Cholesteatoma is a sac of keratinizing skin in the middle ear that can erode bone. It is usually acquired after ear infections cause retraction pockets. On imaging, it appears as soft tissue with bone erosion. Treatment involves surgical removal via modified radical mastoidectomy to eliminate the disease and create a self-cleaning ear. The surgery follows the cholesteatoma from back to front to fully remove it while preserving hearing if possible.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
Inner ear malformations and ImplantationUtkal Mishra
This slide vividly describes relevant anatomy & embryology of cochlea. It gives the reader insights into various cochlear malformations & implantation.
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Perilymph Fistula can be difficult to diagnose as a standalone condition. Post-trauma symptoms such as dizziness, headache, etc. can be linked to other conditions like a traumatic brain injury with a concussion.
Inner ear malformations and ImplantationUtkal Mishra
This slide vividly describes relevant anatomy & embryology of cochlea. It gives the reader insights into various cochlear malformations & implantation.
This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.
Chronic Otitis Media - Squamosal type ( UG)AlkaKapil
Chronic Otitis Media - Squamosal / atticoantral/ unsafe Type
Theories of cholesteatoma
cholesteatoma
levenson's criteria
congenital cholesteatoma
classification of cholesteatoma
sade's classification of retraction of pars tensa
Toss classification of pars flaccida retraction
cholesterol granuloma
clinical features of Squamosal CSOM
Complications of COM/CSOM
Investigations - HRCT Temporal bone
Mastoid exploration
cortical mastoidectomy
modified radical mastoidectomy
Radical mastoidectomy
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
5. Cholesteatoma is defined as a sac of keratinizing stratified squamous
epithelium in the middle ear cleft containing desquamated epithelium
as keratin debris.
Has bone eroding property.
Also described as ‘ Skin in the wrong place ’.
Cholesteatomas are the end stage of (squamous epithelial) retractions
of the pars tensa or flaccida that are not self-cleansing, retain
epithelial debris and often elicit a secondary, inflammatory mucosal
reaction.
7. Arises from embryonic
epidermal cell rests in middle
ear cleft or temporal bone.
Occurs at : Middle ear, petrous
apex or cerebellopontine angle
Presents as white mass behind
the intact TM
8. LEVENSON CRITERIA:
White mass behind intact TM
Normal pars flaccida and pars tensa
No prior H/O otorrhea or any otological procedure
9. Primary:
No previous H/O ear discharge or TM perforation
Secondary:
Occurs in already diseased ear [ pre-existing TM perforation ]
10. Retraction pocket theory
Theory of migration
Metaplasia
Implantation theory
Basal cell hyperplasia
11. (A) Invagination theory
(retraction pocket theory).
(B) Epithelial invasion or
migration theory
(immigration theory).
(C) Squamous metaplasia
theory.
(D) Basal cell hyperplasia
theory (papillary ingrowth
theory).
19. Posterior mesotympanic
cholesteatoma illustrating the
pathways to the mastoid and
middle ear. Note that the
penetration to the mastoid is
medial to the ossicles.
Posterior mesotympanic
cholesteatoma tends to
involve the posterior
tympanic spaces: the sinus
tympani and facial recess
22. Ear discharge:
Foul smelling – osteitis and saprophytic infection
Continuous – osteitis
Blood stained – granulations,osteitis
Hearing loss:
Hearing is often preserved until a very late stage in ears containing
cholesteatoma in spite of the ossicular chain being disrupted. [keratoma
hearers]
cholesteatoma sac bridges the gap between the functioning part of the
ossicular chain and the inner ear.
The unfortunate consequence is that removal of the disease surgically may
reduce the hearing by increasing the air–bone gap.
