cause permanent damage to the ear, however a chronic infection causes less sever symptoms.

Chronic middle ear infection includes several clinical entities which differ in aetiology , pathology and in the part of middle ear cleft principally involved.

Chronic Otitis MediaChronic Otitis MediaDivided into :

1- Chronic non-specific otitis media. a-Chronic suppurative otitis media.

b-Chronic non-suppurative otitis media.

2- Chronic specific otitis media.

Or devided into:Or devided into:

1.Chronic active otitis media.1.Chronic active otitis media. A. Safe B. UnsafeA. Safe B. Unsafe

2.Chronic inactive otitis media.2.Chronic inactive otitis media. A.Sequally of CSOM B. Adhesive OMA.Sequally of CSOM B. Adhesive OM

Chronic Suppurative Otitis MediaChronic Suppurative Otitis Media It is a chronic inflammation of the

middle ear space & mastoid cavity. Duration is from 6 weeks - 3 months or

more. Presents with recurrent ear

discharges through a tympanic membrane perforation. CSOM is a major cause of acquired hearing impairment in developing countries.

EpidemiologyEpidemiologyThe true incidence of CSOM with or without

Cholesteatoma is unknown.

Risk factors :Risk factors :

**Poor living conditions & living in crowded conditions.

**Poor nutrition & hygiene.

**Being a member of a large family.

**Studies of parental education ,passive smoking, breast feeding ,socioeconomic status and

the annual number of upper resp.tract infection are inconclusive.

**Multiple episodes of acute otitis media.

**Craniofacial anomaliesCraniofacial anomalies increase the risk like :cleft lip or palate ,downs syndrome ,cri-du-chat syndrome ,choanal atresia & microcephaly ,all increase risk presumably because of altered eustachian tube anatomy & function.

* * Age:Age: Children more than adults.**Ethnic groupEthnic group : : Native Americans,Alaskan,Green-

land,Australian aborigines,New Zealand natives all have higher incidence of CSOM.

ClassificationClassification

CSOM CSOM is usually classified in to two main groups : :

1.Tubotympanic disease1.Tubotympanic disease

**Non cholesteatomatus CSOM.

**Safe CSOM.

2.Atticoantral disease2.Atticoantral disease

**Cholesteatomatus CSOM.

*Tympanomastoid CSOM.

*Unsafe CSOM.

Tubotympanic diseaseTubotympanic disease

**Charactrised by a perforation of the pars tensa[[central perforation]]..

**adequate atticoantral drainage.

**disease confirm to the mucosa of the antero-

inferior portion of the middle ear cleft.

**risk of serious complication is minimal.

**most perforations arise when an acute perforation occurs during an episodes of acute suppurative otitis media.

Tubotympanic typeTubotympanic type of CSOM is further subdi

-vided in to two typestwo types : :

1-Tubal type1-Tubal type : :the route of infection is from the

eustachian tube.

**the underlying causes of infection lies either

In the nose ,sinuses or nasopharynx.

**usually seen in children of low socio-economic state ,these children present with profuse bilateral mucopurulent discharge.

**often involving both ears.

2-Tympanic type :2-Tympanic type :

**infection reaches the middle ear through a defect

in the tympanic membrane.

*there is a central perforation.

*usually seen in adults.

*usually involves one ear.

*there is scanty discharge which respond to anti- biotic & this is again occurs after the introduction of water into the ear.

BacteriologyBacteriology

--Pseudomonas aerugenosa ( 48 to 98 % )

--Staphylococcus aureus ( 15 to 30 % ).

--Klebsiella spieces ( 10 to 20 % ).

--Proteus merabilis ( 10 to 15% ).

--Polymicrobial ( 5 to 10 % ) which include :

Gram positive ,gram negative ,Aspergillus ,

Candida.

--Anaerobes e.g.Bacteroids ,Peptostrepto- coccus , Propioni bacterium ( 20 to 50 %).

The bacteria are infrequently found in

the skin of the EAC ,but they may proliferate

in the presence of trauma ,inflammation ,lacer

-ations or high humidity.

