This document discusses cholesteatoma and chronic suppurative otitis media (CSOM). Cholesteatoma is defined as the presence of keratinizing squamous epithelium in the middle ear or mastoid. There are various theories for its origin, including invagination of the tympanic membrane or basal cell hyperplasia. CSOM is a long-standing middle ear infection characterized by ear discharge and permanent perforation. It is classified as tubotympanic or atticoantral, with atticoantral being more dangerous due to higher risk of bone-eroding complications like cholesteatoma. Treatment involves surgical resection for atticoantral CSOM and conservative

1. CHOLESTEATOMA &
CHRONIC SUPPURATIVE
OTITIS MEDIA (CSOM)
NUR AINA BINTI AB KADIR

2. CONTENTS
 Cholesteatoma
 Origin
 Classification
 Expansion of
cholesteatoma &
destructive of bone
 Chronic suppurative
otitis media(CSOM)
 Epidemiology
 Types
 Clinical features
 Investigations
 Treatments

4.  presence of keratinizing squamous
epithelium in the middle ear or
mastoid
 “skin in the wrong place”
 2 parts
 Matrix
 Central white mass
DEFINITION

5. ORIGIN OF
CHOLESTEATOMA
Congenital cell rests
Wittmaack’s theory
Ruedi’s theory
Habermann’s theory
Sade’s theory

6. ORIGIN OF
CHOLESTEATOMA
 Wittmaack’s theory
 Invagination of TM
from the attic/
posterosuperior part
of pars tensa in the
form of retraction
pockets
 Ruedi’s theory
 Basal cell
hyperplasia
 Proliferate- infection,
lay down
keratinizing
squamous
epithelium (KSE)

7. ORIGIN OF
CHOLESTEATOMA
 Habermann’s theory
 Epithelial invasion
 From the meatus/
outer drum surface
 Pre-existing
perforation(marginal
)- part of the annulus
tympanicus-
destroyed
 Sade’s theory
 Metaplasia
 Like respiratory
mucosa elsewhere
 d/t repeated
infection
squamous

8. CLASSIFICATION
CONGENITAL
ACQUIRED, 1’
ACQUIRED,2’

9. CONGENITAL
CHOLESTEATOMA
 Embroyonic epidermal cell rests in the middle
ear cleft/ temporal bone
 Middle ear, petrous apex, cerebellopontine
angle
 Middle ear: white mass behind an intact
tympanic membrane conductive hearing loss
 Discovered: routine exam/myringotomy
 May spontaneously rupture- TM discharging
ear

10. PRIMARY ACQUIRED
CHOLESTEATOMA
 No h/o previous OM/ pre-existing perforation
 Invagination of pars flaccida
 Persistent negative pressure in the attic
retraction pocket which accumulates keratin
debris.
 Infected expand middle ear
 Basal cell hyperplasia
 Proliferation of the basal layers of PF induced by
subclinical childhood infection
 Squamous metaplasia
 Normal pavement epithelium of attic undergoes
metaplasia, keratinizing squamous epithelium

11. SECONDARY ACQUIRED
CHOLESTEATOMA
 Already a pre-existing perforation in pars
tensa
 Associated with posterosuperior marginal
perforation
 Migration of squamous epithelium
 KSE of EAC/ outer surface of TM migrates
through the perforation into the middle ear
 Metaplasia: repeated infections of middle ear-
pre-existing perforation

12. EXPANSION OF
CHOLESTEATOMA AND
DESTRUCTION OF BONE
 Enter the middle ear cleft invades the
surrounding structures
 Attic cholesteatoma: extend backwards into
the aditus, antrum, mastoid. Downwards into
the mesotympanum; medially, it may surround
the incus and/or head of malleus.
 Destroy bone, ear ossicles, erosion on bony
labyrinth
 Enzymes : collagenase, acid phosphatase,
proteolytic enzymes(osteoclast, mononuclear
inflammatory cells)

