Chronic otitis media and squamosal disease involve retraction pockets in the tympanic membrane that can develop into cholesteatomas. Cholesteatomas are benign keratinizing cysts that cause bone destruction through various mechanisms including osteoclastic bone resorption induced by cytokines and enzymes. Management depends on whether the disease is inactive with stable retraction pockets or active with a cholesteatoma. For inactive disease, follow up or suction may suffice while an intact canal wall mastoidectomy or canal wall down approach is used for active cholesteatomas to fully remove the disease while preserving hearing if possible.

1. CHRONIC OTITIS MEDIA
SQUAMOSAL DISEASE
Presenter: Dr Avinav Gupta
Moderator: Dr Karandeep
Consultant: Dr Achal Gulati

2. Pathophysiology
Eustachian
tube
dysfunction
Negative
pressure
Retraction
pocket
Self
cleansing
Non self
cleansing
Retained
keratin
debri
• Inhibitor of DNA-binding (Id1)
• Cell immortalization, induces up regulation of NF-κB/cyclin D1/ keratin 10 in
the keratinocytes
• Proliferation: upregulation of p53 tumour suppressor gene, c-jun and
c-myc protein

3. • Multinucleated osteolasts
• Lipopolysaccharides
• Preosteoclastic cells, primed with receptor activator NF-kB (RANKL)
• TGF-β (stroma) [chronic wound healing process]
• TLRs lead to the mobilization of cytokines, chemokines and
interferons as well as proteases, defensins, collectins, lysozyme and
lactoferrin.

4. • TLRs can induce NF-κB as well as TNF-α
• TGF-α upregulate matrix metalloproteinase-9 (MMP-9) which cause
bone distruction
• Epidermal growth factor, TNFα, IL-1a, IL-1b, IL-6, INF B, and PTHrP.
• Nitric oxide type II, has been shown to enhance osteoclastic
activation
• Measure of proliferation: Ki67

5. Types of Cholesteatoma
• Congenital
• Primary Acquired
• Retraction pocket (Wittmaack)
• Basal cell hyperplasia (Ruedi)
• Squamous Metaplasia (Sade)

6. • Secondary Acquired
• Squamous Metaplasia
• Epithelial migration (Habermann)
• Tertiary Acquired: Post traumatic, post tympanoplasty

7. Congenital Cholesteatoma
• Persistence of congenital rest cells in middle ear, petrous apex,
cerebello-pontine angle.
• Diagnosis:
• White mass behind intact Tympanic membrane
• Normal pars tensa and pars flacida
• No prior history of otorrhea or any ontological procedure

8. Why is pediatric cholesteatoma more
aggressive??
• More aerated mastoid
• Greater risk of otitis media and associated inflammatory process,
accelerate and stimulate cholesteatoma growth
• Perimatrix of pediatric cholesteatomas rich in mononuclear
inflammatory elements
• Higher levels of Ki-67 and matrix metalloproteinases

9. Inactive squamous epithelial Chronic otitis
media
• Retraction pocket
• Epidermization

10. Active squamous epithelial Chronic Otitis
Media (Acquired Cholesteatoma)
• Cholesteatoma is a benign keratinizing epithelial lined cystic
structure found in the middle ear and mastoid
• Destruction of the local structures – ossicular chain and otic
capsule, thereby leading to complications
• Johannes Muller
• 2.3 times
• Apoptosis rate

11. Cause of bone distruction
• Hyperimic decalcification
• Osteoclastic bone resorption:
• Acid phosphatase, collagenase, acid protease, proteolytic
enzymes, leukotrienes, cytokeratin
• Pressure necrosis
• Bacterial toxins

12. Role of biofilm
• Sessile community of microbes, that are irreversibly
attached to a surface or to each other, and embedded in
a matrix of extracellular polymeric substance produced
by the organisms.
• Exhibits altered phenotype with respect to growth rate
and gene transcription
• Epithelial cell signaling, such as induction of epidermal
growth factors and upregulation of cytokines,
specifically IL-6
• 60%
• Squamous disease 82% vs 42% Mucosal disease

13. Spread of Cholesteatoma
•Posterior epitympanic
cholesteatoma passes
through superior
incudal space to
involve aditus and
antrum

14. • Posterior mesotympanic
cholesteatoma invades the
sinus tympani and facial
recess
• Anterior epitympanic
cholesteatoma can involve
the geniculate ganglion of
facial nerve

15. History
• Hearing loss (83%)
• Otorrhoea (56%)
• Otalgia (39%)
• Childhood ear disease (43%)

16. Otoscopy
• Inactive squamous retractions:

22. • Vestibular assessment
• Imaging
• High Resolution Computed Tomography
• Diffusion-weighted magnetic resonance imaging
• Endoscopy
• Bacteriology

