This document discusses chronic suppurative otitis media tubotympanic disease (CSOM TT). It defines CSOM TT as a pyogenic middle ear infection lasting over 3 months with persistent tympanic membrane perforation and ear discharge. It describes the types and sizes of tympanic membrane perforations, stages of the disease, predisposing factors, pathological changes, clinical features, investigations including audiometry and microscopy, and treatment approaches including non-surgical and surgical options like myringoplasty and tympanoplasty. Surgical treatment aims to close perforations, restore hearing, and stop ear discharge.
1. Chronic Suppurative Otitis Media:
Tubotympanic Disease (CSOM TT,
COM Mucosal type)
Dr. Krishna Koirala
2020-05-18
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. Small perforation:
Involves only one
quadrant or <10%
of pars tensa
Types of Perforations of pars tensa in CSOM TT
Medium size
perforation:
Involves two
quadrants
or 10 to 40 %
of pars tensa
Large perforation:
Involves 3 or 4
quadrants with wide
TM remnant or >40%
of pars tensa
involvement
12. Routes of infection
1. Via Eustachian tube
â U.R.T.I., nose blowing, regurgitation of milk
2. Via tympanic membrane perforation
â Following A.S.O.M. or post-traumatic
3. Haematogenous (rare): exanthematous fever
14. Clinical Features
⢠Ear discharge: intermittent, profuse, mucoid to muco-
purulent, whitish, odorless, not blood-stained
⢠Hearing Loss:
â Usually conductive (25-50 dB) but might be normal
in small, dry perforations
â Round window shielding by ear discharge may lead
to better hearing in acute exacerbations
⢠Tympanic membrane: central perforation
16. Investigations for CSOM TTD
⢠Ear discharge swab (in active disease): for Gram
stain, culture and sensitivity
⢠Examination under microscope
⢠Pure tone audiometry
⢠Patch test: historical
⢠X-ray mastoid: B/L 300 lateral oblique (Schuller)
â Done when cortical mastoidectomy is required in CSOM TT
not responding to antibiotics
17. 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
18. Pure Tone Audiometry
⢠Uses
â Presence of hearing loss
â Degree of hearing loss
â Type of hearing loss
â Hearing status of other ear
â Record to compare hearing post-operatively
â Medico legal purpose
19. Patch Test
⢠Performed when deafness is around 40-50 dB
â Do pure tone audiometry: for hearing threshold
â Put Aluminum foil patch over T.M. perforation
â Repeat pure tone audiometry
⢠Hearing improved ď Ossicular chain intact &
mobile
⢠Hearing same / worse ď Ossicular chain
broken or fixed
22. Precautions
⢠Encourage breast feeding with childâs 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
23. ⢠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
26. Kartush T.M. Patcher
⢠Indicated in:
â Perforation in only hearing ear
â Patient refuses surgery
â Patient unfit for surgery
â Age < 7 years
27. Surgical Treatment
⢠Indicated in inactive or quiescent stage
âMyringoplasty
âTympanoplasty
⢠Indicated in active stage
âCortical Mastoidectomy
âAural polypectomy
28. Methods to close perforation
⢠T.M. perforation < 2 mm
â Chemical cautery with silver nitrate
âFat grafting
(Myringoplasty if these measures fail)
⢠T.M. perforation > 2 mm
â Tympanic membrane patcher
â Myringoplasty
34. Hearing Restoration
⢠Myringoplasty
â Surgical closure of tympanic membrane
perforation
⢠Ossiculoplasty
â Surgical reconstruction of ossicular chain
⢠Tympanoplasty
â Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery
35. 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
37. 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
38. Contraindications
⢠Purulent ear discharge
⢠Otitis externa
⢠Respiratory allergy
⢠Age < 7 yr (Eustachian tube not fully developed)
⢠Only hearing ear
⢠Cholesteatoma
39. 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
47. 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
48. Onlay Underlay
Graft cholesteatoma No
Blunting of anterior tympano-
meatal angle
No
Lateralization of graft No
Delayed healing time (6 wks) 3-4 weeks
No middle ear inspection Possible
Difficult & takes more time Easier & quicker
49. 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. 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 )
53. Ossiculoplasty
⢠Ossicular graft material
â Autograft
⢠Ossicles : incus/malleus
⢠Cartilage : Tragal/ conchal
⢠Bone : spine of Henle/mastoid
â Homograft: ossicles/cartilage/bone
â Biomaterials: plastic(polyethylene)/ceramic/ teflon/gold
(Biomaterials available as PORP and TORP)