This document summarizes chronic suppurative otitis media (CSOM), which is a chronic inflammation of the middle ear cleft caused by bacterial infection. It discusses the two types of CSOM - tubotympanic and atticoantral - and their respective characteristics and complications. Tubotympanic CSOM mainly affects the middle ear mucosa and has fewer complications, while atticoantral CSOM affects deeper structures in the ear and is associated with more severe complications like cholesteatoma formation. The document outlines treatments for CSOM including conservative management and surgical procedures like tympanoplasty and mastoidectomy. Potential complications of suppurative otitis media affecting

1. Chronic suppurative
otitis media
DR AHLAM ALZUWAY

2. Chronic suppurative otitis media
 This is a chronic inflammation of the mucosal lining of the
middle ear cleft by pyogenic organisms.
 Its characterized by irreversible pathological changes, intermittent or
persistent aural discharge and a perforation in the T.M.
 Types:
A .Tubotympanic (safe) type (affects the mucosa of middle ear cleft, (has less
complications)
B. Atticoantral (unsafe) typeaffects (affects attic, antrum and mastoid, the
linning mucosa changes into sequamous epithelium and its associated with
formation of polypi and granulations, (has more complications)

4. Tubotympanic CSOM
 Aetiology
It occurs usually secondary to A.S.O.M. due to:
1. Inadequate treatment: inadequate antibiotic therapy, or inadequate
drainage of discharge (small or high perforation).
2. High virulence of the organism.
3. Repeated middle ear infection through the Eustachian tube or through a
persistent T.M. perforation.
4. Low resistance of the patient.

5.  clinical picture
Symptoms
1. Persistent or intermittent aural discharge.
2. Deafness.
3. Tinnitus.
Signs
1. Aural discharge: It is mucopurulent or mucoid, odourless, profuse in
amount due to mastoid reservoir. It may be pulsating in cases of acute
exacerbations.
2. T.M. perforation: The perforation is usually central in the pars tensa, and
there is a rim of the T.M. all around the perforation.

6. 3 .Middle ear mucosa:
if visible through the perforation may look:
 Odematous, congested and velvety pink during active infection.
 Thin pale during the inactive phase.
 Granulations are common, these are sessile reddish projections and
bleed easily on touch. They are due to chronic irritation of the mucosa.
 Aural polyp: It is pedunculated odematous mucosa passing through
the T.M. perforation and appearing in the external canal.

7. Tubotympanic otitis media
4 Tunning fork tests: Variable degree of conductive hearing loss,
due to:
 T.M. perforation.
 Impaired ossicular chain mobility due to discharge and granulations.
N.B. The ossicular chain is usually intact, but it may be eroded and
the commonest is the long process of incus.

8. Tubotympanic otits media
 Investigation
1. Audiogram (PTA): Variable degrees of conductive hearing loss.
2. Plain X-ray of mastoid; to detect the state of the mastoid and the
position of the lateral sinus and dural plates.
3. Culture and sensitivity of the discharge to detect the infecting organism
and select the best antibiotic.

9.  Treatment
A. Conservative treatment, The aim is to obtain a safe dry ear to allow
spontaneous healing of the perforation or as a preparation before surgery.
1 Systemic antibiotics:
 Best according to culture and sensitivity.
 Avoid ototoxic drugs e.g. aminoglycosides.
2 Topical antibiotic ear drops ,but avoid ototoxic ones(e.g. polymixin and
neomycin). The safest are tetracyclines and chloramphenicol. They are better
combined with steroids.
3 Aural toilet: Repeated local cleaning and removal of discharge either by;
 Suction with a sterile fine cannula or dry mopping by sterile cotton tipped
probe especially in children,Then disinfection after aural toilet by hydrogen
peroxide or alcohol 70% with a cotton tipped probe

10. 4. Avoidance of reinfection:
 Avoid forcible blowing of the nose during rhinitis.
 Avoid wetting the ear during washing the head or bathing.
 Control upper respiratory tract infection e.g. sinusitis, tonsillitis,
Adenoidectomy in cases of enlarged adenoids.
5. Aural polypectomy:
 Excision of an aural polyp from the external auditory canal if
present to improve drainage of discharge, facilitate aural toilet and to
facilitate application of topical ear drops. Don't pull on the polyp
(avulsion is forbidden) as it may be attached to ossicles especially
the stapes, labryinthin fistula or to an exposed facial nerve

