Chronic suppurative otitis media Dr. T. Balasubramanian M.S. D.L.O.
Definition <ul><li>CSOM is defined as a chronic infection of middle ear mucosa lining the middle ear cleft </li></ul><ul><...
Tubotympanic disease <ul><li>Also known as safe ear </li></ul><ul><li>It does not cause any serious complications </li></u...
Why is Tubotympanic disease safe? <ul><li>There is no risk of bone erosion </li></ul><ul><li>Not known to cause intracrani...
Aetiology <ul><li>Inadequately treated ASOM </li></ul><ul><li>ASOM causing persistent perforation (Persistent perforation ...
Microbiology <ul><li>Gram negative bacilli has been commonly isolated </li></ul><ul><li>Ps. aeruginosa, E. coli, and B. pr...
Clinical features <ul><li>Discharge is profuse and Mucopurulent </li></ul><ul><li>It is not foul smelling </li></ul><ul><l...
Stages of Tubotympanic disease <ul><li>Acute stage  </li></ul><ul><li>Inactive stage </li></ul><ul><li>Quiescent stage </l...
Acute stage <ul><li>Ear is actively discharging </li></ul><ul><li>Middle ear mucosa hypertrophied and congested </li></ul>...
Inactive stage <ul><li>Dry perforation of ear drum + </li></ul><ul><li>Perforation involves the pars tensa </li></ul><ul><...
Quiescent stage <ul><li>Perforation of ear drum present </li></ul><ul><li>Middle ear is dry </li></ul><ul><li>Middle ear m...
Healed stage <ul><li>Healing of drum by thin scar </li></ul><ul><li>Tympanosclerotic patches may be seen </li></ul><ul><li...
Tuning fork tests <ul><li>Rinne negative on the affected side </li></ul><ul><li>Weber lateralized to deaf ear </li></ul><u...
Pure tone audiometry <ul><li>Shows conductive hearing loss </li></ul><ul><li>Hearing loss commonly ranges between 30 - 40 ...
Conservative management <ul><li>Aural toileting - in active disease </li></ul><ul><li>Suction clearance </li></ul><ul><li>...
Role of systemic drugs <ul><li>Antibiotics </li></ul><ul><li>Antihistamines </li></ul><ul><li>Ototoxic drugs to be avoided...
Precautions <ul><li>The ear must be kept dry </li></ul><ul><li>Pre-existing sinus infections to be treated aggressively </...
Surgical management <ul><li>Surgery towards eradication of focal sepsis </li></ul><ul><li>Surgery aimed towards eradicatio...
Tympanoplasty <ul><li>Tympanoplasty is defined as the surgical procedure which enables reconstruction of middle ear cavity...
Components of tympanoplasty <ul><li>Canalplasty </li></ul><ul><li>Meatoplasty </li></ul><ul><li>Myringoplasty </li></ul><u...
Canalplasty <ul><li>This procedure is used to widen the external canal </li></ul><ul><li>Should be performed before grafti...
Meatoplasty <ul><li>This procedure is performed to enlarge the lateral cartilagenous portion of the external canal </li></...
Ossiculoplasty <ul><li>Used to reconstruct the damaged ossicles of middle ear cavity </li></ul><ul><li>Long process of inc...
Aims of tympanoplasty <ul><li>Disease eradication </li></ul><ul><li>Restoration of middle ear aeration </li></ul><ul><li>R...
Preop investigations <ul><li>Tubal function tests </li></ul><ul><li>Audiometric evaluation </li></ul><ul><li>X-ray / CT sc...
Trans canal surgical approach <ul><li>Performed through ear speculum inserted into the ear canal </li></ul><ul><li>Ear can...
End aural approach <ul><li>Incision is made between tragus and helix </li></ul><ul><li>End aural speculum is used </li></u...
Endaural view of ear drum
Post aural approach <ul><li>Used in cases of narrow external canal </li></ul><ul><li>Used to close anterior ear drum perfo...
Ideal Tympanic membrane grafts <ul><li>Temporalis fascia </li></ul><ul><li>Dura </li></ul><ul><li>Periosteum </li></ul>
Why temporalis fascia is favoured? <ul><li>It  has a low basal metabolic rate </li></ul><ul><li>Its thickness more or less...
Types of grafting techniques <ul><li>Overlay technique </li></ul><ul><li>Underlay technique </li></ul><ul><li>Interlay tec...
Underlay technique <ul><li>Commonly used technique </li></ul><ul><li>The graft is placed under the tympanic membrane remna...
Overlay technique <ul><li>The graft is placed over the bony tympanic sulcus </li></ul><ul><li>A bony ledge is created for ...
