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![SOM,ASOMANDCSOM [TTD]
PRINCIPALS OF MANAGEMENT
AND SURGICAL APPROACHES
SEMINAR PRESNTED BY
DRV SANKAR NAIK](https://image.slidesharecdn.com/3rdseminarvsn-221106050928-9d2956e4/85/3RD-SEMINAR-VSN-pptx-1-320.jpg)
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- 1. SOM,ASOMANDCSOM [TTD] PRINCIPALS OFMANAGEMENT AND SURGICAL APPROACHES SEMINAR PRESNTED BY DRV SANKAR NAIK
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- 3. SEROUSOTITIS MEDIA(SOM) DEFINITION: Otitis media witheffusion (OME) is defined as chronic accumulation of mucus within the middle ear, and rarely this could involve the mastoid air cell system.This accumulation causes conductive hearing loss.
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- 7. PATHOGENISIS Histology andhistopathology of eustachean tube: The pseudostratified ciliated columnar epithelium of respiratory tract extends up the eustachean tube as far as the anterior part of the middle ear cavity.These cells are capable of producing mucous.There are also goblet cells seen in their midst.These cells are also capable of secreting mucous material. Otitis media with effusion is caused by inflammation of this epithelium in the eustachean tube and hypotympanum. In established cases of glue ear, the cuboidal epitheliumof middle ear and mastoid air cells gets replaced by thickened pseudostratified columnar epithelium.The cilia of these cells have also been found to be ineffective in propelling the secretions into the nasopharynx.The submucosa is found to be oedematous, inflammed with dilated blood vessels with increased number of macrophages and plasma cells
- 8. SEROUS OTITIS MEDIA (som) Etiology: 1. Inmany children otitis media with effusion is preceded by an episode of acute otitismedia.This is common in children who is more prone for upper respiratory infections.Common being viral infections which damages the eustachean tube epithelium. 2. Craniofacial abnormalities: Children with cleft palate have deficient palatal muscles causing a poor eustachean tube function leading on to Otitis media with effusion.This occurs despite a successful surgical repair of the cleft palate. Children with Down'ssyndrome are also more prone for OME. Note: Children with bifid uvula donot appear to have higher incidence of OME
- 9. ETIOLOGY:ctd 3. Allergy: Previouslynasal allergy has been postulated as an important factor in the development of Otitis media with effusion. 4. Gastrooesophageal reflux: GERDS has been commonly demonstrated radiologically in children with OME. Furthermore biochemical analysis of middle ear fluid have demonstrated significant amounts of pepsin (in 80% of cases). 5. Parental smoking has been attributed as an important predisposing factor for the development of OME.
- 10. ETIOLOGY:ctd Age of occurrence:OME shows classically a bimodal distribution.The first peak occurs around 2 years of age, and the second peak occurs at about 5 years of age.This distribution occurs roughly around the ages when the child goes to preschool and primary school. Seasonal association: OME commonly occurs during winter season, when there is more likelihood of upper respiratory infections, and also because of the possibility of closer contact with affected children.This is seen in temperate zones. In non temperate zones it is commonly seen during rainy season.
- 12. SYMPTOMS Blocking sensationof the ears Deafness (conductive type ) Child’s performance will be low Wooly feeling in the ear Autophony Nasal discharge Nasal obstruction
- 13. Signs Tympanic membraneretraction Evidence of fluid in the middle ear Mobility ofTM is decreased TM appears dull and lusterless Tuning fork test : Rinnes negative Webers lateralised to affected side ABC normal
- 14. Investigations PLAIN X RAY Waters view of PNS to rule out the sinus infection Lateral view of nasopharynx to rule out hypertrophied adenoids AUDIOMETRY PTA - conductive deafness commonly in low frequency becoz of increase of mass factors in middle ear IA - flat curve with shift in compliance to negative side
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- 19. TREATMENT Prevention ofsecretory otitis media Removal of possible causes e.g. adenoidectomy Anti allergic treatment – anti histamines , desensitisation Advice child to sit in front row Myringotomy with grommet insertion
- 20. MYRINGOTOMY Definition It is incisionof theTM with the purpose to drain suppurative or non suppurative Effusion of the middle ear or to provide aireiation in case of malfunctioning eustachian tube Indication 1:Asom 2:Som 3:Aero-otitis media ( to drain fluid and unlock the ET ) 4:Atelectatic ear ( grommet is often inserted for long term aeriation) Contraindication 1:suspected intratympanic glomus tumour 2: profuse bleeding
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- 22. STEPS OF OPERATION 1.Ear canal cleaned 2 .In asom circumferential incision is made in the posteroinferior quadrant ofTM midway between handle of malleus and tympanic annulus ,avoiding injury to incudostapedial joint 3. som a small radial incision is given in the posteroinferior or anteroinferior quadrant and all the efussion sucked out
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- 25. ACUTE SUPPURATIVE OTITIS MEDIA (ASOM) Definition: pyogenic infection of middle ear clef lasting for less than 3 weeks. ROUTES OF INCETION : 1.Via Eustachain tube 2.ViaTympanic membrane perforation 3.Haematogenous (rare)
- 26. PREDISPOSING FACTORS: 1.Recurrent attacks of common cold, upper respiratory tract infections and exanthematous fevers like measles, diphtheria or whooping cough. 2. Infections of tonsils and adenoids. 3. Chronic rhinitis and sinusitis. 4. Nasal allergy. 5.Tumours of nasopharynx, packing of nose or nasopharynx for epistaxis. 6. Cleft palate
- 27. Bacteriology Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Moraxella catarrhalis H. influenzae β-Hemolytic streptococci (cause acute necrotizing otitis media)
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- 29. STAGESOF ASOM Stage 1:of hyperemia. Stage 2: of exudation. Stage 3: of suppuration. Stage 4: of coalescent mastoiditis. Stage 5: of complication. Stage 6: of resolution.
