Chronic Suppurative Otitis Media with attico-antral disease (CSOM-AAD), also known as COM-Squamous, is a chronic pyogenic ear infection lasting over 3 months with cholesteatoma and granulation tissue in the attic or posterosuperior quadrant of the eardrum. This causes higher risks of bone erosion and complications. Cholesteatoma is a sac lined with keratinizing squamous epithelium that grows at the expense of surrounding bone. Surgical treatment via canal wall down procedures such as attico-antrostomy or modified/radical mastoidectomy is the mainstay for managing CSOM-AAD and removing chole

1. Chronic Suppurative Otitis
Media: Attico - antral disease
(CSOM-AAD)
(COM-Squamous)
Dr. Krishna Koirala

2. Definition:
• Chronic pyogenic infection of middle ear cleft lasting
for >3 months with cholesteatoma & granulation
tissue in attic or postero-superior quadrant of pars
tensa
• Unsafe/ Dangerous : Higher chances of complication
due to bone erosion
• Hallmark of Disease : Cholesteatoma/granulations

3. Cholesteatoma
• Johannes Müller ( 1858)
• Defined as a three dimensional sac lined by
matrix of keratinizing stratified squamous
epithelium that rests on a thin layer of fibrous
tissue and contains desquamated keratin debris
which grows at the expense of surrounding bone
• Not a tumor and has no cholesterol
• Better term : Epidermosis

4. Cholesteatoma

5. Causes of bone destruction
• Hyperaemic decalcification
• Osteoclastic bone resorption
– Acid phosphatase ,collagenase, acid proteases
proteolytic enzymes, leukotrienes, cytokines
•Pressure necrosis No role
•Bacterial toxins ?

6. • Congenital (McKenzie)
• Primary Acquired
– Retraction pocket (Wittmaack)
– Basal cell hyperplasia (Ruedi)
– Squamous metaplasia (Sade)
• Secondary Acquired
– Squamous metaplasia
– Epithelial migration (Habermann)
• Tertiary Acquired : Post-traumatic , post-tympanoplasty
Types of Cholesteatoma

7. Congenital Cholesteatoma
• Persistence of congenital cell rests in middle ear,
petrous apex, cerebello-pontine angle
• Diagnostic criteria
– Intact TM
– No previous H/O otitis media
– Origin from embryonal inclusion of squamous
epithelium

9. Acquired Cholesteatoma
1. Invagination / Retraction pocket (Wittmack’s
theory)
–One of the primary mechanism of
cholesteatoma formation
–Develops in posterosuperior quadrant of Pars
tensa /Attic with adjacent canal wall erosion

10. Retraction pocket formation
Retraction pocket in pars flaccida or Postero-superior
quadrant of pars tensa due to E.T. dysfunction

11. 2. Basal cell hyperplasia (Ruedi)
Hyperplasia of basal cells in epithelial layer of T.M. &
their invasion of sub-epithelial tissues

12. 3. Primary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection without TM perforation

13. 4. Secondary squamous metaplasia
Transformation of middle ear mucosa into squamous
epithelium due to infection via T.M. perforation

14. 5. Epithelial migration
Migration of epithelium via T.M. perforation into
middle ear

15. 6. Tertiary / Post-traumatic cholesteatoma
Mechanisms:
1. Epithelial entrapment in fracture line
2. Ingrowth of epithelium through fracture line
3. Traumatic implantation of epithelium into middle
ear
4. Entrapment of epithelium medial to E.A.C. stenosis

16. Pathological Changes (Pathology)
1. T.M. perforation (marginal or attic)
2. T.M. retraction pocket (attic or P.S.Q.)
3. Cholesteatoma formation
4. Ossicles: destruction
5. Middle ear mucosa: edematous, red, polypoid
6. Aural polyp: red, fleshy
7. Osteitis & granulation tissue formation
8. Mastoid bone: erosion, sclerosis

17. Clinical Features
 Ear discharge: scanty, purulent, continuous, foul-
smelling, blood-stained
 Hearing Loss: conductive or sensori-neural
 T.M. perforation: marginal /attic /total
 T.M. retraction pocket: attic or P.S.Q.
 Cholesteatoma flakes
 Aural polyp, osteitis & granulation tissue

18. Features of Complications
• Severe otalgia, painful swelling around ear
• Vertigo, nausea, vomiting
• Headache + blurred vision + projectile vomiting
• Fever + neck rigidity + irritability / drowsiness
• Facial asymmetry
• Headache/retro-orbital pain (apex petrositis)
• Ataxia

19. Attic cholesteatoma

20. PSQ cholesteatoma & granulation tissue

21. Attico-antral Tubo -Tympanic
Otorrhea Scanty Profuse
Continuous Intermittent
Purulent Mucoid
Blood-stained No
Foul smelling No
Perforation Attic / marginal
retraction pocket
Central perforation
Cholesteatoma,
granulation
Yes No

22. Investigations
• Examination under microscope
• Ear discharge swab: for culture and sensitivity
• Pure tone audiometry
• X-ray mastoid : B/L 300 lateral oblique
(Schuller)
• CT scan: revision surgery, complications,
children

23. Advantages of E.U.M.
• Confirmation of otoscopic findings
• Epithelial migration from margin of perforation
• Cholesteatoma & granulations
• Adhesions & tympanosclerosis
• Assessment of ossicular chain integrity
• Collection of discharge for culture sensitivity

24. Uses of X-ray mastoid
1. Position of dural & sinus plates
2. Type of pneumatization : Cellular (80%), Diploic
(<1%), Sclerotic (20%)small antrum, air cells absent
3. Cholesteatoma (cotton wool appearance)
4. Bone destruction: presence & extent
5. Mastoid cavity

25. Dural & sinus plates

26. Cellular mastoid

27. Sclerotic mastoid

28. Diploic mastoid

29. Attic bone erosion

30. Causes of big mastoid cavity
• Cholesteatoma erosion
• Mastoidectomy cavity
• Tubercular mastoiditis
• Coalescent mastoiditis
• Malignancy
• Eosinophilic granuloma
• Mega-antrum
• Large emissary vein

31. C.T. scan of temporal bone
Posterior canal wall erosion

32. C.T. scan temporal bone
Mastoid cholesteatoma

33. Medical - Conservative
• Topical ear drops + frequent suction clearance
• Indications:
– Early disease with shallow retraction pocket
– Only hearing ear with cholesteatoma
– Elderly patients
– Pts who are not fit for surgery under G.A.
– Pts who can regularly come for follow up
Treatment Options

34.  Canal Wall down
– Attico-antrostomy
– Modified Radical Mastoidectomy (MRM)
– Radical Mastoidectomy
 Canal Wall up
– Combined Approach Tympanoplasty (CAT)
Surgical Treatment - Mainstay