23. Ear ache : inflammation of meatal skin, intra cranial complication
Dizziness : progression erosion of bony LSCC & fistula formation
serous labyrinthitis
Tinnitis
Signs :
Foul smelling blood stained discharge, may contain whitish scales from
cholesteatoma
Attic perforation or marginal perforation
Retraction pocket in attic
Granulation tissue in postero superior quadrant of TM
Occassionally polyp/granulation tissue may be seen coming out of the
perforation
Tuning fork tests: rinnes test negative, webers- lateralized to affected ear
27. Size and site of the defect
State of the remaining TM
Appearance of middle ear mucosa
Presence of polyp & granulation
tissue- site of origin
Retraction pocket- classification
Also for suction clearance &
diagnosis
28. Culture & sensitivity from ear discharge
Rigid oto endoscopy
Audigram [PTA]:
Imaging
29.
30. Schuller’s view
To see bony erosion
Anatomy of mastoid
Occasionally to diagnose cholesteatoma cotton wool appearance
31.
32.
33. Imaging features of cholesteatoma:
The hallmark of cholesteatoma is bony destruction.
Presence of soft tissue density in the middle ear cavity coexistent
with ossicular and mastoid bony erosion is highly specific for
cholesteatoma.
In attic cholesteatomas, the ingrowth of epithelium from the pars
flaccida into the epitympanum is evident by the erosion of the
scutum.
34. Axial CT image showing
non-dependent soft tissue
in the Prussack’s space,
lateral to ossicles in a
patient with pars flaccida
cholesteatoma (arrow)
35. Coronal CT image showing normal scutum on the left side (arrow).
It is seen as a point of superior attachment of the tympanic
membrane.
Scutum is eroded on the right side with soft tissue seen in the
middle ear and external auditory canal.
36. Axial CT reveals widening
of aditus (denoted by A) and
formation of common cavity
between epitympanum
(denoted by E) and aditus
with soft tissue within
37. Axial CT image showing
non-dependent soft
tissue medial to ossicles
in a patient with pars
tensa cholesteatoma
(arrow)
38. Axial CT through the
mesotympanum shows the
sinus tympani (yellow arrow)
and facial recess (white
arrow) which are hidden
areas by otological
examination and should be
carefully inspected on
imaging for the presence of
soft tissue.
39. Axial section through the
epitympanum shows the
normal anterior epitympanic
recess (arrow) which is the
medial extension of
epitympanum. Its importance
lies in its close proximity to the
tympanic segment of the facial
nerve canal (*)
40. Axial CT shows normal “ice cream cone” configuration of ossicles in
epitympanum on the left side formed by the head of the malleus and the
body of the incus. The right ear shows soft tissue in the middle ear and
aditus with non-visualization of ice cream cone suggesting erosion. A
large defect is also seen in the sinodural plate on the right side (yellow
arrow). Left sinodural plate is intact (white arrow)
41. Coronal (a) CT image reveals the “snail eye” view where the turns
of cochlea form the body of snail and labyrinthine and tympanic
segments of facial nerve being the eyes (arrow).
Coronal(b) CT image shows the erosion of the floor of the horizontal
segment of the facial canal (arrow). Erosion of lateral mastoid cortex
is also seen (asterisk)
42. Labyrinthine fistula is a
dreaded complication of
cholesteatoma. The most
commonly affected is the
lateral semi-circular canal
due to its close proximity to
the middle ear cavity.
Extensive disease can affect
cochlea and other semi-
circular canals also.
Axial CT image showing
erosion of the lateral wall of
the lateral semicircular canal
(arrow) with the formation of
labyrinthine fistula
43. Extensive bony destruction of the mastoid and ossicles can occur which may give
the appearance similar to postsurgical cases termed as automastoidectomy.
Spontaneous evacuation of cholesteatoma may be seen with this, termed as mural
cholesteatoma leaving behind no residual mass
Axial CT shows the right mastoid cavity filled with soft tissue and is seen to open
directly into the external auditory canal suggesting automastoidectomy (arrow)
44. Coronal CT image
showing erosion with focal
defects in tegmen tympani
(arrow).
45. In addition to the evaluation of complications of cholesteatoma, imaging
also helps in warning the surgeon of any variant anatomy that may
predispose to life-threatening consequences during surgery or may affect
surgical access to disease such as the following:
Dehiscent facial canal
High and dehiscent jugular bulb
Anteriorly lying sigmoid sinus
Low lying tegmen and dura
Specific patterns of pneumatization and aeration of mastoid
46. Conventional MRI shows cholesteatoma
as a soft-tissue mass but does not
differentiate this from other soft tissues.
