CSOM

ATTICOANTRAL TYPE

Middle Ear Regions

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Middle ear cleft

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Atticoantral type / Unsafe type

 Associated with

Cholesteatoma  Having bone eroding properties , causes risk of complications  Involves posterosuperior part of middle ear cleft (attic, antrum, post tympanum and mastoid)

Wednesday, January 18, 2012

Dr Sajol Ashfaq

CHOLESTEOTOMA
 Definition- A bag or sac of concentrically arranged keratinized stratified squomous epithelium surrounded by fibrous tissue with tendency to bone destruction.  Epidermoid cyst, pearly tumor.  Pathology- encysted and concentrically arranged keratin, capsule or matrix is covered by mucosa.

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Classification
 Congenital  Acquired
Primary acquired (retraction pocket) Secondary acquired

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Pathogenesis
 Congenital
Arise from embryonal rests of epithelial cells Location (petrous pyramid, mastoid and middle ear cleft) Levenson criteria
White mass medial to normal TM Normal pars flaccida and tensa No history of otorrhea or perforations No prior otologic procedures Prior bouts of otitis media not grounds for exclusion

Dr Sajol Ashfaq

Wednesday, January 18, 2012

Congenital cholesteatoma

Dr Sajol Ashfaq

Wednesday, January 18, 2012

10

Pathogenesis
 Primary acquired
Eustachian tube dysfunction Poor aeration of the epitympanic space Retraction of the pars flaccida Normal migratory pattern altered Accumulation of keratin, enlargement of sac

Dr Sajol Ashfaq

Wednesday, January 18, 2012

11

Primary Acquired Cholesteatomas

 Ultimately form due to underlying Eustachian tube dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space which draws pars flaccida medially on top of malleus neck, forming retraction pocket Normal migratory pattern of the tympanic membrane epithelium altered by retraction pocket Enhances potential accumulation of keratin
Dr Sajol Ashfaq Wednesday, January 18, 2012

12

Primary acquired cholesteatoma

Dr Sajol Ashfaq

Wednesday, January 18, 2012

13

Primary Acquired Cholesteatomas

Pars flaccida retraction Pars tensa retraction

Dr Sajol Ashfaq

Wednesday, January 18, 2012

14

Secondary Acquired Cholesteatomas

Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery, foreign body, blast injury, etc.

Metaplasia theory
Transformation of cuboidal epithelium to keratinized stratified squamous epithelium secondary to chronic or recurrent otitis media

Epithelial invasion theory

Squamous epithelium migrates along perforation edge medially along undersurface of tympanic membrane destroying the columnar epithelium

Papillary ingrowth theory

Inflammatory reaction in Prussack s space with an intact pars flaccida (likely secondary to poor ventilation) may cause break in basal membrane allowing cord of epithelial cells to start inward proliferation
Dr Sajol Ashfaq Wednesday, January 18, 2012

15

Dr Sajol Ashfaq

Wednesday, January 18, 2012

16

Pathophysiology,
 Routes of spread:
 Through bone.  Small veins, dural sinuses.  Anatomical pathways -oval and round window.  Non anatomical pathway- Surgical stapedectomy.  Periarterioler space of Virchow Robin.

Wednesday, January 18, 2012

Dr Sajol Ashfaq

17

Cholesteatoma Spread
 Posterior epitympanic cholesteatoma passing

through superior incudal space and aditus ad antrum

Wednesday, January 18, 2012

Dr Sajol Ashfaq

18

Cholesteatoma Spread
 Posterior mesotympanic cholesteatoma invading the

sinus tympani and facial recess

Wednesday, January 18, 2012

Dr Sajol Ashfaq

19

Cholesteatoma Spread
 Anterior epitympanic cholesteatoma with extension

to geniculate ganglion

Wednesday, January 18, 2012

Dr Sajol Ashfaq

20

COMPARISON OF TWO TYPES OF CSOM

Area of inflammation Aetiology
Eustacian tube and tympanum Acute infection Non healed perforation CentralCentral- Pars tensa Attic and mastoid antrum Retraction pocket

Site of perforation Complications Colesteatoma Discharge Treatment

Wednesday, January 18, 2012

Marginal-posterosuperior MarginalPars flaccida Intra and extra cranial Present Scanty, Foul smelling Surgery- MRM/RM Surgery21

Rare, usually conductive deafness Absent Copious, Mucopurulent Conservative, Myringoplasty

Dr Sajol Ashfaq

Complications of cholesteatoma
 Hearing loss  Labyrinthine fistula  Facial paralysis  Intracranial complications

Dr Sajol Ashfaq

Wednesday, January 18, 2012

22

Patient Evaluation
 History
Detailed otologic history
Hearing loss Otorrhea- foul smelling Otalgia Nasal obstruction Tinnitus Vertigo

Previous history of middle ear disease

Chronic otitis media Tympanic membrane perforation Prior surgery
Dr Sajol Ashfaq Wednesday, January 18, 2012

23

Symptoms
 Ear discharge- foul-smelling, scanty.  Hearing loss- mostly conductive. May be normal if ossicular chain is intact or Cholesteatoma destroyed the ossicles but bridges the gap of the ossicles.  Bleeding- due to granulation tissue or polyp when cleaning the ear

Dr Sajol Ashfaq

Wednesday, January 18, 2012

24

Signs
 Perforation of TM- Attic or Posterosuperior marginal type. Sometimes perforation could not be visualised  Retraction pocket- Attic/ Posterosuperior area  Chlosteatoma

Dr Sajol Ashfaq

Wednesday, January 18, 2012

25

Investigations
 X-ray mastoid towne s view  CT- Temporal bone  Audiogram

Dr Sajol Ashfaq

Wednesday, January 18, 2012

26

Preventative Management
 Tympanostomy tube for early retraction pockets

 Surgical exploration for retraction persistence

Dr Sajol Ashfaq Wednesday, January 18, 2012

27

Treatment of Atticoantral type of CSOM

 Without complications- modified radical

mastiodectomy with or without tympanoplasty.  With complicationsIntracranial- Radical mastoidectomy. Extracranial - MRM/ combined approach Mastiodectomy.

 Aim of treatment  Prevent complications and associated mortality

to save life not the ear-to make the ear safe

Dr Sajol Ashfaq Wednesday, January 18, 2012

28

 MRM- eradication of disease of middle ear and mastoid antrum, malleus and incus may be removed, stapes preserved  Radical- Eradication of disease + All remnants of TM, ossicles except footplate of stapes removed

Dr Sajol Ashfaq

Wednesday, January 18, 2012

29

Complications of CSOM
 Next class

Dr Sajol Ashfaq

Wednesday, January 18, 2012

30