Ossicular chain erosion in CSOM

1. Dr ANJANA AVINASH MOHITE
ASSOCIATE PROF. IN ENT
DY PATIL MEDICAL COLLEGE
KOLHAPUR ,MAHARASHTRA
INDIA

2. •Chronic Otitis Media is one of the
leading cause of hearing loss in
Developing Countries like India.
• Ossicular Chain Erosion is a
frequent complication seen in both
Squamosal as well as Mucosal type
of Chronic Otitis Media.
• This propensity for destruction is
much more in Squamosal type due to
presence of cholesteatoma and or
granulations.

3. •Most common- Incus
•Most resistant – Malleus
•Most of the previous studies focus on erosion
of Ossicle as a whole and its replacement.
•Need of the study – Erosion of each
anatomical part was studied with an aim in
future to design individual anatomical part of
an Ossicle.

4. Aim:
To study the Intra Operative status of Ossicular Chain
in Chronic Otitis Media.
Objectives:
To study the incidence of Ossicular Chain Pathology in
Chronic Otitis Media.
To study the frequency of involvement of each Ossicle.
To compare the Ossicular Chain involvement in Safe
and Unsafe type of Chronic Otitis Media.
To compare the frequency of Ossicular involvement in
Safe and Unsafe type of Chronic Otitis Media.

5. •Study type - Prospective Clinical Longitudinal
Observational Study at Tertiary Care Hospital.
•Sample size- 200.
•Duration- 2 years.
•Consent - Informed written consent.
•Detail clinical history & complete ENT
examination, investigations and necessary surgery ie
Tympanoplasty with or without Mastoidectomy.
• Data collected, intra operative ossicular status
• noted and analysed.

6. Inclusion criteria:
All cases of chronic otitis media Mucosal or
Squamosal type undergoing surgery.
Exclusion criteria:
1) Revision mastoid surgery.
2) Children < 10 years.
3) Patients with sensorineural hearing loss.

7. Sex Distribution
Sex wise distribution of
Cases Percentage No. of Cases
Male 57 % 114
Female 43 % 86

8. Age Distribution
Age group (in years) Percentage No. of Cases
<20 12 % 24
21-40 61.5 % 123
>40 26.5 % 53

9. Symptomatology
Symptom Percentage No. of Cases
Otorrhoea 100 % 200
Deafness 100 % 200
Otalgia 0.5 % 1
Tinnitus 0 % 0
Vertigo 0 % 0
Post aural pain 0.5 % 1
Vomiting 0.5 % 1
Headache 0.5 % 1

10. Type of COM
Type of Chronic
Otitis Media Percentage No. of Cases
Mucosal 84.5 % 169
Squamosal 15.5 % 31

11. Incidence of Ossicular Chain
Pathology in COM
Cases Percentage Number
With Ossicular
Erosion 24.5 % 49
Without Ossicular
Erosion 75.5 % 151

12. Incidence of Ossicular Chain Pathology in
Squamosal and Mucosal Type of COM
Type of COM
With Ossicular
Erosion
Without
Ossicular
Erosion
Mucosal 10.65 % 89.34 %
Squamosal 100 % 0 %

13. Frequency of Involvement of each
Ossicle
Ossicle Involved
Mucosal COM
(No. of cases)
Squamosal COM
(No. of cases)
Malleus 5 8
Incus 18 31
Stapes 0 6

14. Frequency of Involvement of Anatomical Part of
each Ossicle and Combo in Mucosal and Squamosal
COM
Ossicle Involved
Mucosal COM
(No. of cases)
Squamosal COM
(No. of cases)
Long process of Incus 7 10
Lenticular process of Incus 6 7
HOM +Long process of
Incus 5 8
Stapes Suprastructure + Long
process of Incus 0 6

15. Frequency of Type of Ossicular
Chain Defect as per Austin
Type of Defect Percentage No. of Cases
M+S+ 100 49
M+S- 12.24 6
M-S+ 26.53 13
M-S- 0 0

16. Statistical Analysis - Z-test - Comparison of
Ossicular Chain Involvement in Safe and Unsafe
Type of Chronic Otitis Media
Mucosal COM Squamosal COM
p- value
No. of
Cases with
Ossicular
Erosion Percentage
No. of
Cases with
Ossicular
Erosion Percentage
18 10.65 % 31 100 %
< 0.01
Significant

