CSOM is a long standing

infection of a part or
whole of middle ear cleft
characterized byEar discharge
And a permanent
perforation

TYPES
Clinically it is divided into
two types
1.Tubotympanic
2.Atticoantral

TUBOTYMPANIC
It involves anteroinferior part of middle
ear cleft (eustachian tube,
mesotympanum) and is associated with a
central perforation
Safe/benign type
No risk of serious complications

Atticoantarl
It involves posterosuperior part of
the cleft (attic ,antrum,mastoid)
Associated with an attic or marginal
perforation
It is often associated with bone
eroding process such as
cholesteatoma,granulations or osteitis
Risk of complications is high
Unsafe/dangerous type

property

Tubotympanic

Atticoantral

Discharge

Profuse,mucoid,
odourless

Scanty,purulent,
foul smelling

Perforation

Central

Marginal

Granulations Uncommon

Common

Polyp

Pale

Red and fleshy

Cholesteato
ma

Absent

Present

Complicatio
ns

Rare

Common

Audiogram

Mild to
moderate
conductive
deafness

Conductive or mixed
deafness

1.TUBOTYMPANIC
1.AETIOLOGY
The disease starts in childhood and is
common in that age group
Sequela of acute otitis media usually
following exanthematous fever and leaving
behind a large central perforation
Ascending infections via eustachian
tube causes persistent and recurring
otorrhoea
Allergy to ingestants (milk,egg) causes
persistent mucoid otorrhoea

2.PATHOLOGICAL CHANGES
Perforation of pars tensa-it is a central
perforation, size and position varies
Middle ear mucosa-disease is
quiescent/inactive- normal mucosa
disease active- oedematous and velvety
mucosa
Polyp-pale to pink
Ossicular chain- intact , mobile but shows
some degree of necrosis( long process of incus)
Tympanosclerosis-hyalinization and
subsequent calcification of subepithelial
connective tissue.. Causes conductive deafness
Fibrosis and adhesions- result of healing
process
impair mobility of ossicular chain/block
eustachian
tube

4.Alternative classification of Chronic

otitis media

Mucosal disease-tubotympanic disease:

Squamous disease-atticoantral disease;

Tubotympanic

Atticoantral

Mucosal disease with no

evidence of invasion of
squamous epi.

Squamous disease of middle ear

Active-perforation of pars
tensa with inflammation of
mucosa and mucopurulent
discharge

Active-presence of
cholesteatoma in posterosuperior
part of pars tensa/in pars
flaccida. Erodes bone ,form
granulation tissue,has purulent
offensive discharge

Inactive- permanent
perforation of pars tensa but
middle ear mucosa isnt
inflamed & theres no
discharge.

Inactive-retraction in pars
tensa/pars flaccida,no discharge

Healed-tm is healed (by 2

layers)is atrophic,easily
retracted if ve pressure in
middle ear

Clinical features
Ear discharge-nonoffensive , mucoid/mucopurulent
,constant/intermittent.
Appears at the time of URT infection or on accidental
entry of
water into ear
Hearing loss-conductive type (rarely exceeds 50dB)
Perforation- always central ! May lie
ant./post./inferior to handle of malleus. Can be
small/med./large
Middle ear mucosa- seen when perforation is large.
normally-pale pink & moist
inflamed-red , edematous
occasionally polyp is seen

2.Atticoantral
1.Aetiology
It is seen in sclerotic
mastoid
cholesteatoma

2.Pathology
It is associated with the following
pathological processes
Cholesteatoma-skin in wrong place
It is presence of keratinized squamous
epithelium in the middle ear or mastoid
Osteitis and granulation tissueinvolves outer attic wall and
posteriosuperior margin of tympanic ring
Ossicular necrosis- hearing loss
Cholesterol granuloma- mass of
granulation tissue with foreign body giant
cells surrounding the cholesterol crystals

3.Symptoms
Ear discharge- scanty but foul
smelling due to bone destruction,
purulent
Hearing loss- hearing is normal
when ossicular chains are intact or
when cholesteatoma (cholesteatoma
hearer) conductive/mixed deafness
Bleeding from granulation/polyp

4.Signs
Perforation- attic/posterosuperior marginal type
Retraction pocket an invagination of tympanic
membrane is seen in attic/posterosuperior area of
pars tensa.
Stages:a) Stage 1 tympanic membrane is retracted
but doesnt contact incus (MILD RETARCTION)
b) STAGE 2- tympanic memb. Is retracted deep
& it contacts the incus; middle ear mucosa isnt
affected.
c) Stage3 middle ear atelectasis : middle ear
comes to lie on promontory & ossicles
d) Stage 4- adhesive otitis medi : TM is very thin;
wraps promontory & ossicles; no middle ear
space; mucosal lining of middle ear is absent;
retraction pockets formed; erosion of long process
of incus stapes superstructure

3. Cholesteatoma pearly white flakes of

cholesteatoma can be sucked from retraction
pockets

5.INVESTIGATIONS
Examination under microscope- imp.
Part of clinical assessment of any type
of CSOM
Tuning fork test and audiogram
Xray mastoids/CT scan of temporal
bone for extent of bone destruction
and degree of mastoid pneumatization
Culture and sensitivity of ear discharge

Thank you