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Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT)

Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT) is an important topic for MBBS and MS ENt students. Dr Krishna Koirala will be explaining this topic in a simplified way.

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Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT)

  1. 1. Chronic Suppurative Otitis Media: Tubotympanic Disease (CSOM TT, COM Mucosal type) Dr. Krishna Koirala 2016-05-03
  2. 2. Definition • Pyogenic infection of middle ear cleft mucosa lasting for more than 3 months characterized by persistent perforation of pars tensa of tympanic membrane, ear discharge and decreased hearing
  3. 3. Tubo-tympanic vs. Attico-antral
  4. 4. Perforations of Pars Tensa in CSOM TT
  5. 5. Involves only one quadrant or < 10% of pars tensa Small perforation
  6. 6. Medium perforation Involves two quadrants or 10 – 40 % of pars tensa
  7. 7. Large perforation
  8. 8. Retraction of pars Tensa of TM
  9. 9. Grade I retraction • Dull, lusterless T.M. • Prominent annulus • Cone of light absent • Prominent lateral process • Handle of malleus medialized • Malleal folds sickle shaped
  10. 10. Grade II retraction TM touches the incus
  11. 11. Grade III retraction TM touches the promontory (atelectasis) but mobile on Valsalva maneuver or Siegelization
  12. 12. Grade IV retraction TM firmly adherent to promontory & immobile on Valsalva maneuver or Siegelization
  13. 13. Predisposing factors for CSOM TT • Upper respiratory tract infection (recurrent) • Upper respiratory tract allergy • Pre-existing otitis media with effusion • Cleft palate • Immune deficiency: diabetes, AIDS • Poor socio-economic status
  14. 14. Bacteria responsible • Staphylococcus aureus • Pseudomonas aeruginosa • Klebsiella • Proteus • Streptococcus • Bacteroides
  15. 15. Routes of infection 1. Via Eustachian tube – U.R.T.I., nose blowing, regurgitation of milk 2. Via tympanic membrane perforation – Following A.S.O.M. or post-traumatic 3. Haematogenous (rare): exanthematous fever
  16. 16. Pathological Changes 1. Eardrum – Central perforation; myringosclerosis 2. Ossicles – Destruction (hyperemic decalcification) – Tympanosclerosis, Fibrosis + Adhesions 3. Middle ear mucosa: edematous, pale, congested 4. Mastoid bone: sclerosis
  17. 17. Clinical Features • Ear discharge: intermittent, profuse, mucoid to muco- purulent, whitish, odorless, not blood-stained • Hearing Loss: – Usually conductive (25-50 dB) but might be normal in small, dry perforations – Round window shielding by ear discharge leads to better hearing in acute exacerbations • Tympanic membrane: central perforation
  18. 18. Stages of Tubotympanic disease Stage Otorrhoea Eardrum perforation Last ear discharge Active Present Present - Quiescent Absent Present < 6 months Inactive Absent Present > 6 months Healed Absent Absent -
  19. 19. Investigations for CSOM TTD • Examination under microscope • Ear discharge swab: for culture sensitivity • Pure tone audiometry • Patch test • X-ray mastoid: B/L 300 lateral oblique (Schuller) (Done when cortical mastoidectomy is required in CSOM TT not responding to antibiotics)
  20. 20. Examination under microscope • Confirmation of otoscopic findings • Epithelial migration at perforation margin • Cholesteatoma & granulations • Adhesions & Tympanosclerosis • Assessment of Ossicular chain integrity • Collection of discharge for culture sensitivity
  21. 21. Pure Tone Audiometry • Uses – Presence of hearing loss – Degree of hearing loss – Type of hearing loss – Hearing of other ear – Record to compare hearing post-operatively – Medico legal purpose
  22. 22. Patch Test • Performed when deafness is around 40-50 dB – Do pure tone audiometry: for hearing threshold – Put Aluminum foil patch over T.M. perforation – Repeat pure tone audiometry • Hearing improved  Ossicular chain intact & mobile • Hearing same / worse  Ossicular chain broken or fixed
  23. 23. Treatment of CSOM Tubo-tympanic Disease
  24. 24. Non-surgical Treatment • Precautions • Aural toilet • Antibiotics : Systemic & Topical • Antihistamines : Systemic & Topical • Nasal decongestants : Systemic & Topical • Treatment of respiratory infection & allergy • Tympanic membrane patcher
  25. 25. Precautions • Encourage breast feeding with child’s head raised. Avoid bottle feeding • Avoid forceful nose blowing • Plug E.A.C. with Vaseline smeared cotton while bathing & avoid swimming • Avoid putting oil , water or self-cleaning of ear
