Chronic suppurative otitis media (CSOM) is a long-standing middle ear infection characterized by ear discharge and tympanic membrane perforation, with two types: tubo-tympanic (safe) and attico-antral (unsafe). Clinical features include various ear discharges and hearing loss, and treatment options involve both medical management, such as antibiotics and aural toilet, and surgical interventions like myringoplasty and mastoid exploration. Complications can arise from CSOM, including both intratemporal and intracranial issues, necessitating thorough investigation and management.

3. Chronic Suppurative Otitis Media
By
Lt Col Saeed Ullah
ENT, Head and Neck
Surgeon.
CMH Quetta

4. Definition
It is long standing
infection of a part or
whole of the middle
ear cleft
characterized by ear
discharge and
permanent
perforation of
tympanic membrane

5. Types of CSOM
 Tubo-tympanic
– Safe type
– Mucosal disease
 Attico-antral
– Un safe
– Squamous disease

7. Tubotympanic disease

8. Pathology
 Localized to the middle ear
 Process of destruction
 Process of healing
 Virulence of organism
 Immunity of host

9. Pathology
 Perforation
– Central perforation
– Pars tensa
 Middle ear mucosa
 Ossicular chain
 Fibrosisi and adhesions
 tympanosclerosis

10. Microbiology
 Pseudomonas aeruginosa
 Proteus mirabilis
 Staphylococcus aureus
 Peptostrpptococcus
 Bacteroides fragilis
 Klebsiella pneumoniae, and diphtheroids

11. Clinical features
 Ear discharge
 Hearing loss

12. Discharge (Mucosal disease)
 Profuse
 Mucopurulent
 Odor less
 Continous

13. Hearing loss
 Baffle's effect
 Phase differential
 Upto 60 dB

14. Perforation
 Central perforation
– Pin point
– Large
– Subtotal
– Total
– Marginal

15. Investigations
 Clinical
 Tuning fork tests
 Audiometry
 Exam under Microscope
 Culture and sensitivity
 X-Ray Mastoids
 C T scan temporal bone

16. Treatment

17. General management
 Aural Toilet
– Dry mopping
– Suction clearance
 Systemic antibiotics to clear infection
– Ciprofloxacin
– levofloxacin
 Topical antibiotics
– Quinolones
– Gentimycin
– Polymaxins
 Topical steroids

18. Surgical treatment
 Myringoplasty
– Stenting of TM
– Underlay
– Overlay or onlay

19. Attico-antral disease

20. Pathology
 Cholesteatoma
– Congenital
– Acquired
– Secondary
 Osteitis
 Cholesterol granuloma

21. Cholesteatoma
 A three dimentional epithelial and connective
tissue mass usually in the form of a sac
with a lining of stratified squamous epitheliu
m, filled with desquamating debris frequently
containing cholesterol.

25. Cholesteatoma
 Congenital cell rest
 Retraction pocket
 Basal cell hyperplasia
 Epithelial invasion
 Metaplasia

26. Mechanism of destruction
 Enzymatic destruction
– Collagenase
– Phosphatase
– Proteolytic enzymes
 Osteitis

27. Clinical features
 Hearing loss
 Discharge

28. Discharge ( attico-antral disease)
 Scanty
 Intermittent
 Purulent
 Foul smelling

29. Features indicating complications
 Persistent headache
 Vertigo
 Facial weakness
 Fever, nausea, weakness
 Diplopia

30. Investigations
 Clinical
 Tuning fork tests
 Audiometry
 Exam under Microscope
 Culture and sensitivity
 X-Ray Mastoids
 C T scan temporal bone

31. Surgical management
 Mastoid exploration
– Canal wall up procedures
 Cortical mastoidectomy
 Combined approach
– Canal wall down procedures
 Radical mastoidectomy
 Modified radical mastoidectomy

32. Conservative management
 Aural toilet
 Local antibiotics
 Systemic antibiotics

33. Pathways for spread
 Direct bone erosion
 Venous thrombophlebitis
 Preformed pathways
– Congenital dehiscences
– Suture lines
– Previous skull fractures
– Surgical defects
– Oval and round windows

34. Complications
 Intratemporal
– Mastoiditid
– Mastoid abscess
– Lateral sinus thrombosis
– Labyrinthitis
– Petrositis
– Otitic hydrocephalus

35. Complications
 Intracranial complications
– Extra dural abscess
– Subdural abscess
– Brain abscess
– Meningitis
– Encephalitis

36. Thank you