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Chronic otitis media Squamosal disease

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Chronic otitis media Squamosal disease

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This presentation describes the Squamosal chronic otitis media disease in brief. It discusses the basic underlying pathology and disease presentation.

This presentation describes the Squamosal chronic otitis media disease in brief. It discusses the basic underlying pathology and disease presentation.


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Chronic otitis media Squamosal disease

  1. 1. CHRONIC OTITIS MEDIA SQUAMOSAL DISEASE Presenter: Dr Avinav Gupta Moderator: Dr Karandeep Consultant: Dr Achal Gulati
  2. 2. Pathophysiology Eustachian tube dysfunction Negative pressure Retraction pocket Self cleansing Non self cleansing Retained keratin debri • Inhibitor of DNA-binding (Id1) • Cell immortalization, induces up regulation of NF-κB/cyclin D1/ keratin 10 in the keratinocytes • Proliferation: upregulation of p53 tumour suppressor gene, c-jun and c-myc protein
  3. 3. • Multinucleated osteolasts • Lipopolysaccharides • Preosteoclastic cells, primed with receptor activator NF-kB (RANKL) • TGF-β (stroma) [chronic wound healing process] • TLRs lead to the mobilization of cytokines, chemokines and interferons as well as proteases, defensins, collectins, lysozyme and lactoferrin.
  4. 4. • TLRs can induce NF-κB as well as TNF-α • TGF-α upregulate matrix metalloproteinase-9 (MMP-9) which cause bone distruction • Epidermal growth factor, TNFα, IL-1a, IL-1b, IL-6, INF B, and PTHrP. • Nitric oxide type II, has been shown to enhance osteoclastic activation • Measure of proliferation: Ki67
  5. 5. Types of Cholesteatoma • Congenital • Primary Acquired • Retraction pocket (Wittmaack) • Basal cell hyperplasia (Ruedi) • Squamous Metaplasia (Sade)
  6. 6. • Secondary Acquired • Squamous Metaplasia • Epithelial migration (Habermann) • Tertiary Acquired: Post traumatic, post tympanoplasty
  7. 7. Congenital Cholesteatoma • Persistence of congenital rest cells in middle ear, petrous apex, cerebello-pontine angle. • Diagnosis: • White mass behind intact Tympanic membrane • Normal pars tensa and pars flacida • No prior history of otorrhea or any ontological procedure
  8. 8. Why is pediatric cholesteatoma more aggressive?? • More aerated mastoid • Greater risk of otitis media and associated inflammatory process, accelerate and stimulate cholesteatoma growth • Perimatrix of pediatric cholesteatomas rich in mononuclear inflammatory elements • Higher levels of Ki-67 and matrix metalloproteinases
  9. 9. Inactive squamous epithelial Chronic otitis media • Retraction pocket • Epidermization
  10. 10. Active squamous epithelial Chronic Otitis Media (Acquired Cholesteatoma) • Cholesteatoma is a benign keratinizing epithelial lined cystic structure found in the middle ear and mastoid • Destruction of the local structures – ossicular chain and otic capsule, thereby leading to complications • Johannes Muller • 2.3 times • Apoptosis rate
  11. 11. Cause of bone distruction • Hyperimic decalcification • Osteoclastic bone resorption: • Acid phosphatase, collagenase, acid protease, proteolytic enzymes, leukotrienes, cytokeratin • Pressure necrosis • Bacterial toxins
  12. 12. Role of biofilm • Sessile community of microbes, that are irreversibly attached to a surface or to each other, and embedded in a matrix of extracellular polymeric substance produced by the organisms. • Exhibits altered phenotype with respect to growth rate and gene transcription • Epithelial cell signaling, such as induction of epidermal growth factors and upregulation of cytokines, specifically IL-6 • 60% • Squamous disease 82% vs 42% Mucosal disease
  13. 13. Spread of Cholesteatoma •Posterior epitympanic cholesteatoma passes through superior incudal space to involve aditus and antrum
  14. 14. • Posterior mesotympanic cholesteatoma invades the sinus tympani and facial recess • Anterior epitympanic cholesteatoma can involve the geniculate ganglion of facial nerve
  15. 15. History • Hearing loss (83%) • Otorrhoea (56%) • Otalgia (39%) • Childhood ear disease (43%)
  16. 16. Otoscopy • Inactive squamous retractions:
  17. 17. • Vestibular assessment • Imaging • High Resolution Computed Tomography • Diffusion-weighted magnetic resonance imaging • Endoscopy • Bacteriology
  18. 18. Inactive Squamous chronic otitis media • Retraction of the pars flacida • Fundus visible? • Self cleansing? • Retraction of pars tensa • Self cleansing? • Incudostapedial joint? Errosion? • Boney External auditory cannal erosion? • Other factors
  19. 19. Progression of retraction pockets • Reach a big size • Loss of elasticity and rigidity of tympanic membrane • Cleft palate (20%) • Turner syndrome (50%) • Cystic fibrosis
  20. 20. Management • Management of nasal disease • Aural toilet • Surgical treatments • Managemnet of tympanic membrane • Excision, no graft • Excision, myringoplasty • Excision, myringoplasty, cortical mastoidectomy • Ventilatory tubes
