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: Clinical Features
Dr. Vishal Sharma

Chronic (> 3 months) pyogenic infection of middle ear cleft mucosa, characterized by persistent perforation of tympanic membrane, ear discharge & decreased hearing Prevalence in Nepal: 7.2 %

Types of C.S.O.M.
Tubo-tympanic: chronic pyogenic infection of middle ear cleft mucosa with persistent perforation in pars tensa Attico-antral: chronic pyogenic infection of middle ear cleft with cholesteatoma & granulations in attic or postero-superior quadrant of pars tensa

Middle ear cleft

Tubo-tympanic vs. Attico-antral

Tympanic Membrane Perforations

Perforation of Pars Tensa 1. Central tubo-tympanic Small Medium Large Subtotal

2. Central with ingrowing epithelium attico-antral 3. Marginal attico-antral 4. Total attico-antral Perforation of Pars Flaccida 1. Attic attico-antral

4 quadrants of T.M.


Small perforation
Involves only
one quadrant

< 10% of pars tensa

Medium perforation
Involves two quadrants or

10 40 %
of pars tensa

Medium perforation

Large perforation
Involves 3 or 4

quadrants with
wide T.M.

or > 40 % of pars tensa

Subtotal perforation
Involves all 4 quadrants & reaches up to annulus fibrosus

In growing epithelium
T.M. perforation with

migration of epithelium

Marginal perforation
Erodes annulus fibrosus & one

margin is
formed by bony tympanic annulus

Total perforation
Total erosion of pars tensa

& anulus

Attic perforation


Tympanic Membrane Retractions

Grade 1 retraction
Dull, lustreless T.M.

Prominent annulus
Cone of light absent Handle medialized Prominent lateral process Malleolar folds sickle shaped

Grade 2 retraction
Eardrum touches incus

Grade 3 retraction
TM touches


but mobile on
Valsalva maneuver or Siegalization

Grade 4 retraction
TM firmly adherent to promontory &

immobile on

maneuver or

PSQ retraction pocket

Attic retraction pocket

Otological examination
1. Pre-auricular region: sinus, lymph node 2. Pinna: size, position, deformity, swelling 3. Post-auricular region: surgical scar, swelling, fistula, lymph node 4. External auditory canal: meatal opening, otitis externa, wax, fungal debris, ear discharge

Otological examination
5. Tympanic membrane:

intact: colour, position, mobility, tympanosclerosis,

retraction pocket

perforated: type, site, size & margin of perforation

handle of malleus; middle ear cavity (mucosa, ear

discharge, polyp, granulations, cholesteatoma

flakes); pars flaccida

Otological examination
6. Mastoid cavity: size, facial ridge, discharge,

epithelialization, granulations, polyps

7. Tragal tenderness: associated otitis externa

8. Mastoid tenderness: cymba conchae, mastoid

body + tip & posterior zygoma root

9. Fistula sign

10. Facial nerve function

11. Tuning Fork Tests

Tubo-tympanic Disease

Predisposing factors
Upper respiratory tract infection (recurrent) Upper respiratory tract allergy Pre-existing otitis media with effusion Cleft palate Immune deficiency: diabetes, AIDS Poor socio-economic status

Bacteria responsible
Staphylococcus aureus Pseudomonas aeruginosa Klebsiella Proteus Streptococcus Bacteroides

Routes of infection
1. Via Eustachian tube: U.R.T.I., nose blowing, regurgitation of milk 2. Via tympanic membrane perforation: following A.S.O.M. or post-traumatic 3. Haematogenous (rare): viral exanthematous fevers

Pathological Changes
1. Eardrum: central perforation; myringosclerosis 2. Ossicles: Destruction (hyperaemic decalcification) Tympanoslerosis Fibrosis + Adhesions 3. Middle ear mucosa: edematous, pale pink 4. Mastoid bone: sclerosis

