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Chronic suppurative otitis Chronic suppurative otitis mediamedia

Dr. T. Balasubramanian M.S. D.L.O.Dr. T. Balasubramanian M.S. D.L.O.

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DefinitionDefinition

CSOM is defined as a CSOM is defined as a chronic infection of chronic infection of middle ear mucosa middle ear mucosa lining the middle ear lining the middle ear cleftcleft

The duration of The duration of infection should be infection should be more than 3 weeksmore than 3 weeks

Middle ear cleft Middle ear cleft includes eustachean includes eustachean tube, middle ear tube, middle ear proper and mastoid proper and mastoid air cell systemair cell system

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Tubotympanic diseaseTubotympanic disease

Also known as Also known as safe earsafe ear

It does not cause It does not cause any serious any serious complicationscomplications

Infection limited Infection limited to the antero to the antero inferior part of inferior part of middle ear cleftmiddle ear cleft

Associated with Associated with central central perforationperforation

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Why is Tubotympanic Why is Tubotympanic disease safe?disease safe?

There is no risk of bone erosionThere is no risk of bone erosion Not known to cause intracranial Not known to cause intracranial

complicationscomplications Discharge from middle ear flows freely Discharge from middle ear flows freely

through the perforation in the pars through the perforation in the pars tensatensa

Usually the perforation of pars tensa is Usually the perforation of pars tensa is surrounded by a rim of intact drumsurrounded by a rim of intact drum

The annulus is intact in all these casesThe annulus is intact in all these cases

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AetiologyAetiology

Inadequately treated ASOM

ASOM causing persistent perforation (Persistent perforation syndrome)

Presence of focal sepsis in Nose / throat causing EC

Infected traumatic central perforation

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MicrobiologyMicrobiology

Gram negative bacilli has been Gram negative bacilli has been commonly isolatedcommonly isolated

Ps. aeruginosa, E. coli, and B. proteus Ps. aeruginosa, E. coli, and B. proteus These organisms are not commonly These organisms are not commonly

found in the respiratory tractfound in the respiratory tract These organisms are commonly These organisms are commonly

found in the skin of external canal found in the skin of external canal Always number your slides

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Clinical featuresClinical features

Discharge is profuse and MucopurulentDischarge is profuse and Mucopurulent It is not foul smellingIt is not foul smelling Since the infected area is open at both Since the infected area is open at both

ends discharge doesn't accumulate in ends discharge doesn't accumulate in the middle ear cavitythe middle ear cavity

Ossicular chain is mostly uninvolvedOssicular chain is mostly uninvolved Pts have conductive deafness – 30 – Pts have conductive deafness – 30 –

40 dB40 dB Pain is usually due to otitis externaPain is usually due to otitis externa

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Stages of Tubotympanic Stages of Tubotympanic diseasedisease

Acute stage Acute stage Inactive stageInactive stage Quiescent stageQuiescent stage Healed stageHealed stage

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Acute stageAcute stage

Ear is actively dischargingEar is actively discharging Middle ear mucosa Middle ear mucosa

hypertrophied and congestedhypertrophied and congested The ear discharge is The ear discharge is

MucopurulentMucopurulent Discharge is not foul smellingDischarge is not foul smelling

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Inactive stageInactive stage

Dry perforation of ear drum +Dry perforation of ear drum + Perforation involves the pars tensaPerforation involves the pars tensa Annulus is intactAnnulus is intact Middle ear mucosa is normal and Middle ear mucosa is normal and

healthyhealthy

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Quiescent stageQuiescent stage

Perforation of ear drum present

Middle ear is dry

Middle ear mucosa may be normal / hypertrophied

Discharge stopped just a few days back

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Healed stageHealed stage

Healing of drum by thin scarHealing of drum by thin scar Tympanosclerotic patches may be Tympanosclerotic patches may be

seenseen Ossicular chain invariably intactOssicular chain invariably intact

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Tuning fork testsTuning fork tests

Rinne negative on the affected Rinne negative on the affected sideside

Weber lateralized to deaf earWeber lateralized to deaf ear

ABC - Not reducedABC - Not reduced

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Pure tone audiometryPure tone audiometry

Shows conductive hearing lossShows conductive hearing loss Hearing loss commonly ranges Hearing loss commonly ranges

between 30 - 40 dBbetween 30 - 40 dB If hearing loss exceeds 60 dB then If hearing loss exceeds 60 dB then

ossicular chain disruption should ossicular chain disruption should be suspectedbe suspected

Associated sensorineural loss Associated sensorineural loss should arouse suspicion of toxic should arouse suspicion of toxic deafnessdeafness

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Conservative Conservative managementmanagement

Aural toileting - in active diseaseAural toileting - in active disease Suction clearanceSuction clearance Syringing of affected ear using warm Syringing of affected ear using warm

saline mixed with 1.5 % acetic acidsaline mixed with 1.5 % acetic acid Topical antibiotics administered Topical antibiotics administered

after culture report becomes after culture report becomes availableavailable

Ear drops is administered by Ear drops is administered by displacement methoddisplacement method

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Role of systemic drugsRole of systemic drugs

