Chronic suppurative otitis media (CSOM) is a long-standing ear infection characterized by ear discharge and permanent ear drum perforation. It is clinically divided into two main types - tubotympanic and atticoantral. Tubotympanic CSOM involves the lower middle ear and has a low risk of complications, while atticoantral CSOM involves the upper middle ear and carries a higher risk of complications like cholesteatoma due to bone erosion. Surgical treatment is the mainstay for atticoantral CSOM to remove disease while reconstructive surgery can help restore hearing.

1. Chronic Suppurative Otitis
Media
Gitanjali kumari
110201312

2. CSOM is a long standing
infection of a part or
whole of middle ear cleft
characterized byEar discharge
And a permanent
perforation

3. EPIDEMIOLOGY
Incidence is higher in developing
countries
Affects both sexes and all age
groups
Most important cause of hearing
impairment in rural population

4. TYPES
Clinically it is divided into two
types
1.Tubotympanic
2.Atticoantral

5. TUBOTYMPANIC
 It involves anteroinferior part of middle ear
cleft (eustachian tube, mesotympanum)
and is associated with a central perforation
 Safe/benign type
 No risk of serious complications

6. Atticoantarl
It involves posterosuperior part of the
cleft (attic ,antrum,mastoid)
Associated with an attic or marginal
perforation
It is often associated with bone eroding
process such as
cholesteatoma,granulations or osteitis
Risk of complications is high
Unsafe/dangerous type

7. property
Tubotympanic
Atticoantral
Discharge
Profuse,mucoid,
odourless
Scanty,purulent,
smelling
Perforation
Central
Marginal
Granulations
Uncommon
Common
Polyp
Pale
Red and fleshy
Cholesteato
ma
Absent
Present
Complicatio
ns
Rare
Common
Audiogram
Mild to moderate Conductive or mixed
conductive
deafness
deafness
foul

8. 1.TUBOTYMPANIC
1.AETIOLOGY
The disease starts in childhood and is common
in that age group
Sequela of acute otitis media usually
following exanthematous fever and leaving
behind a large central perforation
Ascending infections via eustachian tube
causes persistent and recurring otorrhoea
Allergy to ingestants (milk,egg) causes
persistent mucoid otorrhoea

9. 2.PATHOLOGICAL CHANGES
 Perforation of pars tensa-it is a central
perforation, size and position varies
 Middle ear mucosa-disease is quiescent/inactivenormal mucosa
disease active- oedematous and velvety mucosa
 Polyp-pale to pink
 Ossicular chain- intact , mobile but shows some
degree of necrosis( long process of incus)
 Tympanosclerosis-hyalinization and subsequent
calcification of subepithelial connective tissue..
Causes conductive deafness
 Fibrosis and adhesions- result of healing process
impair mobility of ossicular chain/block eustachian
tube

10. 3.BACTERIOLOGY
 Pus culture in both aerobic and anaerobic types of csom show
multiple organisms
Aerobes
Anaerobes
Pseudomonas
aeruginosa
Bacteroides fragilis
Proteus
Anaerobic streptococci
Escherichia coli
Staphylococcus aureus

11. 4.Alternative classification of Chronic otitis media
Mucosal disease-tubotympanic disease:
Squamous disease-atticoantral disease;

12. Tubotympanic
Atticoantral
Mucosal disease with no
evidence of invasion of
squamous epi.
Squamous disease of middle ear
Active-perforation of pars tensa Active-presence of
with inflammation of mucosa
cholesteatoma in posterosuperior
and mucopurulent discharge
part of pars tensa/in pars flaccida.
Erodes bone ,form granulation
tissue,has purulent offensive
discharge
Inactive- permanent
perforation of pars tensa but
middle ear mucosa isn’t
inflamed & there’s no
discharge.
Healed-tm is healed (by 2
layers)is atrophic,easily
retracted if –ve pressure in
middle ear
Inactive-retraction in pars
tensa/pars flaccida,no discharge

13. Clinical features
 Ear discharge-nonoffensive , mucoid/mucopurulent
,constant/intermittent.
Appears at the time of URT infection or on accidental entry
of
water into ear
 Hearing loss-conductive type (rarely exceeds 50dB)
 Perforation- always central ! May lie ant./post./inferior to
handle of malleus. Can be small/med./large
 Middle ear mucosa- seen when perforation is large.
normally-pale pink & moist
inflamed-red , edematous
occasionally polyp is seen