*these bacteria may then again enter into the

middle ear through a chronic perforation.

*among these bacteria for e.g. pseudomonas

has been particularly blamed for the deep sea

-ted & progressive destruction of the middle

ear & mastoid structures ,through its toxins &

enzymes .

Histopathological features of CSOMHistopathological features of CSOM Otitis media presents as an early acute

phase with essentially reversible mucosal & bony pathological changes which continues to a late chronic phase with well established intractable mucoperiosteal disease .

The recurrent episodes of otorrhoea& mucosal changes are characterized by osteoneogenesis ,bony erosions & osteitis ,that include the temporal bone & ossicles ,this is followed by ossicular destruction& or ankylosis which together with TM perforation contribute to hearing loss.

Clinical Features of CSOMClinical Features of CSOM1.1.DischargeDischarge : :it is mucoid,often scanty,usually

intermittent,but becoming purulent&profuse during exacerbations.the ear is usually pain

-less except when eczematoid otitis externa

intervenes.

* * it may be blood stained discharge ,when it is associated with aural polyps ,excessive granulations , ulceration or tumor..

2.2.DeafnessDeafness : :usually conductive in type ,the degree varies with the size & position of the

perforation.

Clinical Assessment :Clinical Assessment :1.1.For the scar of previous surgery.

2.2.For discharge.

3.3.Otoscopy & Otomicroscopy :

For the presence of TM perforation ,site & size of perforation ,the state of reminder of TM.

For the mucosa of middle ear ,for the ossicular chain ,presence of epithelialization ,granulations,ulceration & polyp.

4.4.Nose & Throat examination.

5.5.Eustachian tube function assessment..

6.6.Audiological assessmentAudiological assessment : :**Pure tone audiomtryPure tone audiomtry : :detect level of hearing

loss & type of hearing loss..

**Speech audiomtrySpeech audiomtry : :which measures speech

recognition(reception)threshold & speech dis-

crimination ability reflected in the speech

recognition score (speech may be presented

by Monitored live voice , Cassette tape or

Compact disc CD).

Radiological assessmentRadiological assessment

**Plain radiogramPlain radiogram :it is of value in cholesteat

-omatus cases(shows lytic lesions) ,also it detect variation in anatomic landmarks.

**CT-Scan :CT-Scan : CTscanning performed when:

1. intratemporal or intracranial

complications are suspected

2. surgical intervention being planned

3.to study anatomy of temporal bone These studies should include both axial & coronal fine cuts (1-1.5mm) through the temporal bone.

Treatment of CSOMTreatment of CSOM

*Swab should be taken for culture&senstivity.

*Aural toiletAural toilet daily by suctioning the ear ,it is

better to be done under the microscope.

*Antibiotics Antibiotics : Usually after aural toilet & placement of ototopic medication is all

that is needed to stop the chronic otorrhoea.-Ofloxacin otic drops- combination of (neomycin,polymixin

B ,ciprofloxacin )with steroids like hydro-cortisone.The addition of corticosteroids aids in the resolution of inflammation.

Topical antimicrobial therapy frequently results in rapid resolution of the otorrhoea in 1to 2 weeks.

Oral antimicrobial agents alone are frequently ineffective in treating CSOM.

In patients with refractory otorrhoea ,consideration must be given to: -a resistant organism. -poor drug delivery.

- the presence of chronic otomastoid osteitis,granulation tissue,or cholesteatomas.

Culture Directed intravenous antibiotics are a reasonable approach ,usually an antipseudomonal penicillin or a second or third generation cephalosporin will cover the offending organisms ,daily suctioning & inst-

illation of ototopic agents is also useful ,in these

cases 7 to 10 days of treatment will usually dry

the ear without the need of further therapy.

Surgical Surgery should be considered for failure to

respond to a combination of topical and systemic therapy.

A tympanomastoidectomy can eliminate infection and stop otorrhoea in 80% of patients.

Tympanoplasty(Myrigoplasty and ossiculoplasty) can seal a perforation and prevents transfer of bacteria from the external ear canal into the middle ear and reconstruct the hearing mechanism.

Attico-antral CSOM.Attico-antral CSOM.

