Chronic suppurative otitis

media(CSOM)

DR BUKANU
ENT SPECIALIST
DODOMA REFFERAL HOSPITAL
 Definition
• Inflammatory condition of the
mucoperiosteum of the middle ear cleft of
more than three months duration and
associated with tympanic membrane
perforation
 types of chronic suppurative otitis
media
A) Tubo-tympanic SOM-commonest type,
abt 99% of patients
B) Attico antro SOM-more in temperate ares
and mainly due to weather
 Tubo-tympanic CSOM
• Characterized by chronic inflammation of
mucoperiosteum and anterior tympanic
membrane perforation
• Wet type is associated with pus
• It is usually a sequela of AOM
 Predisposing factors

• Virulence of bacteria in AOM

• Low host resistance
• Inadequate treatment of AOM
• Susceptibility of bacteria to chemotherapy
 Route of entry of bacteria
• Ascending from the nasopharynx via the
eustachian tube(about 90%)
• Through a tympanic membrane perforation
• Through hematogenous way due to
bacteremia
 Pathology
A) Thickened, edematous occasionally
polypoid mucosa
B) Granulation tissue which is a composite of
C) Drum perforation
D) Osteotis and ossicular necrosis
E) Mucopurulent discharge-goblet cells that
produce mucus increase in amount and
inflammation
 Bacteriology
1. Pseudomonas aureginosa-commonest
bacteria
2. Proteus vulgaris
3. Staphylococcus aureus
4. Klebsiella pneumonia
5. Anaerobic bacteria eg bacteroides-
Bacteroides melonogenicus
6. Mycobacterium tuberculosis
 Investigations
• Culture and sensitivity of the pus
• Full Blood Picture
• Audiometry-to find out whether the ear
drum has been severely or moderately
damaged
• X-ray of the mastoid because the mastoid
will be sclerosed
• CT scan of the temporal bone
 Clinical presentation
• Hearing loss
• Pain but not a feature of CSOM but due to
complication
• Ear discharge (otorhea-discharge of pus
from the ear)
• Tinnitus
• Dizziness which is associated with motion
hallucinations(vertigo)
 Treatment
1. Aural toilet-cleaning of the ear by using a
cotton bud or sunction machine
2. Local antibiotic therapy in form of ear drops,
ciproflaxin ear drop
3. Systemic antibiotics
4. Mastoidectomy
5. Tympanoplasty-operation done to the
middle ear to repair the tympanic membrane
and ossicular chain
6. Adenotonsillectomy
 Atico antro CSOM
• This is the presence of chronic otitis media
with cholesteatoma in the middle ear
• More severe because it is associated with
a mass which produce collagen.
 Cholesteatoma
• This is the presence of keratinizing
squamous epithelium in an ectopic site(.eg
middle ear or brain)
 Site
• Attico antro COM occurs in the
epitympanum (attic) and mastoid antrum
 Etiology
• Congenital theory-due to reminant of cells left
behind
• Metaplasia theory-due to irritation of
columnar epithelium to squamous epithelium
• Migration theory-migration of cells from the
external ear to the middle ear due to
perforation
• Retraction pocket theory-about 90% of
cholesteatoma enters through this mean
 Congenital type
• Download from the internet
 Metaplasia
• Middle ear columnar
 A large cholesteatoma
• Download a pic from the internet
 Clinical features
1. Otorrhea: thick foul discharge with white
blotting paper like material (cholesteatoma)
2. Blood perforation
3. Hearing loss: may be mild or severe
4. Ear ache: occur if there associated otitis
externa
5. Bleeding: may occur if associated with
granulation tissue is traumatized
6. Vertigo: occurs if the horizontal
7. Headache: this sx suggests pending
intracranial complications
 Investigation
• Culture and sensitivity
• CT scan
• Audiometry
• FBP
 CT scan
• CT scanning is the imaging modality of
choice
• Adv
• Can detect subtke bony defects eg
labyrynth fistula and ossicular involvement
• MRI
 Rx
• This diseases is more often associated with
complications than tubo tympanic CSOM
• Rx is surgical unless there are contra
indications to surgery
• Aim of the surgery is to have
– an ear free of cholesteatoma
– Create a safe ear
– Hearing improvemnent
 Types of surgery
• Mastoidestomy: opening into the mastoid
antrum
• Tympanoplasty
 Complications of SOM
• Extracranial complications
• Intracranial complications
• Complication occur when the infection
spread beyond the mucoperiosteum of the
middle ear cavity
 Predisposing factors
• Poor host immunity
• Inadequate treatment
 Extracranial complications
• Mastoiditis
• Facial nerve palsy
• Labyrinthitis
• Petroritis
 Mastoiditis
• Mastoiditis-destruction of the mastoid air
cells by inflammatory exudate under
pressure occurs.
– a sub periosteal abscess may occur(post
auricula abscess)
– Pus from the mastoid may extend along the
sternomastiod muscle forming an abscess
 Petroritis
• Petroritis-this is the inflammation of the
petrous pyramoid, such inflammation may
involve adjacent structures i.e the
trigeminal nerve ganglion and the abducent
nerve leading to a triad syndrome i.e
– Otorhea
– Diplopia
– Facial pain
 Facial nerve paralysis
• Occurs when there is an infection
extending into the fallopian canal through
the bone erosion
 Labyrinthitis
• Serous type: hyperemia of the labyrinth
• Suppurative type: infection has directly
entered labyrinth fluid causing pus
• Clinical feature
• Hearing loss
• Vertigo
• Tinnitus and horizontal nystagmus
 Intracranial complications
• Extradural abscess
• Subdural abscess
• Brain abscess
• The above will present with:
– Headache, otorrhea, fever, vomiting and
papiloedema
– Impairment of consciousness
– Convulsions and other neurologic signs
 Complications CT
• Otic meningitis-most common
complication
• Lateral sinus thrombophlebitis-ususlly follo
chronic mastoididtis
• Otitic hydrocephalus-may follow due to
destruction of the ventricles
 Management of the
complications
a. This depends on the type of complication,
however mastoidectomy is indicated to
control the aural infection
b. A neurosurgeon is involved to handle the
intracranial complications
c. Drug therapy must take into account gram
negative bacillus and anaerobic bacteria(3rd
generation cephalosporin, ciproflacin