- 30. Stage 1: Hyperemia Earache Fullness of the ear Fever Deafness-mild conductive type Running nose and nasal obstruction
- 31. signs Tympanic membranecongested Cartwheel appearance Nasal mucosa congestion
- 32. treatment Antibiotics Analgesics and antipyretics Decongestants Nasaldrops Steam inhalation
- 33. Stage 2: exudation Earpain will increase. Blocking sensation of the ear will increase. Deafness increase Signs: TM thick,congested,bulging X-ray mastoid –haziness,cloudy. Treatment: Antibiotics Myringotomy
- 34. X Ray ofMastoid
- 35. Stage 3: Suppuration Symptoms: Earpain decrease-because of discharge Discharge –blood stained,serosanguineous,mucoplurent Signs TM small central perforation Light house sign. Treatment: Aural toilet-dry mopping Broad spectrum antibiotic ear drops gentamycin,neosporin
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- 37. Pathogenesis of coalescent mastoiditis Hyperemia Neo vascularity Mucosaledema Obstruction of aditus Failure of drainage Venous stasis Localised acidosis Dissolvation of the wall of air cells because of hyperemic decalcification Coalescence of mastoid air cells mastoid will be bag of pus
- 38. Stage 4: coalescent mastoiditis Symptoms : Earache increase after period of 2 weeks of remission Fever Discharge-mucoplurent Deafness Signs: Mastoid tenderness Ironed out mastoid Tm-cp with polypoidal middle ear mucosa Sagging of the posterior superior meatal wall X-ray mastoid clouding of air cells Treatment : cortical mastoidectomy and drainage of pus
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- 41. Stage 5: complications Untreatedcases can lead to complications which can be divided into two :Intra and extra cranial complications. extra cranial complications Mastoiditis and mastoid abscess Facial nerve paralysis Labyrinthitis Petrositis Otogenic tetanus
- 42. Intracranial complications Extraduralabscess Subdural abscess Brain abscess Lateral sinus thrombosis Otitic hydrocephalous Meningitis Treatment depends on type of complications
- 43. Stage 6: resolution Cessationof ear discharge Normal hearing Healed perforation
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- 45. DEFINITION & CLASSIFICATION It is definedas chronic inflammation of mucoperiosteal lining of the middle ear cleft . CLASSIFICATION 1.TUBOTYMPANICTYPE / SAFETYPE Inactive mucosal COM ( permanent perforation without discharge) Active mucosal COM ( permanent perforation with discharge ) Healed COM
- 46. 2. ATTICOANTRAL TYPE/UNSAFE TYPE 2. ATTICOANTRALTYPE/ UNSAFETYPE Inactive squamous COM (Retraction pocket with potential of being active with cholesteatoma ) active squamous ( retraction pocket with cholesteatoma)
- 47. TUBO TYMPANIC TYPE -ETIOLOGY Predisposing factors Impropertreatment ofASOM Infection of surrounding areas Some diseases likeTB Pneumatisation of mastoid Exciting factors Gram negative organisms like pseudomonas ,proteus , e-coli Streptococcus Staphylococcus
- 48. SYMPTOMS 1.Discharge : profuse,intermittent ,predominantly mucoid ,occasionally mucopurulent , non –foul smelling , whitish to yellowish and tenacious. Active Inactive Healed 2.Deafness : mild conductive 3.Earache
- 49. SIGNS 1.Discharge 2.Tympanic membrane :centralperporation can be A – small / pin hole perforation Tests to identify pin hole perforation 1.Bonsins test 2.Valsalva test 3.Drop of otobiotic ear drops instilled in ear then pt. is asked to doValsalva , air bubbles are seen B- medium sized perforation C- large / sub – total perforation D complete / total perforation
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- 51. Auditory function tests 3.Tuning forktests Rinnes negative Webers lateralised to affected side Abc normal
- 52. INVESTIGATIONS Culture and sensitivity Examination under microscope PTA Xrayof mastoid X ray PNS X ray of soft tissue neck lateral view DNE Improved / decreased/no Hearing Then perforation is closed with cigarette foil And repeat audiogram Before patching PTA taken PATCHTEST
- 53. TREATMENT Active stage: conservative treatment with medical management Quiscent stage : if infective focus is limited to mastoid , a myringo plasty .tympanoplasty can be done along with cortical mastoidectomy. Inactive stage .
