Chronic suppurative otitis media (CSOM) is a long-standing inflammation of the middle ear that causes intermittent or continuous ear discharge and hearing loss. It can be classified as tubotympanic or atticoantral depending on the area of involvement. Atticoantral CSOM poses higher risks due to complications like cholesteatoma that can destroy local bones. Treatment involves surgery like cortical mastoidectomy for drainage or radical/modified radical mastoidectomy to fully remove the disease.

1. CHRONIC SUPPURATIVE OTITIS
MEDIA (CSOM)
Department of Otorhinolaryngology
AIIMS, Jodhpur

2. • CSOM is a long standing inflammation of the
mucoperiosteum of the middle ear cleft
(eustachian tube, tympanic cavity, attic,
antrum and mastoid air cell system)
• May be Associated with intermittent or
continuous mucopurulent ear discharge,
hearing impairment and tympanic membrane
perforation

3. • In 400 B.C, Hippocrates, recognized that a
painful, discharging ear with fever was a life
threatening condition and represented classical
symptoms of otitis media.
• The Roman physician Celsus mentioned that,
“Inflammation and pain of the ear lead
sometimes to insanity and death”.
• But it was Morgagni who first recognized that the
ear infection came first and brain abscess was
secondary.

4. • In 16th century, surgery for mastoid infection
was first proposed by Ambrose Pare on young
King Charles-II of France, who was dying with
a high fever and discharging ear
• Sir William Wilde in 1853 introduced post
aural incision for suppuration of the ear with
post aural abscess.

5. • The first scholarly treatise on mastoid surgery for
suppurative disease was by Schwartz in 1873. The
procedure he described was a cortical mastoidectomy
with limited exenteration of mastoid air cells for acute
and coalescent mastoiditis.
• Later on, it became evident that creating an open
cavity was necessary for these diseases, and in 1890
Zaufal described removing the superior and posterior
canal wall, tympanic membrane, and the ossicular
chain, a procedure now known as the radical
mastoidectomy

6. • Radical mastoidectomy procedure was modified by
Bondy, who recognized that disease limited to the pars
flaccida could simply be exteriorized, leaving the
uninvolved middle ear alone.
• Hearing preservation and restoration gained further
attention after Lempert introduced the fenestration
operation in 1938.
• During the next decade, Jansen, Sheehy, and others
extended these principles of restoring function and
maintaining normal anatomy with the introduction of
the intact canal wall mastoidectomy with facial recess
approach.

7. • The WHO definition requires only two weeks
of otorrhoea for classifying a case as CSOM
but Otolaryngologists tend to adopt a longer
duration e.g. more than three months of
active disease

8. • Histological degeneration of tympanic
membrane occurs in the outer and inner
fibrous layers of the lamina propria and in the
submucosal layer
• These changes may reduce the elastic
properties of the tympanic membrane,
making it more susceptible to chronic
perforation or retraction

9. Epidemiology:
• In India, prevalence rate is 7.8% which is very
high. In Britain, 0.9% of children & 0.5% of
adults have CSOM with no difference between
male and females.
• Worldwide, there are between 65-330 million
sufferers, of whom 60% receive significant
hearing loss. This burden falls
disproportionately on children in developing
countries

10. Risk Factors
• Multiple episodes of acute otitis media
• Frequent upper respiratory infections, nasal
diseases
• Poor living conditions
• Attending congested Day Care centres
• Bottle feeding
• Inadequate antibiotic treatment
• Family history of Otitis Media

11. Types
Tubotympanic: safe or benign type, involving the
anteroinferior part of middle ear cleft and is
associated with central perforation. No risk of
complications
Atticoantral: unsafe or dangerous type due to risk
of its complications, involving posterosuperior
part of middle ear cleft namely the attic, antrum
and mastoid and is associated with an attic or
marginal perforation. Associated with
complications

12. Classification of COM
• Healed COM : local or generalized opacification of
the pars tensa without perforation or retraction.
• Inactive (mucosal) COM : permanent perforation
of the pars tensa but the middle ear mucosa may
not be inflamed.
• Inactive (squamous) COM : retraction of the pars
flaccida or pars tensa (usually postero-superior)
which has the potential to become active with
retained debris.

13. • Active (mucosal) type : permanent defect of
the pars tensa with an inflamed middle ear
mucosa which produces mucopus that may
discharge
• Active (squamous) COM : retraction of the
pars flaccida or tensa that has retained
squamous epithelaial debris and is associated
with inflammation and the production of pus,
often from the adjacent mucosa

14. TUBO TYMPANIC C.S.O.M
• Deafness
• Discharge
• Central perforation

15. Types
• Active Tubo Tympanic C.S.O.M.
• Inactive Tubo Tympanic C.S.O.M.

16. • Some cases of “safe” CSOM, ear remains dry
and inactive after recovery from acute
infection. Subsequently there is persistence of
perforation whose margins are covered with
healed epithelium associated with or without
ossicular discontinuity, but the mucosa heals
and there is no further discharge. Such cases
are labeled as “permanent perforation
syndrome” or “Lillie type 1 disease”

17. Diagnosis
• History
Long standing, unilateral, bilateral, painless
otorrhoea, deafness
• Discharge intermittent, mucoid,
mucopurulent,
• Non odorous
• Follow U.R.T.I. and entry of water.