Clinical Features
Ear discharge: profuse, mucoid / muco-purulent, intermittent, odourless, not blood-stained Hearing Loss: usually conductive (25-50 dB)

absent in small, dry perforations

round window shielding by ear

discharge leads to better hearing

Tympanic membrane: central perforation

Stages of Tubotympanic disease

Otorrhoea Active Quiescent Inactive Healed Present Absent Absent Absent Eardrum perforation Present Present Present Absent Last ear discharge < 6 months > 6 months -

Attico-antral disease

Term used by Johannes Mller in 1858 Three dimensional sac lined by matrix of keratinizing stratified squamous epithelium which rests on a thin layer of fibrous tissue Contains desquamated keratin debris Grows at the expense of surrounding bone

Not a tumor & has no cholesterol

Epidermosis is a better term



Causes of bone destruction

1. Hyperaemic decalcification

2. Osteoclastic bone resorption due to:

Acid phosphatase Collagenase

Acid proteases

Proteolytic enzymes

3. Pressure necrosis: No role

4. Bacterial toxins: No role

Types of Cholesteatoma
Congenital (McKenzie) Primary Acquired 1. Retraction pocket (Wittmaack) 2. Basal cell hyperplasia (Ruedi) 3. Squamous metaplasia (Sade) Secondary Acquired 1. Squamous metaplasia 2. Epithelial migration (Habermann) Tertiary Acquired 1. Post-traumatic 2. Post-tympanoplasty

Congenital cholesteatoma

Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle

Congenital cholesteatoma

Retraction pocket formation

Retraction pocket in pars flaccida or Postero-superior quadrant pars tensa due to E.T. dysfunction

Basal cell hyperplasia

Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues

Primary squamous metaplasia

Transformation of middle ear mucosa into squamous epithelium due to infection, with no T.M. perforation

Secondary squamous metaplasia

Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation

Epithelial migration

Migration of epithelium via T.M. perforation into middle ear

Post-traumatic cholesteatoma
Mechanisms: 1. Epithelial entrapment in fracture line 2. In growth of epithelium through fracture line 3. Traumatic implantation of epithelium into middle ear

4. Trapping of epithelium medial to E.A.C. stenosis

Pathological Changes
1. T.M. perforation: marginal or attic

2. T.M. retraction pocket: attic or P.S.Q.

3. Cholesteatoma formation 4. Ossicles: destruction 5. Middle ear mucosa: edematous, red 6. Aural polyp: red, fleshy 7. Osteitis & granulation tissue formation 8. Mastoid bone: erosion, sclerosis

Clinical Features
Ear discharge: scanty, purulent, continuous, foul-

smelling, blood-stained
Hearing Loss: conductive or sensori-neural

T.M. perforation: marginal or attic or total

T.M. retraction pocket: attic or P.S.Q. Cholesteatoma flakes Aural polyp, osteitis & granulation tissue

Features of Complications
Severe otalgia, painful swelling around ear

Vertigo, nausea, vomiting

Headache + blurred vision + projectile vomiting

Fever + neck rigidity + irritability / drowsiness

Facial asymmetry Gradenigo syndrome (apex petrositis) Ataxia

Otorrhoea & aural polyp

Attic cholesteatoma

Attic cholesteatoma

PSQ cholesteatoma & granulation tissue

Otorrhoea: Scanty Continuous Purulent Blood-stained Foul smelling Attic / marginal perforation, retraction pocket Cholesteatoma, granulation

Profuse Intermittent Mucoid No No Central perforation No

Tuberculous Otitis Media

Painless, odorless otorrhoea refractory to antibiotics Multiple TM perforations large perforation Middle ear mucosa pale (congestion around E.T.O.)

Pale granulations in mastoid & middle ear

Severe deafness with bony necrosis (caries) Facial palsy & labyrinthitis Tx: Anti-TB therapy + cortical mastoidectomy

Multiple T.M. perforations

Thank You