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- 55. DEFINITION Myringoplasty is aprocedure used to seal a perforated tympanic membrane using a graft material Temporalis fascia is the commonly used graft material because: 1. It is an autograft with excellent chance of take 2. It is available close to the site of operation making its harvest 3. It has a low basal metabolic rate, brightening its success rate 4. Its thickness is more or less similar to that of tympanic membrane
- 56. There aretwo available methods of performing myringoplasty: Overlay technique Under lay technique Overlay technique: This is a difficult technique to master. Here the graft material is inserted under the squamous (skinlayer) of the ear drum. It is a difficult task peeling only the skin layer away from the tympanic membrane, placing the graft over the perforation and redraping the skin layer. Underlay technique: This is a simpler and commonly used technique. Here the graft is placed under the tympano meatal flap which has been elevated hence the name under lay.The major advantage of this procedure is that it is easy to perform with a good success rate.
- 57. Indications of Myringoplasty: 1.Central perforation which has been dry atleast for a period of 6 weeks. 2. As a follow up to mastoidectomy procedure to recreate the hearing mechanism
- 58. Prerequisites for myringoplasty 1. Central perforationwhich has been dry for at least 6 weeks 2. Normal middle ear 3. Intact ossicular chain 4. Good cochlear reserve
- 59. STEP I Firstlya temporalis fascia of adequate site must be harvested and allowed to dry. The surgery is performed under local anesthesia Temporalis fascia graft is harvested under local anesthesia conventionally and allowed to dry. The external auditory canal is then anesthetised using 2 % xylocaine mixed with 1 in 10,000 adrenaline injection. About 1/2 cc is infiltrated at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o clock positions about 3mm from the annulus. The patient is premedicated with intramuscular injections of 1 ampule fortwin and 1 ampule phenergan.
- 60. Step I Fresheningthe margins of perforation In this step the margins of the perforation is freshened using a sickle knife of an angled pick This step is very important because it breaks the adhesions formed between the squamous margin of the ear drum (outer layer) with that of the middle ear mucosa These adhesions if left undisturbed will hinder the take up of the neo tympanic graft. This procedure will infact widen the already present perforation.There is nothing to be alarmed about it
- 61. STEP II Thisstep is otherwise known as elevation of tympano meatal flap. Using a drum knife a curvilinear incision is made about 3 mm lateral to the annulus. This incision ideally extends between the 12 - o clock, 3 - o clock, and 6 - o clock positions in the left ear, and 12 - o clock, 9 - o clock and 6 - o clock positions in the right ear. The skin is slowly elevated away from the bone of the external canal. Pressure should be applied to the bone while elevation. This serves two purposes: 1. It prevents excessive bleeding 2. It prevents tearing of the flapThis step ends when the skin flap is raised up to the level of the annulus.
- 62. STEP III Elevationof the annulus and incising the middle ear mucosa. In this step the annulus is gradually lifted from its rim. As soon as the annulus is elevated a sickle knife is used to incise the middle ear mucosal attachement with the tympano meatal flap. This is a very important step because the inner layer of the remnant ear drum is continuous with the middle ear mucosa. As soon as the middle ear mucosa is raised, the flap is pushed anteriorly till the handle of the malleus becomes visible.
- 63. STEP IV Freeingthe tympano meatal flap from the handle of malleus. In this step the tymano meatal flap is freed from the handle of malleus by sharp dissection of the middle ear mucosa. Sometimes the handle of the malleus may be turned inwards hitching against the promontory In this scenario, an attempt is made to lateralise the handle of the malleus. it is not possible to lateralise the handle of the malleus, the small deviated tip portion of the handle can be clipped. The handle of the malleus is freshened and stripped of its mucosal covering
- 64. STEPV Placement ofgraft (underlay technique). Now a properly dried temporalis fascia graft of appropriate size is introduced through the ear canal. The graft is gently pushed under the tympano meatal flap which has been elevated. The graft is insinuated under the handle of malleus. The tympano meatal flap is repositioned in such a way that it covers the free edge of the graft which has been introduced. Bits of gelfoam is placed around the edges of the raised flap. One gel foam bit is placed over the sealed perforation. This gelfoam has a specific role to play. Due to the suction effect created it pulls the graft against the edges of the perforation thus perventing medialisation of the graft material.