--Cholesteatomatus CSOM

--Tympanomastoid CSOM

--Unsafe CSOM

Tympanomastoid otitis mediaTympanomastoid otitis media In this type of infection the bone of attic,antrum or mastoid process is involved as well as the mucosa of the middle ear cleft , therefore it is regarded as atticoantral disease as erosion of bone may extend to adjacent vital structures ,there is always a danger of

serious complications. The bony involvement may give rise to granulations or polypi ,these may be true granulation tissue ,but it may be due to an inflammatory swelling of themucosa of the ear ,however there presence

Is evidence of bony involvement.

There are three basic pathologicalthree basic pathological findings in the

Tympanomasoid type of the disease :

.

1.1.Cholesteatoma .

2.2.Granulation tissue with osteitis.

3.3.Cholesterol granuloma.

1- Cholesteatoma1- Cholesteatoma

It is an epidermal inclusion cyst ,localized

in the middle ear & petrous bone ,whose caps

-ule & matrix is formed from stratified squamo

-us epithelium.

The desquamating debris include pearly white

Lamellae of keratin that accumulate concentri

-cally ,forming the cholesteatomatus masscholesteatomatus mass.

The term cholesteatoma is actually misnomer

it is derived from Greek “chole” or bile “steat

-os” or fat & “oma” tumor.

The suffix “oma” is more appropriate ,because it can be considered as an epidermal inclusion cyst.

It is made up of :It is made up of :

--cystic content :a nucleate keratin squamous.

--matrix keratinizing squamous epithelium .

--peri matrix granulation tissue ,incontact with

Bone (( produces proteolytic enzymes ).).

2-Granulation tissue:2-Granulation tissue:This is basically a low grade osteitis of the Mastoid bone ,it may be localized to one area e.g. Posterosuperior meatal wall & middle ear, or Extend through out the middle ear & mastoid ,it Can also cause destruction of surrounding Structures.3-3-Cholesterole granuloma Cholesterole granuloma : this can be seen on its own or in combination with either cholesteatoma or granulations ,it appear as a dark brown often with a lot of bone destruction & if present in the middle ear

gives the TM a dark blue or black appearance .

Histological examinationHistological examination shows it to consist of

Cholesterol crystals surrounded by FB giant

Cells & granulation tissue.

Classification of CholesteatomaClassification of Cholesteatoma

1.1.Congenital.Congenital.

2.2.Acquired :Acquired :

-Primary acquired-Primary acquired

(retraction pocket )(retraction pocket )

-Secondary acquired-Secondary acquired

pathogenesis of congenital cholesteatomapathogenesis of congenital cholesteatomaArises from entrapped ectodermal cellular de-

bris ,during embryonic development.

LocationLocation ( ( petrous pyramid ,mastoid & middle

ear cleft ).).

**Levisohn criteria :Levisohn criteria :

--white mass medial to normal TM (retrotympa-

nic mass).

--normal pars flaccida & pars tensa.

--no history of otorrhoea or perforation.

-no prior otologic procidures.

-prior bouts of otitis media not grounds for

exclusion .

  A small congenital cholesteatoma was found at time of a well-child visit. The tumor is seen through an intact tympanic membrane. Only the anterosuperior quadrant of the middle ear space appears involved. At surgery, the tumor was encapsulated and did not involve the ossicles or extend beyond the middle ear

  A large congenital cholesteatoma, found subsequent to hearing loss identified at time of a school hearing screening test. The tumor completely fills all visible middle ear space beneath the tympanic membrane. At surgery, ossicular erosion was present as well as tumor extension into the attic and mastoid.

Pathogenesis of acquired :Pathogenesis of acquired :

Primary acquired ( epitympanic retraction

Pocket) that become so deep that keratin

debris no longer expelled ,leading to it is

accumulation ,such retraction pocket may be

asymptomatic until it become infected ,

Progressive hearing loss may be the only

Symptom due to erosion of ossicular chain.

Primary acquired Primary acquired cholesteatomacholesteatoma

Predisposing factors for acquired :Predisposing factors for acquired :

--Eustachian tube dysfunction .