Underlay technique
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CSOM

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  • CSOM

    1. 1. Chronic suppurative otitis media Dr. T. Balasubramanian M.S. D.L.O.
    2. 2. Definition <ul><li>CSOM is defined as a chronic infection of middle ear mucosa lining the middle ear cleft </li></ul><ul><li>The duration of infection should be more than 3 weeks </li></ul><ul><li>Middle ear cleft includes eustachean tube, middle ear proper and mastoid air cell system </li></ul>
    3. 3. Tubotympanic disease <ul><li>Also known as safe ear </li></ul><ul><li>It does not cause any serious complications </li></ul><ul><li>Infection limited to the antero inferior part of middle ear cleft </li></ul><ul><li>Associated with central perforation </li></ul>
    4. 4. Why is Tubotympanic disease safe? <ul><li>There is no risk of bone erosion </li></ul><ul><li>Not known to cause intracranial complications </li></ul><ul><li>Discharge from middle ear flows freely through the perforation in the pars tensa </li></ul><ul><li>Usually the perforation of pars tensa is surrounded by a rim of intact drum </li></ul><ul><li>The annulus is intact in all these cases </li></ul>
    5. 5. Aetiology <ul><li>Inadequately treated ASOM </li></ul><ul><li>ASOM causing persistent perforation (Persistent perforation syndrome) </li></ul><ul><li>Presence of focal sepsis in Nose / throat causing EC </li></ul><ul><li>Infected traumatic central perforation </li></ul>
    6. 6. Microbiology <ul><li>Gram negative bacilli has been commonly isolated </li></ul><ul><li>Ps. aeruginosa, E. coli, and B. proteus </li></ul><ul><li>These organisms are not commonly found in the respiratory tract </li></ul><ul><li>These organisms are commonly found in the skin of external canal </li></ul>Always number your slides
    7. 7. Clinical features <ul><li>Discharge is profuse and Mucopurulent </li></ul><ul><li>It is not foul smelling </li></ul><ul><li>Since the infected area is open at both ends discharge doesn't accumulate in the middle ear cavity </li></ul><ul><li>Ossicular chain is mostly uninvolved </li></ul><ul><li>Pts have conductive deafness – 30 – 40 dB </li></ul><ul><li>Pain is usually due to otitis externa </li></ul>
    8. 8. Stages of Tubotympanic disease <ul><li>Acute stage </li></ul><ul><li>Inactive stage </li></ul><ul><li>Quiescent stage </li></ul><ul><li>Healed stage </li></ul>
    9. 9. Acute stage <ul><li>Ear is actively discharging </li></ul><ul><li>Middle ear mucosa hypertrophied and congested </li></ul><ul><li>The ear discharge is Mucopurulent </li></ul><ul><li>Discharge is not foul smelling </li></ul>
    10. 10. Inactive stage <ul><li>Dry perforation of ear drum + </li></ul><ul><li>Perforation involves the pars tensa </li></ul><ul><li>Annulus is intact </li></ul><ul><li>Middle ear mucosa is normal and healthy </li></ul>
    11. 11. Quiescent stage <ul><li>Perforation of ear drum present </li></ul><ul><li>Middle ear is dry </li></ul><ul><li>Middle ear mucosa may be normal / hypertrophied </li></ul><ul><li>Discharge stopped just a few days back </li></ul>
    12. 12. Healed stage <ul><li>Healing of drum by thin scar </li></ul><ul><li>Tympanosclerotic patches may be seen </li></ul><ul><li>Ossicular chain invariably intact </li></ul>
    13. 13. Tuning fork tests <ul><li>Rinne negative on the affected side </li></ul><ul><li>Weber lateralized to deaf ear </li></ul><ul><li>ABC - Not reduced </li></ul>
    14. 14. Pure tone audiometry <ul><li>Shows conductive hearing loss </li></ul><ul><li>Hearing loss commonly ranges between 30 - 40 dB </li></ul><ul><li>If hearing loss exceeds 60 dB then ossicular chain disruption should be suspected </li></ul><ul><li>Associated sensorineural loss should arouse suspicion of toxic deafness </li></ul>
    15. 15. Conservative management <ul><li>Aural toileting - in active disease </li></ul><ul><li>Suction clearance </li></ul><ul><li>Syringing of affected ear using warm saline mixed with 1.5 % acetic acid </li></ul><ul><li>Topical antibiotics administered after culture report becomes available </li></ul><ul><li>Ear drops is administered by displacement method </li></ul>
    16. 16. Role of systemic drugs <ul><li>Antibiotics </li></ul><ul><li>Antihistamines </li></ul><ul><li>Ototoxic drugs to be avoided </li></ul><ul><li>Nasal decongestants ? Rhinitis medicamentosa </li></ul>
