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

5. Retraction of pars Tensa of TM

6. Grade I retraction
• Dull, lusterless T.M.
• Prominent annulus
• Cone of light absent
• Handle of malleus medialized
with prominent lateral process
• Malleal folds sickle shaped

7. Grade II retraction
TM touches the incus

8. Grade III retraction
TM touches the promontory (atelectasis) but mobile
on Valsalva maneuver or Siegelization

9. Grade IV retraction
TM firmly adherent to promontory & immobile on Valsalva
maneuver or Siegelization

10. 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

11. Bacteria responsible
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Klebsiella
• Proteus
• Streptococcus
• Bacteroides

12. 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

13. Pathological Changes
1. Eardrum
– Central perforation, myringosclerosis
2. Ossicles
– Destruction (hyperemic decalcification)
– Tympanosclerosis, fibrosis and adhesions
3. Middle ear mucosa: edematous, pale, congested
4. Mastoid bone: sclerosis

14. 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 may lead
to better hearing in acute exacerbations
• Tympanic membrane: central perforation

15. Stages of tubotympanic disease
Stage Otorrhoea Eardrum
perforation
Last ear
discharge
Active + +
Quiescent _ + < 6 months
Inactive _ + > 6 months
Healed _ _ > 6 months

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)
– 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
– Presence of hearing loss
– Degree of hearing loss
– Type of hearing loss
– Hearing status of other ear
– Record to compare hearing post-operatively
– Medico legal purpose

19. 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

20. Treatment of CSOM Tubo-tympanic
Disease

21. Non-surgical Treatment
• Precautions
• Active stage
– Aural toilet
– Antibiotics : Systemic & Topical
– Antihistamines
– Nasal decongestants
– Treatment of respiratory infection & allergy
• Tympanic membrane patcher

22. 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

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

24. Antibiotics
• Topical Antibiotics:
• Ciprofloxacin, Gentamicin, Tobramycin
• Antibiotics + Steroid: for polyps, granulations
• Neosporin + Betamethasone / Hydrocortisone
• Oral Antibiotics: for severe infections
• Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

25. Antihistamines and Decongestants
• Antihistamines
– Chlorpheniramine
– Cetirizine
– Fexofenadine
– Loratadine
– Levocetrizine
– Azelastine (topical)
• Systemic Decongestants
– Pseudoephedrine
– Phenylephrine
• Topical Decongestants
– Oxymetazoline
– Xylometazoline
– Hypertonic saline

26. Kartush T.M. Patcher
• Indicated in:
– Perforation in only hearing ear
– Patient refuses surgery
– Patient unfit for surgery
– Age < 7 years

27. Surgical Treatment
• Indicated in inactive or quiescent stage
–Myringoplasty
–Tympanoplasty
• Indicated in active stage
–Cortical Mastoidectomy
–Aural polypectomy

28. 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

29. Chemical cautery

30. Surgical Approaches to the
middle ear

31. Wilde’s post-aural incision

32. Lempert’s end-aural incision

33. Rosen’s permeatal incision

34. 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

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

36. Myringoplasty
Surgical closure of perforation of pars
tensa of Tympanic membrane without
ossicular reconstruction

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

40. Overlay Myringoplasty

41. Underlay Myringoplasty

43. Steps of underlay
Myringoplasty

44. Tympanomeatal flap raised

45. Placement of graft

46. Tympanomeatal flap replaced

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

50. Tympanoplasty

51. Types

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
– 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)