-poor aeriation of epitympanic space.

-retraction of pars flaccida.

-normal migratory pattern altered.

-perforation of weakened area.

-accumulation of keratin & invasion of attic.

-enlargement of the sac (which may surround

the ossicles & invade the aditus).

Pathogenesis of secondary acquired:Pathogenesis of secondary acquired:--implantation by:implantation by: surgery, foreign body , blast injury.-metaplasia :metaplasia : transformation of cuboidal epithelium to squamous epithelium from chronic infection .--invasion / migration :invasion / migration : medial migration along permanent perforation of TM.--papillary ingrowths :papillary ingrowths : intact pars flaccida ,

inflammation in Prussack’s space,break down in the basal membrane ,cords of epithelium migrates inward.

EvaluationEvaluation--History

**Hearing lossHearing loss conductive in type ,may be the only symptom.**Otorrhoea Otorrhoea (fetid ,vary in amount ,s.t. bloody )**otalgiaotalgia, tinnitus, vertigo ,headache, facial palsy**Previous historyPrevious history of chronic otitis media, tympanic

membrane perforation or otologic surgery*Progressive unilateralProgressive unilateral hearing loss with chronic

fetid otorrhea suspicious

EvaluationEvaluation--Physical ExaminationPhysical Examination

--Otoscopy & OtomicroscopyOtoscopy & Otomicroscopy :**TM perforation situated in Shrapnel’s membrane or

marginally in the Posterosuperior quadrant**It may be visible through the perforation as a grayish

paper like substance ,or as pearly sheet of keratin ** Posterosuperior retraction pocket .**Granulation from diseased bone**Aural polyps--Pneumatic otoscopy – positive fistula response

suggests erosion into labyrinth--Cultures should be obtained in infected ears

EvaluationEvaluation-Audiology Audiology – usually conductive loss.

-ImagingImaging *CT temporal boneCT temporal bone :: for -revision cases -complications of

chronic suppurative otitis media -sensorineural hearing loss -vestibular symptom -other complications of cholesteatoma

Management of cholesteatomaManagement of cholesteatoma Definite objectivesDefinite objectives

--management of complications which takes priority over the

other objectives .

--total eradication of cholesteatoma to obtain a safe , dry ear .

--to restoration or maintaining the functional capacity of the

ear , the hearing .

--is to maintain a normal anatomic appearance of the ear if

Possible .

Management of cholesteatomaManagement of cholesteatoma

--Medical Medical : : Elderly patient with a poor general medical condition & patient with unacceptable anesthetic risks.

--Otomicroscopy and aggressive aural toilet to prevent extension of the disease process and development of infection and other complications.

--This is particularly useful in those patients in whom disease is limited. Topical antibiotic therapyTopical antibiotic therapy may prove useful in alleviating otorrhea.

--preventivepreventive : :

*Tympanostomy tube insertion for ventilation of the middle ear may alleviate early tympanic membrane retraction associated with eustachian tube dysfunction.

** a long term ventilation tube is often necessary.

* * If the pocket persists despite tube placement, surgical

exploration is indicated.

Management of cholesteatomaManagement of cholesteatoma

--cholesteatoma is a surgical disease .- the surgical procedure to be used should be designed for

each individual case according to the extent of disease.

- Surgical ManagementSurgical Management

--Intact-canal-wall up (closed) Tympanoplasty

--Canal-wall-down (open) Tympanoplasty

Canal-wall-down Canal-wall-down

a canal wall down operation, the entire mastoid is exteriorized into the ear canal and the posterior and superior portion of the ear canal is removed down to the region of the facial nerve.  The facial nerve is left intact covered by a ridge of bone called the facial ridge.  This leaves a large cavity called a mastoid bowl which has to be cleaned by the doctor every 3 to 12 months.  In order to clean this cavity, the meatus or the external opening into the ear canal is surgically widened - 

Picture of a right mastoidectomy, surgeon's view.  Note the blue color of the skeletonized sigmoid sinus.

Picture of a left mastoidectomy, surgeon's view.