17. Total Cases included in our study was 200.
• In our study, there was male predominance consistent with similar
studies by Sharma and Shetty D.P (2016), Chavan et al. (2017) and
O’reilly et al. (2005).
• 24 patients (12%) were in the age group of less than 20 years, 176
patients (88%) above 20 years. The mean age in our study was 33.02
and standard deviation +/- 11.76. Haidar et al (2015), in a study of 211
patients found the mean age to be 33.4 +/- 8.9.
•All the 200 Cases included in this study presented with ear discharge
and reduced hearing consistent with studies by Sharma and Kuchhal
(2017) Gulati and Sheahan .
• 84.5% Cases in our study had Mucosal disease, while 15.5% had
Squamosal incidence being 84.5%. It is comparable to other studies by
Basak et al, Sharma M and Shetty D.P Haidaret al (2015), Verma et al
(2016).

18. Overall Ossicular Chain Erosion was seen in 24.5% Cases. These
findings are comparable to studies by Haidar et and Rao et al who
reported the incidence to be 23.6% and 38.66% respectively.
Ossicular chain erosion was seen in 10.65% of Mucosal disease
and 100% of Squamosal disease .Similar findings were reported by
Rao et al, Verma et al and Shetty et al.
Incus was most labile Ossicle in both Mucosal and Squamosal
type followed by Malleus and Stapes. Verma et al (2016), Rao et al
(2016) and Haidar et al (2015) all reported Incus to be the most
commonly affected Ossicle

19. In Mucosal variety, erosion of isolated long process of Incus was
followed by lenticular process and then a combination of long
process erosion with Malleus handle was seen.
While in Squamosal variety in addition to above, the long process of
Incus and Stapes suprastructure was the next combination observed
to be eroded. Similar findings were seen in studies by Verma et al and
Rao et al.
Regarding Malleus, its handle along with erosion of long process of
Incus was observed in both Squamosal (8) and Mucosal (5) type.
Similar findings were reported by Sade et al.
The Stapes suprastructure along with erosion of long process of Incus
was observed in only Squamosal type of COM.

20. • Ossicular Chain Erosion is seen more frequently
in Squamosal variety of Chronic Otitis Media.
•Incus is the most commonly affected Ossicle in both types of
COM.
•The most commonly eroded anatomical part of Incus is the long
process followed by the lenticular process.
•Malleus erosion occurs along with erosion of long process of
Incus.
•Erosion of Stapes suprastructure is seen only in Squamosal
variety and the footplate of Stapes was the most resistant part of
Ossicle.
•These findings are of clinical significance so that in near future a
new prosthesis may be designed which will replace only the
affected part of the Ossicle rather than the entire Ossicle.

21. References
1. Albera R, Canale A, Piumetto E, Lacilla M, Dagna F. Ossicular chain lesions
in cholesteatoma. Acta otorhinolaryngologica Italica: organo ufficiale della
Societa italiana di otorinolaringologia e chirurgia cervico-facciale.
2012;32(5):309–13.
2. Mostafa BE, Fiky LE, Hassan O. Functional results in ossiculoplasty with
different titanium prostheses. Egyptian J Ear, Nose, Throat Alli Sci.
2013;14(2):79–84.
3. Haidar H, Sheikh R, Larem A, Elsaadi A, Abdulkarim H, et al (2015)
Ossicular Chain Erosion in Chronic Suppurative Otitis Media. Otolaryngol
(Sunnyvale) 5:203. doi:10.4172/2161-119X.1000203.
4. Hossain, M., Ahamed, M., Kabir Sumon, M., & Shoyeb, B. (2016). Status of
Ossicles in Cholesteatoma. Bangladesh Journal Of Otorhinolaryngology,
21(2), 97-101. doi:http://dx.doi.org/10.3329/bjo.v21i2.27.
5. Varshney S, Nangia A, Bist SS, Singh RK, Gupta N, Bhagat S. Ossicular
chain status in CSOM in adults Indian J Otolarymqol Head Neck Surg
2010;62;621.
6. Glasscock – Shambaugh. Surgery of the Ear, 2010;6th edition:8
7. Scott-Brown’s Otorhinolaryngology, Head and Neck Surgery, 2018:8th
edition, volume 2;533-535,537.