Chronic suppurative otitis media is defined as long standind infection of a part or whole of the middle ear cleft characterized by ear discharge and a permenent perforation in tympanic membrane
To understand the concept of CSOM we should be having a clear concept of two anatomical structures ie tympanic membrane and middle ear,tympanic membrane forms the partition between external auditory canal and middle ear,it is composed of two parts,parstensa which forms most of tympanic embrane and pars flacida.both the parts can be well appreciated in the next diagram.
Tympanic membrane basically consists of three layers,outer epithelial layer continuous with the skin lining the meatus.inner mucosal layer which is continuous with the mucosa of the middle ear,middle fibrous layer which encloses the handle of malleus.
Middle ear togeather with the aditus,antrum,mastoid air cells and eustachian tube is called middle ear cleft.It has three parts mesoepi and pro tympanum.mesotympanum at the level of pars tensaepitympanum above the level of pars tensa and hypotympanum below the level of pars tensa.the portion of middle ear around eustachian tube opening is some times called protympanum.
Walls of the middle ear and the structures related to them can be seen in the figure
CSOM is further classified into two types.tubotympanic or the safe and atticoantral or the unsafe
Tubotympanic type can be caused as a sequela of acute otitis media or due to ascending infections via eustachian tube as a result of adenoids tonsilitis or any URTI,it can also be due to persistent otorrhea as a result of some allery or could be due to traumatic perforation.
Perforation of tympanic membrane coupled with ottorhea results in epithelialization of the margins of the perforation. This results in a permanent tympanic membrane defect esposing the middle ear mucosa to contaminants of external auditory canal resulting in inflammation of the middle ear mucosa with the formation of polyps and granulations
This picture shows tubotympanic type of CSOM with central perforation in lower part of parstensa
Pus cultures in both types of aerobic and anaerobic CSOM may show multiple organisms.grampos gram neg and bacteriods are present
Patients history will be centered on two complaints that is deafness and discharge. Pain is not a feature of uncomplicated CSOM. Presence of pain implies secondary otitis externa or more importantly a complication of csom .discharge may be copious mucopurulent non offensive and continuous or intermittent without blood.the discharge basically depends either the disease is active or in active….hearing loss is of conductive type
Aural examination reveals a perforation of tympanic membrane is central small medium or subtotal in size with discharge from middle ear. At this time inspection of middle ear mucosa is necessary…in some cases polyps may appear but they can be differentiated from atticoantral as they are pale….On tuning fork test as in most of cases hearing loss is conductive..rinne may be neg on affected side…while the weber will be lateralized affected side
pus swab may yield growth of both gram posndneg as well as anaerobes … PTA documents the type and severity of hearing loss.… usually it shows cconductive hear loss widab gap of upto 50 db if only ear drum is perforated or may be more if ossicular chain disrupted…x ray may show normal air cells or hazziness of mastoid air cells..bone erosion is not a feature of tubotympanic disease
Treatment comprises of meticulous aural toilet, and antibiotic therapy both topical and systemic. Surgical treatment in form of myringoplasty is done to render the ear dry….following are the surgical procedures depending upon the defect or pathology
Atticoantral type may be due to any of the following pathological cause….but most importantly formation of cholesteatoma
Cholesteatoma is the presence of keratinized stratified squamous epithelium in the middle ear mucosa.it may cause destruction of ossicles,erosion of bony labyrinth facial canal and several othereccomplications.
Pus cultures show both types of aerobic and anaerobic bacteria…. CSOM may show multiple organisms.grampos gram neg and bacteriods
Patients will give history of deafness with blood stained ear discharge…cholesteatoma ….
On examination Perforation may be attic posterosuperior or marginal….,persistent negative pressure in the attic causes retraction pocket….while formation of cholesteatoma has already been described
This diagram shows a case of atticoantral type of CSOM with marginal perforation and attic granulations
In addition to PTA and x ray mastoids CT scan Petromastoid area is must to document extent of disease.x ray mastoid will indicate extent of mastoid sclerosis and bony erosion (of tegmenlat facial canal)….brain abscess subdural abscess extra dural abscess if present might be visible in CT scan
PTA indicates the type and severity of deffness and air bone gap
Complications could be intra temporal or intra cranial
The indications of complications include pain vertigo facial paralysis neck stiffness and abscess around the ear…..
Apart from the medical treatment which includes auratl toilet topical and systemic anti biotics…main strayTreatment of atticoantral type of disease is surgical to render the ear safe, and the choice of procedure rests on extent of disease,the objective of mastoidectomy is removal of disease and ventilation….i thank u all
Csom by Bssam Khalid
CSOMCHRONIC SUPPURATIVE OTITIS MEDIA BASSAM KHALID
“ LONG STANDING(more than 3 months) INFECTION OF A PART OR WHOLE OF THE MIDDLE EAR CLEFT , CHARACTERIZED BY CONSTANT OR INTERMITTENT EAR DISCHARGE AND APERMANENT PERFORATION IN TYMPANIC MEMBRANE “
TYMPANIC MEMBRANE• IT FORMS THE PARTITION BETWEEN THE EXTERNAL AUDITORY CANAL AND THE MIDDLE EAR • PARTS • PARS TENSA • PARS FLACCIDA