  21. 21. Recommendation for management for an inactive retraction In Adult patients: • Stable • No significant hearing loss + retraction pocket is selfcleansing, then follow-up • Retraction pocket is not self-cleansing, then regular microscopic suction clearance • Conductive hearing impairment • Wishes of the patient, the hearing in the other ear and the expertise of the surgeon • Myringolpasty + Ossiculoplasty
  22. 22. In a child undetr 12 years • Unstable • Hearing normal, no intervention • Treat otitis media with effusion • Progressive retraction: surgery
  23. 23. Active Squamosal Chronic otitis media(Cholesteatoma) • Pneumatisation • Progression toward healing • Automastoidectomy • No longer produce or accumulate squamous epithelium • Progression of disease • Hearing in Active Squamous disease • Presentation
  24. 24. Examination:
  25. 25. Imaging • High Resolution Computed Tomography • Scutum • Ossicular erosion • Semicircular cannal dehiscence • Facial nerve dehiscence (66-88%) • Non echoplanar diffusion weighted magnetic resonance imaging
  26. 26. Management • Aim: • Eradication of disease • An epithelialized, self-cleaning ear • Hearing maintenance or improvement.
  27. 27. Cannal wall down mastoidectomy • Modified radical mastoidectomy using the posterior to anterior approach. • Large cavity 1.4 cm3 vs 2.4 cm3 • high facial ridge • sump in cavity below floor of external auditory canal • perforation in tympanic membrane • small external auditory meatus. • Recurrence (5-15%)
  28. 28. Cannal wall up mastoidectomy • Combined approach tympanoplasty • Recurrence (20-50 %) • Second look procedure can be avoided • Both procedures have similar results
  29. 29. • Pars tensa cholesteatoma • Confines to middle ear • Ossiculoplasty • Theoretical risk that use of incus could cause recurrence • Complication of surgery • 1% facial • 2% dead ear
  30. 30. ROUTES OF SPREAD TO CRANIAL CAVITY • Direct erosion of osteitic bone by the inflammatory process • Infected thrombophlebitis of the emissary veins traversing the bone and dura. • Fractures and surgical defects. • Oval and round windows, the internal auditory meatus and cochlear aqueduct.
  31. 31. Definitions and Classifications of Mastoidectomy • " Approach" method of access to the middle ear through the soft tissues; “Route" method of access to the middle ear through the bone. • Atticotomy • Denotes opening of the attic, performed through the transmeatal route. The lateral wall of the attic is drilled away, and the lateral attic is exposed. • Atticoantrotomy • extension of the atticotomy in a posterior direction through the transmeatal route. The lateral attic and aditus walls are removed, and the antrum is entered.
  32. 32. • Bondy's Operation • An atticoantrotomy is described as Bondy's operation if the tympanic cavity is not entered. The lateral part of the cholesteatoma matrix is removed and the medial part is left in place, marsupializing the cholesteatoma • Cortical Mastoidectomy • The cortical mastoidectomy (Schwartze 1873) is a transcortical opening of the mastoid cells and the antrum. • Conservative Radical Operation • Denoting a mastoidectomy with opening of the antrum and attic, removal of the posterosuperior bony canal wall, either drilling away of the bony bridge and lowering of the facial ridge or preserving the thinned-down bony bridge
  33. 33. • Classical Radical Operation • Structures within the tympanic cavity are removed • Closure of the eustachian tube • Canal wall down mastoidectomy techniques are: Atticotomy, Bondy's operation (1910), atticoantrotomy, classical radical operation, retrograde mastoidectomy • Canal wall-up techniques are simple mastoidectomy, cortical mastoidectomy, classic intact canal wall mastoidectomy, combined- approach tympanoplasty, or modifications of these canal wall-up techniques.
  34. 34. Recent Advances • Transcannal endoscopic ear surgeries (TEES) • Trans Mastoid endoscopic ear surgeries (TMEES) • Exoscopes or extracorporeal video microscope • Diffusion Weighted Magnetic Resonance Imaging
  35. 35. Thank you

Editor's Notes

  • Cholesteatoma is an erosive process defined by trapped squamous epithelium that produces and accumulates desquamated keratin debris.
  • Classify the retraction according to Tos. Can I see the fundus of the retraction pocket or not? Is this thought to be selfcleansing or not? Whether a retraction pocket is self-cleansing or not is a qualitative judgement based upon size and appearance. A small, clean retraction pocket in the pars flaccida or pars tensa is likely to be self-cleansing, but such judgements can only be confirmed over time by clinical review.
  • reach such a size and configuration that they cease to become self-cleansing and accumulate inactive squamous debris.
    Retraction may lead to histological changes in the tympanic membrane with loss of elasticity and rigidity so that the tympanic membrane no longer ‘drives’ the ossicular chain or areas of the tympanic membrane may be eroded leaving a perforation.