    17. 17. Precautions <ul><li>The ear must be kept dry </li></ul><ul><li>Pre-existing sinus infections to be treated aggressively </li></ul><ul><li>Presence of focal sepsis in the throat should also be managed </li></ul>
    18. 18. Surgical management <ul><li>Surgery towards eradication of focal sepsis </li></ul><ul><li>Surgery aimed towards eradication of middle ear disease (Mastoidectomy) </li></ul><ul><li>Surgery aimed at reconstruction of sound conduction mechanism (Myringoplasty and tympanoplasty) </li></ul>
    19. 19. Tympanoplasty <ul><li>Tympanoplasty is defined as the surgical procedure which enables reconstruction of middle ear cavity and ossicular system. It also involves reconstruction of the perforated ear drum </li></ul>
    20. 20. Components of tympanoplasty <ul><li>Canalplasty </li></ul><ul><li>Meatoplasty </li></ul><ul><li>Myringoplasty </li></ul><ul><li>Ossiculoplasty </li></ul>
    21. 21. Canalplasty <ul><li>This procedure is used to widen the external canal </li></ul><ul><li>Should be performed before grafting anterior perforations </li></ul><ul><li>This procedure facilitates better healing </li></ul><ul><li>External canal can be cleansed without any difficulty </li></ul><ul><li>Useful when performing second stage ossiculoplasty </li></ul>
    22. 22. Meatoplasty <ul><li>This procedure is performed to enlarge the lateral cartilagenous portion of the external canal </li></ul><ul><li>This enlargement should be in proportion to the size of the bony portion of the external canal </li></ul>
    23. 23. Ossiculoplasty <ul><li>Used to reconstruct the damaged ossicles of middle ear cavity </li></ul><ul><li>Long process of incus is found to be commonly eroded </li></ul><ul><li>TORP </li></ul><ul><li>PORP </li></ul>
    24. 24. Aims of tympanoplasty <ul><li>Disease eradication </li></ul><ul><li>Restoration of middle ear aeration </li></ul><ul><li>Reconstruction of sound conduction mechanism </li></ul><ul><li>Creation of self cleansing dry cavity </li></ul>
    25. 25. Preop investigations <ul><li>Tubal function tests </li></ul><ul><li>Audiometric evaluation </li></ul><ul><li>X-ray / CT scan of temporal bones </li></ul><ul><li>Tests for anesthetic fitness </li></ul>
    26. 26. Trans canal surgical approach <ul><li>Performed through ear speculum inserted into the ear canal </li></ul><ul><li>Ear canal should be wide </li></ul><ul><li>There should not be any bony overhang obscuring the edges of perforation </li></ul>
    27. 27. End aural approach <ul><li>Incision is made between tragus and helix </li></ul><ul><li>End aural speculum is used </li></ul><ul><li>Posterior bony overhang can easily be drilled out </li></ul><ul><li>Better for anterior visualization of the ear drum </li></ul>
    28. 28. Endaural view of ear drum
    29. 29. Post aural approach <ul><li>Used in cases of narrow external canal </li></ul><ul><li>Used to close anterior ear drum perforations </li></ul><ul><li>William Wild’s post aural incision is used </li></ul>
    30. 30. Ideal Tympanic membrane grafts <ul><li>Temporalis fascia </li></ul><ul><li>Dura </li></ul><ul><li>Periosteum </li></ul>
    31. 31. Why temporalis fascia is favoured? <ul><li>It has a low basal metabolic rate </li></ul><ul><li>Its thickness more or less resembles that of normal ear drum </li></ul><ul><li>It can be harvested through the same post aural incision </li></ul><ul><li>It is available in plenty </li></ul><ul><li>It has a good take rate </li></ul>
    32. 32. Types of grafting techniques <ul><li>Overlay technique </li></ul><ul><li>Underlay technique </li></ul><ul><li>Interlay technique </li></ul>
    33. 33. Underlay technique <ul><li>Commonly used technique </li></ul><ul><li>The graft is placed under the tympanic membrane remnant and bone </li></ul><ul><li>To facilitate this process a tympanomeatal flap will have to be elevated </li></ul>
    34. 34. Overlay technique <ul><li>The graft is placed over the bony tympanic sulcus </li></ul><ul><li>A bony ledge is created for this purpose if the sulcus is absent </li></ul><ul><li>The overlaid graft is supported by the remnant ear drum if present </li></ul>
    35. 35. Underlay technique
    36. 36. Thankyou
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