18. Examination
• Main basis to assess activity , type , extent
• Inspection , otoscopy, e.u.m.
• Mucoid
• Perforation , central
• Pale mucosa
• Rarely polyp
• Pus for cs

19. Audiological Tests
• Voice test
• Tuning fork test Rinne, Webers , A.B.C.
• Pure tone audiogram

21. Radiology

23. Medical Management
• Aural toilet
a. Cotton buds
b. Suction and cleaning
• Antibiotics
a. Topical antibiotics
b. Systemic antibiotics

24. Surgical Treatment
• Precipitating disease
a. Adenoid
b. DNS
c. Nasal polyps
• Aural polypectomy
• Functional reconstruction tympanoplasty

25. ATTICOANTRAL DISEASE
• Chronic pyogenic infection of middle ear cleft
with cholesteatoma & granulations in attic or
postero-superior quadrant

26. CHOLESTEATOMA
• Is a three dimensional epidermal and connective
tissue structure.
• Usually in the form of a sac and frequently
conforming to the architecture of the various
spaces of the middle ear, attic, and mastoid.
• Having the capacity for progressive and
independent growth at the expense of underlying
bone, displacing or replacing the middle ear
mucosa, and tendency to reoccur after removal

27. • Cholesteatoma was coined by Johannes Muller in 1838.
• Virchow, in 1855, considered cholesteatoma to be a tumor
arising from the metaplasia of mesenchymal cells to
epidermal cells, growing then as tumoral cells.
• Politzer, in 1869, assumed that cholesteatoma was a
glandular neoplasm of middle ear mucosa.
• Bezold and Habermann, in 1889, considered
cholesteatoma to be the result of migration of the external
ear canal epidermis into the tympanic cavity via a marginal
perforation after acute or chronic otitis.

28. Clinical features
• Scanty, foul smelling, some times blood
stained ear discharge
• Conductive or mixed HL
• Earache
• Polyp, granulations or cholesteatoma flakes
• TM perforation (attic or marginal)
• TM retraction

29. Complications
Intra temporal complications:
• In Middle ear: Facial nerve paralysis, ossicular lesion,
perforation of tympanic membrane.
• In Mastoid: Petrositis, reduced pneumatisation,
coalescent mastoiditis.
• In Inner Ear: Labyrinthitis, sensory neural hearing loss.
Extra Temporal complications:
• Intracranial complications: Extradural abscess, subdural
abscess, meningitis, lateral sinus thrombophlebitis.
• Extracranial complications: Bezolds abscess, zygomatic
abscess, post auricular abscess.

30. Mastoid Surgeries
Cortical mastoidectomy: simple or complete mastoidectomy
or Schwartz operation, is complete exenteration of all
accessible mastoid air cells and converting them in to a
single cavity. Posterior meatal wall is left intact and middle
ear structures are not disturbed.
Indications:
• Acute coalescent mastoiditis, Masked or latent mastoiditis
• Incompletely resolved acute otitis media with reservoir sign
• Decompression of facial nerve
• Chronic suppurative otitis media not responding to medical
management
• As a part of other surgeries for approach through mastoid
region

31. Complications:
• Injury to facial nerve
• Dislocation of incus
• Injury to horizontal semicircular canal
• Injury to sigmoid sinus with profuse bleeding
• Injury to dura of middle cranial fossa
• Postoperative wound infection

32. • Radical mastoidectomy: to eradicate disease
from the middle ear and mastoid without any
attempt to reconstruct hearing. Posterior meatal
wall is removed and the entire area of middle ear,
attic, antrum and mastoid converted in to a single
cavity. All remnants of tympanic membrane,
ossicles except stapes foot plate and
mucoperiosteal lining are removed. Eustachian
tube is obliterated. Aim of this operation is to
permenantly exteriorize the diseased area.

33. Indications:
• When all cholesteatoma cannot be safely removed or
when it invades eustachian tube, round window niche,
perilabyrinthine or hypotympanic cells.
• Promontory cochlear fistula caused by cholesteatoma.
• Chronic perilabyrinthine osteitis or cholesteatoma that
cannot be removed and must be cleaned or inspected
periodically.
• Resection of temporal bone neoplasms with periodic
monitoring.

34. Complications:
• Facial paralysis
• Perichondritis of pinna
• Injury to dura or sigmoid sinus
• Labyrinthitis
• Severe conductive deafness

35. • Modified radical mastoidectomy: modification
of the radical mastoidectomy where as much
of the hearing mechanism as possible is
preserved.
• The disease process which is often localized
to the attic and antrum is removed and the
whole area fully exteriorised in to the meatus
by removal of posterior meatal and lateral
attic walls

36. Indications:
• Cholesteatoma confined to the attic and
antrum
• Disease in only hearing ear
• CSOM with severe complications
• Unconstructable posterior canal wall
• Localised chronic otitis media