Clinical Features

A. Tubotympanic Type

Ear discharge
It is non-offensive, mucoid or mucopurulent, constant or
intermittent.
Appears mostly at time of upper respiratory tract infection
or on accidental entry of water into the ear.
Hearing loss
lt is conductive type; severity varies but rarely exceeds 50
dB

Perforation
Always central, it may lie anterior, posterior or
inferior to the handle of malleus.
It may be small, medium or large or extending
up to the annulus.
Middle ear mucosa
It is seen when the perforation is large.
Normally, it is pale pink and moist; when
inflamed it looks red, oedematous and swollen.
Occasionally, a polyp may be seen.
B. Atticoantral Type

Ear discharge
Usually scanty, but always foul-smelling due to bone
destruction
Pus, in these cases, may find its way internally and cause
complications.
Hearing loss
Hearing loss is mostly conductive but sensorineural
element may be added
Bleeding
It may occur from granulations or the polyp when cleaning
the ear.
Perforation
It is either attic or posterosuperior marginal
type
Retraction pocket
An invagination of tympanic membrane is seen
in the attic or posterosuperior area of pars
tensa
Cholesteatoma
Pearly-white flakes of cholesteatoma can be
sucked from the retraction pockets
Diagnosis
History-taking
History-taking should be carried out to elicit the symptoms of
ear pain, ear discharge, ear tugging or crying when the ear is
touched, all of which suggest an ear problem.
Suspicion of CSOM-previous ear discharge, especially when
accompanied by episodes of colds, sore throat, cough or some
other symptom of upper respiratory infection.
History of vigorous ear cleaning, itching or swimming that
could traumatize the external ear canal suggests acute otitis
externa (AOE), and not usually CSOM.
A history of ear pain suggests AOE or AOM, not usually CSOM.
In the case of AOM, the ear is only painful until the eardrum
perforates, relieving the pressure.
Thus, if the main symptom is painless otorrhoea, the duration
of otorrhoea will help distinguish AOM from CSOM.

Investigation
1) Examination under microscope (Otoscopy)
Essential in every case and provides useful information
regarding presence of granulations, in-growth of squamous
epithelium from the edges of perforation, status of ossicular
chain, tympanosclerosis and adhesions.
It may reveal presence of cholesteatoma, its site and extent,
evidence of bone destruction, granuloma, condition of
ossicles and pockets of discharge.
2) Audiogram
It gives an assessment of degree of hearing loss and its
type. Usually, the loss is conductive but a sensorineural
element may be present.
3) Culture and sensitivity of ear discharge
It helps to select proper antibiotic ear drops

4) Mastoid X-rays/CT scan temporal bone
Tubotympanic type - Mastoid is usually sclerotic but
may be pneumatised with clouding of air cells
Atticoantral type - Presence of bone destruction.
X-rays- extent of bone destruction and degree of
mastoid pneumatisation.
Cholesteatoma causes destruction in the area of attic
and antrum (key area), better seen in lateral view. CT
scan of temporal bone gives more information and is
preferred to X-ray mastoids.