A large, adequate meatoplasty. Such a meatoplasty is usually necessary to create a problem-free cavity.

                   

 

L Canal Wall Down Mastoidectomy.  This patient had a modified radical mastoidectomy with tympanoplasty.  The posterior bony canal has been removed and part of the dry "mastoid bowl" is visible posterior and superior to the reconstructed tympanic membrane

Magnification of the above photograph.   A meatoplasty has been performed to enlarge the external auditory canal and allow easy access to the mastoid bowl for inspection and cleaning.  The reconstructed eardrum is seen anteriorly.

Intact-canal wall Intact-canal wall procedureprocedure

In this left canal wall up mastoidectomy, the tympanic membrane has been elevated forward and a cholesteatoma sac is visible in the attic.

This is a "canal wall up" mastoidectomy because the posterior bony canal has been preserved.

In this picture of a right tympano- mastoidectomy, a prosthesis has been interposed between the manubrium of

the malleus and the capitulum of the stapes. 

Transcanal anterior Transcanal anterior atticotomyatticotomy

Complications of Complications of cholesteatomacholesteatoma

Hearing loss Labyrinthine fistula Facial paralysis Intracranial complications

Chronic non Suppurative Otitis MediaChronic non Suppurative Otitis Media

-- it is a clinical condition characterized by the presence of a non purulent fluidnon purulent fluid in the middle ear cleft .

--acute acute & chronicchronic forms can be distinguished ,

according to the mode of onset & by their duration ,but the distinctions may not be clear & the condition is often recurrent.

--most children get glue ear at some stage intheir lives.

--Synonyms :Synonyms : Glue ear, serous or secretary

otitis media , catarrhal otitis media or

mucinous otitis media.

Aetiology Aetiology 1.1.AdenoidsAdenoids :large adenoids at the back of the nose & passive smoking are the commonest causes for glue ear to persist in children.

Other causes of tubal occlusion :Other causes of tubal occlusion :

**stricture or adhesion after adenoidectomy.

**ulceration or neoplasm of the postnasal

space involving the orifice of the tube.

**Paralysis of palatal muscles from myopathic

or neuropathic causes e.g. Myasthenia gravis

**nasopharyngeal atresia ,congenital or acquired

**post nasal packs.

2.2.Extension of infection through the ET from the RT

3.3.Thick mucoid fluid plugging the tubal isthmus. 4.Unresolved acute OMUnresolved acute OM

5.5.ViralViral infectioninfection of ME :adenoviruses & rhinoviruses

causing nasopharyngitis & rhinitis.

6.6.Allergic reactionAllergic reaction e.g. Hay fever may be associated

with ME effusion .

7.7. Cleft palate or Downs syndrome .

Clinical featureClinical feature

1.1.Deafness Deafness :

--conductive in type.

--of mild to moderate degree.

--often it is the only symptom.

--one or frequently both ears affected in children.

--onset may be sudden or gradual.

--may be unrecognised for a long period in young

children.

--adult often refer the onset to a recent cold or

even to one acquired months previously.

--changes of position of the head cause changes in

the degree of deafness ,when the fluid is thin.

--speech may be delayed ,especially if deafness

occurs early in childhood.

2.2.TinnitusTinnitus :

--older children & adults often complain of noises in

the ears.

--variable may be cracking & bubbling noises .

--sensation of fluid in the ear especially on blowing

nose & swallowing.

--may be buzzing & whistling like noises.

3.3.Some sufferers get frequent earaches , usually

worse at night .

4.4. Poor balance & clumsiness may be a feature .

DiagnosisDiagnosis

1.1.diagnosis is based on history , physical exam.

& special investigations.

--specialist may be able to see the signs of fluid

behind the TM with the otoscope , this is not always

possible ,because wax or discharge may block the

the view , some children may not be sufficiently

Cooperative for examination .

2.2.Otoscopic appearance of TMOtoscopic appearance of TM :

--it is usually dull & retracted .

--the malleus short process is prominent .

--the handle of malleus is shortened & more horizontal .

--when the ME is completely filled with fluid the TM

may not be distorted , bubbles or even foam

formation may be seen in the fluid .