24. Inactive Squamous chronic otitis media
• Retraction of the pars flacida
• Fundus visible?
• Self cleansing?
• Retraction of pars tensa
• Self cleansing?
• Incudostapedial joint? Errosion?
• Boney External auditory cannal erosion?
• Other factors

25. Progression of retraction pockets
• Reach a big size
• Loss of elasticity and rigidity of tympanic membrane
• Cleft palate (20%)
• Turner syndrome (50%)
• Cystic fibrosis

26. Management
• Management of nasal disease
• Aural toilet
• Surgical treatments
• Managemnet of tympanic membrane
• Excision, no graft
• Excision, myringoplasty
• Excision, myringoplasty, cortical mastoidectomy
• Ventilatory tubes

27. Recommendation for management for an
inactive retraction
In Adult patients:
• Stable
• No significant hearing loss + retraction pocket is selfcleansing,
then follow-up
• Retraction pocket is not self-cleansing, then regular microscopic
suction clearance
• Conductive hearing impairment
• Wishes of the patient, the hearing in the other ear and the expertise of the surgeon
• Myringolpasty + Ossiculoplasty

28. In a child undetr 12 years
• Unstable
• Hearing normal, no intervention
• Treat otitis media with effusion
• Progressive retraction: surgery

29. Active Squamosal Chronic otitis
media(Cholesteatoma)
• Pneumatisation
• Progression toward healing
• Automastoidectomy
• No longer produce or accumulate squamous epithelium
• Progression of disease
• Hearing in Active Squamous disease
• Presentation

30. Examination:

31. Imaging
• High Resolution Computed Tomography
• Scutum
• Ossicular erosion
• Semicircular cannal dehiscence
• Facial nerve dehiscence (66-88%)
• Non echoplanar diffusion weighted magnetic resonance imaging

32. Management
• Aim:
• Eradication of disease
• An epithelialized, self-cleaning ear
• Hearing maintenance or improvement.

33. Cannal wall down mastoidectomy
• Modified radical mastoidectomy using the posterior to anterior
approach.
• Large cavity 1.4 cm3 vs 2.4 cm3
• high facial ridge
• sump in cavity below floor of external auditory canal
• perforation in tympanic membrane
• small external auditory meatus.
• Recurrence (5-15%)

34. Cannal wall up mastoidectomy
• Combined approach tympanoplasty
• Recurrence (20-50 %)
• Second look procedure can be avoided
• Both procedures have similar results

35. • Pars tensa cholesteatoma
• Confines to middle ear
• Ossiculoplasty
• Theoretical risk that use of incus could cause recurrence
• Complication of surgery
• 1% facial
• 2% dead ear

36. ROUTES OF SPREAD TO CRANIAL CAVITY
• Direct erosion of osteitic bone by the inflammatory process
• Infected thrombophlebitis of the emissary veins traversing the bone
and dura.
• Fractures and surgical defects.
• Oval and round windows, the internal auditory meatus and cochlear
aqueduct.

37. Definitions and Classifications of
Mastoidectomy
• " Approach" method of access to the middle ear through the soft tissues;
“Route" method of access to the middle ear through the bone.
• Atticotomy
• Denotes opening of the attic, performed through the transmeatal route. The
lateral wall of the attic is drilled away, and the lateral attic is exposed.
• Atticoantrotomy
• extension of the atticotomy in a posterior direction through the transmeatal
route. The lateral attic and aditus walls are removed, and the antrum is entered.

38. • Bondy's Operation
• An atticoantrotomy is described as Bondy's operation if the tympanic cavity is
not entered. The lateral part of the cholesteatoma matrix is removed and the
medial part is left in place, marsupializing the cholesteatoma
• Cortical Mastoidectomy
• The cortical mastoidectomy (Schwartze 1873) is a transcortical opening of the
mastoid cells and the antrum.
• Conservative Radical Operation
• Denoting a mastoidectomy with opening of the antrum and attic, removal of
the posterosuperior bony canal wall, either drilling away of the bony bridge
and lowering of the facial ridge or preserving the thinned-down bony bridge

39. • Classical Radical Operation
• Structures within the tympanic cavity are removed
• Closure of the eustachian tube
• Canal wall down mastoidectomy techniques are: Atticotomy, Bondy's
operation (1910), atticoantrotomy, classical radical operation, retrograde
mastoidectomy
• Canal wall-up techniques are simple mastoidectomy, cortical
mastoidectomy, classic intact canal wall mastoidectomy, combined-
approach tympanoplasty, or modifications of these canal wall-up
techniques.

40. Recent Advances
• Transcannal endoscopic ear surgeries
(TEES)
• Trans Mastoid endoscopic ear
surgeries (TMEES)
• Exoscopes or extracorporeal video
microscope
• Diffusion Weighted Magnetic
Resonance Imaging

42. Thank you