15. INVESTIGATIONS
Examination under microscope
Audiogram
Culture and sensitivity of ear
discharge
Mastoid xrays/ct scan temporal
bone

17. TREATMENT
 Aural toilet- dry mopping with absorbent cotton buds
suction clearance under microscope
irrigation with sterile normal saline
 Ear drops- antibiotic ear drops containing
neomycin,polymyxin,or gentamycin are used).Often
combined with steroids
 Systemic antibiotics- in case of acute exacerbation
 Precautions- keep water out of ear during bathing.(rubber
inserts) hard nose blowing should be avoided
 Surgical treatment
 Reconstructive surgery

18. 2.Atticoantral
1.Aetiology
It is seen in sclerotic mastoid
 cholesteatoma

19. 2.Pathology
It is associated with the following
pathological processes
Cholesteatoma-”skin in wrong place”
It is presence of keratinized squamous
epithelium in the middle ear or mastoid
Osteitis and granulation tissue-involves
outer attic wall and posteriosuperior
margin of tympanic ring
Ossicular necrosis- hearing loss
Cholesterol granuloma- mass of
granulation tissue with foreign body giant
cells surrounding the cholesterol crystals

20. 3.Symptoms
Ear discharge- scanty but foul
smelling due to bone destruction,
purulent
Hearing loss- hearing is normal when
ossicular chains are intact or when
cholesteatoma (cholesteatoma
hearer) conductive/mixed deafness
Bleeding – from granulation/polyp

21. 4.Signs
 Perforation- attic/posterosuperior marginal type
 Retraction pocket – an invagination of tympanic
membrane is seen in attic/posterosuperior area of
pars tensa.
Stages:a) Stage 1 – tympanic membrane is retracted but
doesn’t contact incus (MILD RETARCTION)
b) STAGE 2- tympanic memb. Is retracted deep & it
contacts the incus; middle ear mucosa isn’t
affected.
c) Stage3 – middle ear atelectasis : middle ear comes
to lie on promontory & ossicles
d) Stage 4- adhesive otitis medi : TM is very thin; wraps
promontory & ossicles; no middle ear space;
mucosal lining of middle ear is absent; retraction
pockets formed; erosion of long process of incus
stapes superstructure

22. 3. Cholesteatoma – pearly white flakes of
cholesteatoma can be sucked from retraction
pockets

23. 5.INVESTIGATIONS
Examination under microscope- imp. Part
of clinical assessment of any type of
CSOM
Tuning fork test and audiogram
Xray mastoids/CT scan of temporal bone
– for extent of bone destruction and
degree of mastoid pneumatization
Culture and sensitivity of ear discharge

24. 6.Features indicating complications
in CSOM
 Pain- uncommon in uncomplicated CSOM.
Persence of pain indicates extardural,perisinis
or brain abscess
 Vertigo-indicates erosion of lateral
semicircular canal , may progress to
labyrinthis/meningitis
 Persistent headache-suggestive of
intracranial complications
 Facial weakness- erosion of facial canal

25.  A listless child refusing to take feeds and
easily going to sleep (extradural abscess)
 Fever ,nausea & vomiting- intacranial
infection
 Irritability and neck rigidity-meningitis
 Diplopia (Gradenigo syndrome)petrositis
 Ataxia (labyrinthitis or cerebellar abscess)
 Abscess around ear (mastoiditis)

26. 7.Treatment
I. Surgical- mainstay treatment
(!)primary aim- remove the disease & render the ear safe
(!!)2nd aim- to preserve/reconstruct hearing
Two types of surgical are done to deal with cholesteatoma:
1. Canal wall down procedure- they leave the mastoid cavity
open in external auditory canal so that the diseased area is
fully exteriorized.
*atticotomy
*modified radical mastoidectomy
*radical mastoidectomy
2. Canal wall up procedures- disease is removed by
combined approach through mastoid and meatus but
retaining the posterior bony meatal wall intact thus avoiding
an open mastoid cavity

28. II. Reconstructive surgery
hearing can be restored by myringoplasty or
tympanoplasty
III. Conservative treatment- done when
cholesteatoma is small and easily accessible to
suction clearance under operating
microscope