It does not provide enough bony detail to
be useful on its own.
More recently, non-echoplanar DW-MRI
has been shown to be very reliable at
detecting cholesteatoma and
differentiating it from other soft tissues.
It has been shown to be of value in
detecting residual cholesteatoma and
reducing the necessity for second-look
surgery
47.
48. The aims of management of active squamous COM are to relieve the
patient’s symptoms and to minimize the risks of complications of the
disease.
Surgical removal is the only effective treatment for cholesteatoma.
When surgical treatment is considered appropriate, topical treatment for
granulations and associated mucosal disease while awaiting surgery may
lessen the otorrhoea and therefore be socially beneficial.
Unfit ptsCareful aural toilet with removal of squamous debris from the
retraction pocket and topical treatment at regular intervals
50. The aims of surgery for active squamous COM are:
eradication of disease
An epithelialized, self-cleaning ear
Hearing maintenance or improvement.
Categorized as :
open cavity (canal wall-down) mastoidectomy
closed cavity (canal wall-up) mastoidectomy
51.
52. The method of choice for removal
of cholesteatoma is Modified
Radical Mastoidectomy
anterior to posterior approach.
Also k/a Small cavity
mastoidectomy, or
atticoantrostomy
The cholesteatoma is identified in
the epitympanum or posterior
mesotympanum and followed
backwards.
53. Conservative method
Exenteration of disease process by removing posteriosuperior meatal
wall making middle ear, attic, aditus, antrum and cellular cavity
into a single chamber.
Added various suitable tympanoplasty surgeries
Accessory procedures like conchomeatoplasty of mastoid cavity
54. Traditional method was posterior to anterior approach.
The mastoid was opened behind the external auditory canal, the
cholesteatoma identified and followed forwards through the aditus into
the attic with removal of the posterior bony wall of the canal.
This usually resulted in a large cavity, much larger than is required to
control the disease.
Large cavities can be problematic : many continue to discharge and they
often do not self-clean.
57. Lowering facial ridge
does not require exposure
of the facial nerve. It is
best to leave 2 to 3 mm of
bone over the nerve to
maintain a middle ear
space.
58. Lowering the floor of
the middle ear to the
level of the facial ridge
(base of the ear canal).
59. Cartilage and fascia
reconstruction in a canal
wall down mastoidectomy
At last conchomeatoplasty
is done
60. In recurrent cases Following significant differences are noted:
High facial ridge
Sump in cavity below floor of external auditory canal
Perforation in tympanic membrane
Small external auditory meatus.
Can be reduced by good surgical technique and by partial obliteration of
cavities, either with cartilage or prosthetic materials.
61. The cavity must be rounded and smoothly contoured with no over-
hanging ridges and no facial ridge in order to allow migration of
epithelium.
The tympanic membrane should be repaired to close all
communication between the mastoid cavity and the mesotympanum
and Eustachian orifice.
The meatus should be an adequate size relative to the size of the
cavity, so a meatoplasty is almost always required.
62. The conchal cartilage removed from the meatus should be used to
reduce the size of the cavity.
Lower rates of recurrence of cholesteatoma (5–15%)
63. Combined approach tympanoplasty.
Exploration of mastoid cavity by removing outer cortical wall of
mastoid antrum.
Saucerization of medial wall of mastoid antrum with intact canal
wall.
Middle ear structures are not disturbed.
64.
65.
66. Intact canal wall technique advantages :
Middle ear air space is maintained
Normal appearance of EAC
For tympanoplasty procedure convenience
67. Incidence of recurrent and residual cholesteatoma is high (20–50%),
therefore second-look operations after 12–18 months are necessary
in most cases, and some cases require further procedures
subsequently.
Second look can often be avoided nowadays by the use of DW-MRI.
68.
69. Post-operative hearing results are better following canal wall-up
mastoidectomy.
Many surgeons, by doing canal wall-down surgery but partially
obliterating the cavity, achieve an outcome that is similar to canal
wall-up surgery.