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CSOM & Cholesteatoma: Causes, Types, Treatments
- 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
- 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)
- 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
- 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