13. Long standing infection of a part or whole of
the middle ear cleft characterized by ear
discharge and permanent perforation
CHRONIC SUPPURATIVE
OTITIS MEDIA (CSOM)

14. EPIDEMIOLOGY
 Developing countries: more
 Both sexes
 All age groups
 Prevalence rate: 46 per thousands (rural), 16
per thousands (urban)

15. TYPES
TUBOTYMPANIC
ATTICOANTRAL

16. ALTERNATIVE
CLASSIFICATION
COM
Mucosal
Active(CSOM)
Inactive (permanent
perforation)
Healed (adhesive
OM)
Squamosal
Retraction pockets
(PT/PF/atelectatic
ear
Active ( C+
discharge)

17. TUBOTYMPANIC-
SAFE/BENIGN
 It involves the
anteroinferior part of
middle ear
 Often associated with
central perforation
 There is no risk of
serious complications
 AETILOLOGY
 Sequela of AOM-
following
exanthematous fever,
leaving behind a large
central perforation
 Ascending infection
via the ET- recurring
otorrhoea
 Persistent mucoid
otorrhoea: allergy to
ingestants

18. TUBOTYMPANIC-
SAFE/BENIGN
 PATHOLOGY
 Perforation of pars
tensa
 Middle ear mucosa-
oedematous/velvety
 Polyp- pale
 Ossicular chain-
intact, mobile,may
show necrosis
 Tympanosclerosis
 Fibrosis and
adhesions
 BACTERIOLOGY
 Aerobics:
pseudomonas
aeruginosa, Proteus,
E.coli, Staph aureus
 Anaerobes:
Bacteroids fragilis,
anaerobic
Streptococci

19. TUBOTYMPANIC-
SAFE/BENIGN
 CLINICAL
FEATURES
 Ear discharge
 Nonoffensive,mucoid
, mucopurulent
 Hearing loss
 Conductive
 Perforation
 Always central
 Middle ear mucosa
 Perforation is large,
pale pink,moist
 INVESTIGATIONS
 Examination under
microscope
 Audiogram
 Culture and
sensitivity of ear
discharge
 Mastoid X-ray/CT
scan temporal bone

20. TREATMENT
 Aural toilet
 remove all discharge
and debris by dry
mopping, suction
clearance or
irrigation
 Ear drops
 antibiotics ear drops
containing neomycin,
polymyxin,
chloromycetin, or
gentamycin +
steroids
 Systemic antibiotics
 useful in acute
 Precautions
 keep water out of
ear, rubber inserts
use
 Treatment of
contributory causes-
 such as infected
tonsils, adenoids,
maxillary antra and
nasal allergy
 Surgical : remove
aural polyps/
granulations
 Reconstructive

21. ATTICOANTRAL-
UNSAFE/DANGEROUS
 Posterosuperior part
of the cleft
 Associated with an
attic/marginal
perforation
 Bone-eroding
process:
cholesteatoma,
granulation/osteitis
 Risk of
complications is
higher
 AETIOLOGY AND
BACTERIOLOGY
 Same with
tubotympanic

22. PATHOLOGY
o Cholesteatoma
o Osteitis and granulation tissue
o Osteitis involves outer attic wall, posterosuperior
margin of tympanic ring
o Granulation tissue surrounds it may even fill the attic,
antrum, posterior tympanum, mastoid
o Fleshy red polypus: meatus

23. PATHOLOGY
o Ossicular necrosis
o Destruction may be limited to the long process of
incus, may also involves stapes superstucture, handle
of malleus/ entire ossicular chain
o Greater hearing loss
o Cholesteatoma hearer
o Cholesterol granuloma
o Mass of granulation tissue with foreign body giant cells
surrounding the cholesterol crystals.