11. B. Surgical treatment
 Tympanoplasty with or without cortical mastoidectomy Aim:
1. Eradication of irreversible changes in the middle ear mucosa
and to clear it from infection.
2. Reconstruction of the conductive hearing mechanism
(ossicular reconstruction).
 Cortical mastoidectomy is combined with tympanic membrane
grafting, if there is persistent aural discharge (mastoid reservoir)
to eradicate the mostoid pathology.
The grafting material commonly used to repair the defect in the
T.M. is temporalis fascia

12. Atticoantral CSOM, cholesteatoma
 A cholesteatoma is a sac lined by keratinizing stratified squamous
epithelium (matrix) and is filled with concentric sheets of white-yellow
keratin flakes in which the cholesterol crystals may be embedded. It has an
onion like appearance on cut section.
 Types:
A. Congenital cholesteatoma.
B. Acquired cholesteatoma:
1. Primary acquired cholesteatoma.
2. Secondary acquired cholesteatoma.

13. cholesteatoma
A. Congenital cholesteatoma (Rare)
 This is a cholesteatoma (epithelial cyst) which develops from embryonic
extradermal cell rests.
 It may occur in any cranial bone, but the commonest is in the temporal bone
in the following sites:
• Cerebellopontine angle.
• Jugular foramen.
• Petrous apex.
• Middle ear.
 It is sterile so long as it is not connected with the external canal (i.e.
cholesteatoma behind an intact T.M.), and becomes infected when it finds its
way outside.

15. B. Acquired Cholesteatoma
Migration of keratinizing stratified squamous epithelium from the surface of the
T.M. and adjoining part of EAC into the middle ear due to:
1. Primary acquired cholesteatoma (No previous history of O.M.)
• Retraction pocket theory (Attic retraction): Most accepted,
prolonged intratympanic negative pressure (due to prolonged E.T.,
obstruction or intratympanic adhesions) causes invagination of part
of T.M. into the middle ear with formation of retracdon pocket which
becomes filled with keratin and debris and subsequent formation of
cholesteatoma.
 Retraction pocket occurs in two sites:
a. Pars flaccida (lacks middle fibrous layer i.e. weak).
b. Posterosuperior quadrant of pars tensa. Here fibrous annulus is
deficient.

16. • Migration theory: the direction of migration of canal epithelium is
reversed being inwards instead of being outwards.
• Metaplasia theory: metaplasia of flat squamous epithelium of the
attic into keratinizing stratified squamous epithelium
2. Secondary acquired cholesteatoma (previous history of O.M)
• Migration therapy: Direct migration of stratified squamous
epithelium from surface of T.M. into the middle ear through a
marginal perforation.
• Metaplasia theory: due to chronic irritation of the middle ear
mucosa by chronic infection.o keratinizing stratified squamous epithelium.

18.  Sequelae of cholesteatoma
I. expansion (due to) Repeated infection and accumulation of keratin.
II. bone erosion is due to:
1. Osteolytic enzymes and collagenase
2. Secondary bacterial infection, so, the cholesteatoma becomes
activated to secrete deminiralizing and osteolytic enzymes.
3. Osteoclastic activity.
4. Pressure necrosis by the cholesteatoma sac leading to bone
resorption due to pressure ischaemia (doubtful).

19.  Active expansion of cholesteatoma is accompanied by:
1. Mastoid sclerosis: bone osteoporosis of mastoid is accompanied
by deposition of new sclerotic bone limiting space available for
expansion of cholesteatoma.
2. Destruction of the ossicular chain especially, long process of
incus, then whole incus, then head of malleus and may be the
whole ossicular chain.
3. If the disease is allowed to run its course, the whole mastoid and
middle ear become replaced by cholesteatoma " natural radical
cavity.
4. Complications of cholesteatoma .

21.  Clinical picture
Symptoms
1. Deafness.
2. Aural discharge and may be bleeding per ear due to
accompanied granulations except in the congenital type where
the drum is intact.
3. Tinnitus.
4. Lower motor neuron facial paralysis may be the early presenting
symptom in the congenital type.
5. Symptoms of complications if they arise.

23. Signs
1. Aural discharge: occurs due to secondary infection of the
cholesteatoma. It is purulent (never mucoid or mucopurulent),and
may be serosanguinous due to formed granulations and polypi. It is
scanty and has a foul odour(characteristic) which is due to bone
necrosis (osteitis) and anerobic infection. It may contain cheesy
white epithelial flakes (debris).
2. T.M. Perforation: It is a marginal perforation(destruction of the
bony annulus), in the posterosuperior quadrant of pars tensa or attic
perforation.
3. A retraction pocket may be seen posterosuperiorly without
perforation in the T.M.

