This document discusses chronic suppurative otitis media (CSOM), specifically atticoantral disease. CSOM is characterized by ear discharge and permanent perforation due to long-standing middle ear infection. Atticoantral CSOM involves the attic and antrum regions and poses a higher risk of complications due to bone-eroding processes like cholesteatoma and granulation tissue. Surgical treatment such as atticotomy or mastoidectomy aims to remove disease and render the ear safe, while reconstructive surgery seeks to preserve or restore hearing.

1. Dr. Chandni P Engoor
PG Resident
Dept of ENT
CHOLESTEATOMA & ATTICO
ANTRAL DISEASE

2. CHRONIC SUPPURATIVE
OTITIS MEDIA (CSOM)
Long standing infection of a part or whole of the middle
ear cleft characterized by ear discharge and permanent
perforation

3. EPIDEMIOLOGY
 Developing countries: more
 Both sexes
 All age groups
 Prevalence rate: 46 per thousands (rural), 16 per
thousands (urban)

4. TYPES
TUBOTYMPANIC
ATTICOANTRAL

5. ALTERNATIVE
CLASSIFICATION
COM
Mucosal
Active(CSOM)
Inactive (permanent
perforation)
Healed (adhesive
OM)
Squamosal
Retraction pockets
(PT/PF/atelectatic
ear
Active ( C+
discharge)

6. 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

7. AETIOLOGY
• It is seen in sclerotic mastoid
• cholesteatoma

8. 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

9. 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.

10. CHOLESTEATOMA -
DEFINITION
 presence of keratinizing squamous
epithelium in the middle ear or mastoid
 “skin in the wrong place”
 2 parts
 Matrix
 Central white mass

12. ORIGIN OF CHOLESTEATOMA
Congenital cell rests
Wittmaack’s theory
Ruedi’s theory
Habermann’s theory
Sade’s theory

13. ORIGIN OF CHOLESTEATOMA
 Ruedi’s theory
 Basal cell hyperplasia
 Proliferate- infection, lay
down keratinizing
squamous epithelium
(KSE)
 Wittmaack’s theory
 Invagination of TM
from the attic/
posterosuperior part of
pars tensa in the form
of retraction pockets

16. ORIGIN OF CHOLESTEATOMA
 Sade’s theory
 Metaplasia
 Like respiratory
mucosa elsewhere
 d/t repeated infection
squamous
 Habermann’s theory
 Epithelial invasion
 From the meatus/
outer drum surface
 Pre-existing
perforation(marginal)-
part of the annulus
tympanicus- destroyed

17. CLASSIFICATION
CONGENITAL
ACQUIRED, 1’
ACQUIRED,2’

18. 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

20. 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

21. 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

23. Bone erosion
• By liberation of chemical
• Ischaemic necrosis theory
• Enzymatic theory: collagenase, acid
phoaphate and proteolytic enzyme
• Passes from aditus to antrum of mastoid further
spread causing many complication
• Hence called as dangerous om

25. SYMPTOMS
Ear discharge
• Scanty,foul smelling
• Total cessation of discharge- seriously
Hearing loss
• Normal: ossicular chain is intact
• Conductive type
Bleeding
• Granulation/polyps
• Cleaning

26. 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

28. 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

29. TREATMENT
SURGICAL
RECONSTRUCTIVE
SURGERY
CONSERVATIVE

30. 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

31. RECONSTRUCTIVE SURGERY
 RECONSTRUCTIVE
 Myringoplasty/ tympanoplasty
 Primary surgery/ 2nd stage procedure

32. 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

33. 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