24. SYMPTOMS
Ear discharge
• Scanty,foul smelling
• Total cessation of discharge- seriously
Hearing loss
• Normal: ossicular chain is intact
• Conductive type
Bleeding
• Granulation/polyps
• Cleaning

25. SIGNS
PERFORATION
• Either attic or posterosuperior marginal type
• can be missed due to crust
RETRACTION
POCKET
• Invagination of TM is seen in the attic/
posterosuperior part of PT
• Early: shallow,self cleansing Later:
deep,acumulation of keratin mass,infected
CHOLESTEATOMA
• Pearly white flakes can be sucked from the
retraction pocket
Grade Description
I Slight retracted TM, not touching incus
II Deep retraction, touching incus, middle ear mucosa not
affected
III Middle ear atelectasis. It lies on the promontory, ossicles
IV Also called Adhesive otitis media where TM becomes
adherent to promontory

26. INVESTIGATIONS
 Examination under microscope. May reveal
presence of cholesteatoma, evidence of bone
destruction etc
 Tuning fork test & audiogram
 X-ray mastoids/CT temporal. Attic and antrum
destruction caused by cholesteatoma best
seen lateral in CT.
 Culture and sensitivity of discharge

27. FEATURES INDICATING
COMPLICATIONS IN CSOM
 Pain.; extradural, perisinus or brain abscess and
sometimes otitits externa
 Vertigo: erosion of lateral semicircular canal
 Persistent headache: intracranial involvement
 Facial weakness: facial canal
 Listless child with refusal of feeding: extradural
abscess
 Fever,nausea,vomiting: IC infection
 Irritability & neck rigidity: menigitis
 Diplopia : (Gradenigo syndrome) petrositis
 Ataxia: labyrinthitis/cerebellar abscess
 Abscess around the ear: mastoiditis

28. TREATMENT
SURGICAL
RECONSTRUCTIVE
SURGERY
CONSERVATIVE

29. SURGICAL
 Primary aim is to
remove disease,
render ear safe
 Secondary aim to
preserve or
reconstruct hearing
 CWD:
 Mastoid cavity open
 Diseased area is fully
exteriorized
 Atticotomy,modified
radical
mastoidectomy, RM
 CWU
 Approach by meatus,
mastoid but retained
the posterior bony
meatal wall intact
 Dry ears, permits easy
reconstruction of
hearing mechanism
CANAL WALL UP CANAL WALL DOWN
MEATUS Normal appearance Widely open meatus
communicating with mastoid
DEPENDENCE Does not require routine
cleaning
Dependence on DR for
cleaning mastoid cavity
once/twice a year
RECURRENCE/
RESIDUAL SX
High rate- cholesteatoma Low rate
2ND LOOK
SURGERY
Require: after 6months of
surgery/rule out
cholesteatoma
Not required
PATIENTS
LIMITATIONS
No. can swim Swimming infection of
mastoid cavity
AUDITORY
REHABILITATIO
N
Easy to wear a hearing
aid if needed
Problems in fitting d/t large
meatus & infected mastoid
cavity

30. RECONSTRUCTIVE
SURGERY
 RECONSTRUCTIV
E
 Myringoplasty/
tympanoplasty
 Primary surgery/ 2nd
stage procedure

31. CONSERVATIVE TREATMENT
 Cholesteatoma is small, easily accesible to
suction clearance under microscope
 Elderly >65 years old
 Unfit for GA/ refused
 Polyps,granulation tissue: cup forceps/ cauterized
by chemical agents (silver nitrate/ trichloroacetic
acid)
 Aural toilet, dry ear precautions

32. CONCLUSION
TUBOTYMPANIC/SAFE ATTICOANTRAL/UNSAFE
DISCHARGE Profuse, mucoid odourless Scanty, purulent, foul smelling
PERFORATION Central Attic/marginal
GRANULATION
S
Uncommon Common
POLYPS Pale Red and fleshy
CHOLESTEATO
MA
Absent Present
COMPLICATIO
NS
Rare Common
AUDIOGRAM Mild to moderate
conductive deafness
Conductive/mixed deafness

33. REFERENCES
 Diseases of ear, nose, throat and head & neck
surgery, PL Dhingra 6th edition,page 65-74