  26. 26. • Done only for active stage • Dry mopping with cotton swab • Suction clearance: best method • Gentle irrigation (wet mopping) • 1.5% acetic acid solution used T.I.D. • Removes accumulated debris • Acidic pH discourages bacterial growth Aural Toilet
  27. 27. Antibiotics • Topical Antibiotics: • Ciprofloxacin, Gentamicin, Tobramycin • Antibiotics + Steroid: for polyps, granulations • Neosporin + Betamethasone / Hydrocortisone • Oral Antibiotics: for severe infections • Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
  28. 28. Antihistamines and Decongestants • Antihistamines – Chlorpheniramine – Cetirizine – Fexofenadine – Loratadine – Levocetrizine – Azelastine (topical) • Systemic Decongestants – Pseudoephedrine – Phenylephrine • Topical Decongestants – Oxymetazoline – Xylometazoline – Hypertonic saline
  29. 29. Kartush T.M. Patcher • Indicated in: – Perforation in only hearing ear – Patient refuses surgery – Patient unfit for surgery – Age < 7 years
  30. 30. Surgical Treatment • Indicated in inactive or quiescent stage –Myringoplasty –Tympanoplasty • Indicated in active stage –Cortical Mastoidectomy –Aural polypectomy
  31. 31. Methods to close perforation • T.M. perforation < 2 mm – Chemical cautery with silver nitrate –Fat grafting (Myringoplasty if these measures fail) • T.M. perforation > 2 mm – Tympanic membrane patcher – Myringoplasty
  32. 32. Chemical cautery
  33. 33. Surgical Approaches to the middle ear
  34. 34. Wilde’s post-aural incision
  35. 35. Lempert’s end-aural incision
  36. 36. Rosen’s permeatal incision
  37. 37. Hearing Restoration • Myringoplasty – Surgical closure of tympanic membrane perforation • Ossiculoplasty – Surgical reconstruction of ossicular chain • Tympanoplasty – Surgical removal of disease + reconstruction of hearing mechanism without mastoid surgery
  38. 38. Principles of hearing restoration • Intact tympanic membrane • Intact ossicular chain • Functioning receiving & relieving windows • Acoustic separation of these windows • Functioning Eustachian tube • Absence of sensorineural hearing loss • Absence of active infection / allergy in middle ear cleft
  39. 39. Myringoplasty Surgical closure of perforation of pars tensa of Tympanic membrane without ossicular reconstruction
  40. 40. Aims • Permanently stop ear discharge : make the ear dry and safe • Improve hearing if ossicles are intact and mobile and there is absence of sensori-neural deafness • Prevention of ongoing complications like further hearing loss, tympanosclerosis, adhesions, mucosal bands, vertigo • Wearing of hearing aid • Occupational: military, pilots • Recreation: swimming, diving
  41. 41. Contraindications • Purulent ear discharge • Otitis externa • Respiratory allergy • Age < 7 yr (Eustachian tube not fully developed) • Only hearing ear • Cholesteatoma
  42. 42. Methods Techniques • Underlay: graft placed medial to fibrous annulus • Overlay: graft placed lateral to fibrous annulus Grafts used • Temporalis fascia, Tragal perichondrium, Vein graft, Fascia lata, Dura mater
  43. 43. Overlay Myringoplasty
  44. 44. Underlay Myringoplasty
  45. 45. Steps of underlay Myringoplasty
  46. 46. Tympanomeatal flap raised
  47. 47. Placement of graft
  48. 48. Tympanomeatal flap replaced
  49. 49. Why temporalis fascia? • Basal metabolic rate lowest (best survival rate) • Easy to harvest • Large size graft can be harvested • Autograft, so no rejection • Same thickness as normal tympanic membrane • Good resistance to infection
  50. 50. Onlay Underlay Graft cholesteatoma No Blunting of anterior tympano- meatal angle No Lateralization of graft No Delayed healing time (6 wk) 3-4 weeks No middle ear inspection Possible Difficult & takes more time Easier & quicker
  51. 51. Advantages of Local Anesthesia • Minimal bleeding • Hearing results can be tested on table • Facial palsy detected immediately • Labyrinthine stimulation detected immediately • No complications of General anesthesia
  52. 52. Tympanoplasty
  53. 53. Types
  54. 54. Type Pathology Graft placed on I Ear drum perforation only Malleus handle II Malleus handle eroded Incus III Malleus + Incus eroded Stapes head IV Only footplate remains: mobile Footplate exposed V Only stapes remains: fixed Lateral SCC opening VI Only footplate remains: mobile Round window exposed (Sono inversion )
  55. 55. Ossiculoplasty • Ossicular graft material – Autograft • Ossicles : incus/malleus • Cartilage : Tragal/ conchal • Bone : spine of Henle/mastoid – Homograft: ossicles/cartilage/bone – Biomaterials: plastic(polyethylene)/ceramic/ teflon/gold (Biomaterials available as PORP and TORP)

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