AntibioticsAntibiotics AntihistaminesAntihistamines Ototoxic drugs to be avoidedOtotoxic drugs to be avoided Nasal decongestants ? Rhinitis Nasal decongestants ? Rhinitis

medicamentosamedicamentosa

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PrecautionsPrecautions

The ear must be kept dryThe ear must be kept dry Pre-existing sinus infections to Pre-existing sinus infections to

be treated aggressivelybe treated aggressively Presence of focal sepsis in the Presence of focal sepsis in the

throat should also be managedthroat should also be managed

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Surgical managementSurgical management

Surgery towards eradication of Surgery towards eradication of focal sepsisfocal sepsis

Surgery aimed towards Surgery aimed towards eradication of middle ear disease eradication of middle ear disease (Mastoidectomy)(Mastoidectomy)

Surgery aimed at reconstruction Surgery aimed at reconstruction of sound conduction mechanism of sound conduction mechanism (Myringoplasty and (Myringoplasty and tympanoplasty)tympanoplasty)

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TympanoplastyTympanoplasty

Tympanoplasty is defined as the Tympanoplasty is defined as the surgical procedure which enables surgical procedure which enables reconstruction of middle ear cavity reconstruction of middle ear cavity and ossicular system. It also and ossicular system. It also involves reconstruction of the involves reconstruction of the perforated ear drumperforated ear drum

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Components of Components of tympanoplastytympanoplasty

CanalplastyCanalplasty MeatoplastyMeatoplasty MyringoplastyMyringoplasty OssiculoplastyOssiculoplasty

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CanalplastyCanalplasty

This procedure is used to widen the This procedure is used to widen the external canalexternal canal

Should be performed before Should be performed before grafting anterior perforationsgrafting anterior perforations

This procedure facilitates better This procedure facilitates better healinghealing

External canal can be cleansed External canal can be cleansed without any difficultywithout any difficulty

Useful when performing second Useful when performing second stage ossiculoplastystage ossiculoplasty

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MeatoplastyMeatoplasty

This procedure is performed to This procedure is performed to enlarge the lateral cartilagenous enlarge the lateral cartilagenous portion of the external canalportion of the external canal

This enlargement should be in This enlargement should be in proportion to the size of the bony proportion to the size of the bony portion of the external canalportion of the external canal

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OssiculoplastyOssiculoplasty

Used to reconstruct the damaged Used to reconstruct the damaged ossicles of middle ear cavityossicles of middle ear cavity

Long process of incus is found to be Long process of incus is found to be commonly erodedcommonly eroded

TORPTORP PORPPORP

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Aims of tympanoplastyAims of tympanoplasty

Disease eradicationDisease eradication Restoration of middle ear aerationRestoration of middle ear aeration Reconstruction of sound conduction Reconstruction of sound conduction

mechanismmechanism Creation of self cleansing dry cavityCreation of self cleansing dry cavity

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Preop investigationsPreop investigations

Tubal function testsTubal function tests Audiometric evaluationAudiometric evaluation X-ray / CT scan of temporal X-ray / CT scan of temporal

bonesbones Tests for anesthetic fitnessTests for anesthetic fitness

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Trans canal surgical Trans canal surgical approachapproach

Performed through Performed through ear speculum ear speculum inserted into the inserted into the ear canalear canal

Ear canal should Ear canal should be widebe wide

There should not be There should not be any bony overhang any bony overhang obscuring the obscuring the edges of edges of perforationperforation

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End aural approachEnd aural approach

Incision is made Incision is made between tragus and between tragus and helixhelix

End aural speculum is End aural speculum is usedused

Posterior bony Posterior bony overhang can easily be overhang can easily be drilled outdrilled out

Better for anterior Better for anterior visualization of the ear visualization of the ear drumdrum

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Endaural view of ear Endaural view of ear drumdrum

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Post aural approachPost aural approach

Used in cases of Used in cases of narrow external narrow external canalcanal

Used to close Used to close anterior ear drum anterior ear drum perforationsperforations

William Wild’s William Wild’s post aural incision post aural incision is usedis used

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Ideal Tympanic membrane Ideal Tympanic membrane graftsgrafts

Temporalis fasciaTemporalis fascia DuraDura PeriosteumPeriosteum

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Why temporalis fascia is Why temporalis fascia is favoured?favoured?

It has a low basal metabolic rateIt has a low basal metabolic rate Its thickness more or less resembles Its thickness more or less resembles

that of normal ear drumthat of normal ear drum It can be harvested through the It can be harvested through the

same post aural incisionsame post aural incision It is available in plentyIt is available in plenty It has a good take rateIt has a good take rate

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Types of grafting Types of grafting techniquestechniques

Overlay techniqueOverlay technique Underlay techniqueUnderlay technique Interlay techniqueInterlay technique

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Underlay techniqueUnderlay technique

Commonly used techniqueCommonly used technique The graft is placed under the The graft is placed under the

tympanic membrane remnant tympanic membrane remnant and boneand bone

To facilitate this process a To facilitate this process a tympanomeatal flap will have to tympanomeatal flap will have to be elevatedbe elevated

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Overlay techniqueOverlay technique

The graft is placed over the The graft is placed over the bony tympanic sulcusbony tympanic sulcus

A bony ledge is created for this A bony ledge is created for this purpose if the sulcus is absentpurpose if the sulcus is absent

The overlaid graft is supported The overlaid graft is supported by the remnant ear drum if by the remnant ear drum if presentpresent

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Underlay techniqueUnderlay technique

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