24. 4. Cholesteatoma itself may be seen as pearly white sheets or cheesy
white masses of keratin.
5. Granulations are frequent and appear projections that bleed easily
on touch.
6. Signs of complications when they arise.
7. Tunning fork tests:
• Variable degrees of conductive hearing loss, but may be mixed
conductive and sensorineural hearing loss if the inner ear is
invaded.
• Sometimes, there is normal or mild conductive hearing loss,
and this occurs with early retraction pocket or when the
cholesteatoma itself" Bridges" the gap in the ossicular chain.

25.  Investigation
1. Audiogram (PTA): Variable degrees of conductive or mixed
hearing loss.
2. Plain X-ray mastoid:
• The cholesteatoma appears as an irregular area surrounded by
sclerosed bone.
• Bone erosion.
• Level of the dural and lateral sinus plates.
3. CT scan of petrous bone: to detect the cholesteatoma mass, bone
erosion and condition of the ossicular chain. It should always be
done if complication is suspected.
4. Culture and sensitivity of discharge

27. Treatment (Surgical)
 The main line of treatment is surgery. Two techniques are used to eradicate the
cholesteatoma.
A. Open (canal wall down) technique
 This entails removal of all or apart of the posterosuperior
bony meatal wall and includes:
1. Atticotomy: in limited attic cholesteatoma.
2. Modified radical mastoidectomy (Bondy operation): in limited
cholesteatoma with good hearing.
3. Radical mastoidectomy: this is the most common procedure performed.
- Indications of radical mastoidectomy
a. extensive cholesteatoma.
b. Severe sensorineural hearing loss.
c. Presence of complication.

28. • It entails lowering of the facial ridge down to the level of lat. S.C.C.
and removal of the malleus and incus.
• Meatoplasty (widening of the external ear canal) should be done
after radical mastoidectomy for adequate drainage of discharge.
• Closure of the tympanic opening of the Eustachian tube is rarely
done nowadays as it interferes with reconstruction later on.
 Problems of a radical cavity:
a. Persistent otorrhea due to failure of the cavity to heal.
b. The labyrinth is exposed and is susceptible to caloric
stimulation(vertigo).
c. Wax and epithelial debris should be removed frequently.

29. B. Closed (Canal wall up) technique
• Combined approach tympanoplasty is the operation done. It
retains the normal anatomical contours as the posterior bony
meatal wall and the annulus, while the facial recess is opened
and removal of the cholesteatoma is managed through it.
• It is done in selected cases with localized atticoantral disease and
in children.
• A second look operation is mandatory after 6 months for detection
of residual or recurrent cholesteatoma.

30. Reconstruction of the radical cavity:
 may be needed including
reconstruction of hearing after being sure of complete eradication
of the cholesteatoma for a year or more later on.
Uses of endoscopy in the treatment of cholesteatoma
 A 1.9 mm endoscope is recently introduced in the treatment
of cholesteatoma. It is used to detect residual or recurrent disease
6 months after performing the closed technique.
 It is introduced in the cavity through a small postauricular incision
under local anesthesia and can be done in an outpatient clinic.

31. Complications of suppurative otitis
media
 Intratemporal
1.Persistent tympanic membrane perforation
2. Mastoiditis
a. Acute coalescent mastoiditis
b. Masked (latent) mastoiditis
3 .Acute petrositis
4 .Facial paralysis
5 .Labyrinthine fistula
6 .Labyrinthitis
a. Labyrinthine fistula
b. Serous labyrinthitis
c. Suppurative labyrinthitis

32. Extratemporal
1. Postauricular abscess
2. Zygomatic abscess
3. Bezold’s abscess
4. Meatal abscess (Luc’s abscess)
5. Behind the mastoid (Citelli’s Abscess)
6. Parapharyngeal and retropharyngeal abscesses

33. Intracranial
1. Extradural (epidural) abscess
a. Middle cranial fossa
b. Posterior cranial fossa
2. Subdural empyema
3. Meningitis
4. Brain abscess
a. Temporal lobe of cerebrum
b. Cerebellum
5. Lateral sinus thrombophlebitis
6. Cerebrospinal fluid otorrhea
7. Otitic hydrocephalus

34. THANKS ☺