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: Clinical Features
Dr. Vishal Sharma
Definition
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
Types
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.
umbo
Small perforation
Involves only
one quadrant
or
< 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.
remnant
or > 40 % of pars tensa
Subtotal perforation
Involves all 4 quadrants & reaches up to annulus fibrosus
In growing epithelium
T.M. perforation with
inward
migration of epithelium
Marginal perforation
Erodes annulus fibrosus & one
margin is
formed by bony tympanic annulus
Total perforation
Total erosion of pars tensa
& anulus
fibrosus
Attic perforation
Involves
pars
flaccida
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
promontory
(atelectasis)
but mobile on
Valsalva maneuver or Siegalization
Grade 4 retraction
TM firmly adherent to promontory &
immobile on
Valsalva
maneuver or
Siegalization
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:
Otological examination
6. Mastoid cavity: size, facial ridge, discharge,
9. Fistula sign
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)
Attico-antral disease
Cholesteatoma
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
Cholesteatoma
Histopathology
Acid proteases
Leukotrienes
Proteolytic enzymes
Cytokines
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 in pars flaccida or Postero-superior quadrant pars tensa due to E.T. dysfunction
Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues
Transformation of middle ear mucosa into squamous epithelium due to infection, with no T.M. perforation
Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation
Epithelial migration
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
Pathological Changes
1. T.M. perforation: marginal or attic
Clinical Features
Ear discharge: scanty, purulent, continuous, foul-
smelling, blood-stained
Hearing Loss: conductive or sensori-neural
Features of Complications
Severe otalgia, painful swelling around ear
Attic cholesteatoma
Attic cholesteatoma
Attico-antral
Otorrhoea: Scanty Continuous Purulent Blood-stained Foul smelling Attic / marginal perforation, retraction pocket Cholesteatoma, granulation
Tubo-tympanic
Profuse Intermittent Mucoid No No Central perforation No
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