--the colour of TM depend on the colour of fluid

behind it .

--it is usually pale yellow , may be grey or even

blue .

--but some time it may be near normal.

33..EarEar dischargedischarge :

--varies in quantity & viscosity .

--it may be clear or opaque , colourless , yellow or

dark brown .

--it varies from serous to a glue like consistency .

--the fluid is generally bacteriologically is sterile .

--but it may be secondarily infected .

--eosinophils swarm in the effusion of allergic cases

is seen .

                            

  Glue ear with fluid level behind right eardrum

                       

Abnormally thin right eardrum damaged by glue ear and showing ossicles - malleus incus and stapes

4.4.TympanogramTympanogram :

--it is a physical test on the movement of the TM . --a flat trace on the tympanogram usually means glue

ear.

5.5.Audiogram Audiogram :

--it is carried out on children old enough to cooperate with the test .--to assess the degree of hearing loss .

TreatmentTreatment--the fluid frequently goes away by itself so a policy of “watchful waiting” is usually advised .--eliminate aetiological & predisposing factors.--antibiotics & painkillers can be used for associated ear infections .--decongestants are often prescribed --other treatments including antihistamines &steroids --glue ear can be seasonal , worse in the winter & better in the summer .

                              

Correct position for putting in eardrops

                              

Tragal massage

                              

Ear plugs held in place by neoprene headband

--if deafness persists for longer than three months ,

an operation is usually needed .

--the decision to operate is always individual , based

on all the factors in that particular case.

--surgical measures may be necessary if the effusion

persists , which include :

1.1.MyringotomyMyringotomy & evacuation& evacuation of fluid under GA ,

the operating microscope & suction should always

be used.

2.2.Indwelling Teflon tubesIndwelling Teflon tubes or grommetsgrommets are often

inserted through the membrane . They left in

position until they rejected spontaneously

usually after nine months .

3.3.Intratympanic injection of urea solutionurea solution may help

to facilitate the evacuation of excessively thick

glue .

4.4.Cortical mastoidectomy may be indicated very

rarely .

-recurrence occurs in about 20 %20 % of cases .

                              

grommet in position right eardrum - abnormally thin due to longstanding retraction prior to fitting grommet. Head of stapes visible, long process of incus partially eroded

                              

Long term ventilation tube in position right eareac = external ear canalvt = ventilation tubetm = tympanic membrane (eardrum)The long term ventilation tube is larger than the standard grommet

Tuberculous Otitis MediaTuberculous Otitis MediaTOM is now it is a rare condition.

It is divided in to two groups :two groups :

1-1-in infants & very young childin infants & very young child ; who are fed on un

Sterilized cows milk ,which contain the bovine type

Of tubercle bacillus ,suppurative OM in an infant

which is not responding to treatment ,should make

One think of TOM.

2-2- in advanced stages of pul. Tub.pul. Tub. disease of the ME

cleft sometime occurs.

TOM incidence :TOM incidence :-In developed countries its incidence is low about 5

To 20 cases / 100000 population.

-in developing countries it is often a disease of

Childhood.

-it is also common in immunocompromisedpatients

Clinical feature of TOM :Clinical feature of TOM :--It has an insidious course.

--painless.

--profuse otorrhoea.

--hearing loss.

--presentation may be painful with acute mastoiditis.

Diagnosis Diagnosis

--Otoscopic examinationOtoscopic examination : :multiple perforation of TM.

watery discharge , pale granulation tissue..

--AFBAFB staining of discharge . .

--PCRPCR for tuberculous bacilli .

--Histopathologic examHistopathologic exam. . For granulation tissue.

--cultureculture..

--chest x-raychest x-ray..

--CT scanCT scan for complications.

TreatmentTreatment

--Medical: Medical: using multidrug therapy because

of changing resistance pattern .

The duration of treatment depend on :The duration of treatment depend on :

**host immune function.

**multidrug resistance tuberculosis.

**primary or reactivation state.

**in general a dry ear need 2 to 4 months treatment.

--in tuberculous mastioditis , , surgerysurgery is needed .