Otitis media

1. Chronic otitis media
Chunfu Dai M.D & Ph. D
Otolaryngology Department
Eye Ear Nose and Throat Hospital
Fudan University

2. Definition
 COM: unresolved inflammatory process of
the middle ear and mastoid associated
with TM perforation, otorrhea and hearing
loss.

3. Etiology
 Unresolved middle ear infection.
1. Uncomplicated inflammatory process of the middle
ear may evolve over time to produce persistent
effusion and irreversible mucosal change
2. Fluid contains enzymes to alter the mucosal lining
of the middle ear, it results in collapse or chronic
perforation
3. Obstruction of narrow communication between the
antrum and the attic, the aditus.

4. Etiology
 Dysfunction of Eustachian tube
 Chronic inflammation in nose and pharynx
 Dysfunction of immune system

5. Bacteriology
 Pseudomonas aeruginosa (40-60%)
 Straphylococus aureus (10-20%)
 Anaerobic bacteria

6. Pathology
 Middle ear mucosa is lined by secretory
epithelium forming glandlike structure.
 Hyalinization or tympanosclerosis
 A healing response
 It occurs during quiescent periods
 It is formed by fused collagenous fibers
 It is hardened by the deposition of calcium and
phosphate crystals
 Conductive hearing loss is associated with masses
restricting ossicular mobility

7. Pathology
 Ossicular erosion is frequent
in COM
 Infection process per se
 Necrosis following vascular
thrombosis
 It most commonly affect the
lenticular process of the incus
and head of the stapes

8. Pathology
 Cholesterol granulomas
 Presence of yellowish masses surrounded by
granulation tissue, edematous mucosa and
fibrous tissue
 It contains many cholesterol crystals and
foreign body giant cells.

9. Pathology
 Cholesteatoma: cystlike, expanding lesions
of the temporal bone, lined by stratified
epithelium and containing desquamated
keratin and purulent material.
 Classification
 Congenital cholesteatoma
 Acquired cholesteatoma

10. Pathology
 Mechanics of mucosal
transformation and
epithelial ingrowth
have been the focal
point of
cholesteatoma
 Pocket retraction:
dysfunction of
Eustachian tube

11. Pathology
 Epithelial migration: the
edge of a peripheral
perforation
 Inward growth of the
surface epithelium follows
papillary proliferation of
the germinative layer of
the pars flaccida.
 Metaplasia from
pseudostratified ciliated
columnar epithelium

13. Cholesteatoma Formation

14. Cholesteatoma Formation

15. Pathology
 Pathogenesis of congenital cholesteatoma:
 Ectodermal epithelial in proximity of the
geniculate ganglion, medial to the neck of the
malleus

16. Pathology
 Diagnosis criteria:
 Patients without
previous history of ear
disease, with normal
and intact TM
 The temporal bone
pneumatization should
be normal

17. Clinical presentations
 Otorrhea
 Malodorous associated with cholesteatoma
 Hearing loss
 Air conduction threshold is within 40 dB
means TM proferation with intact ossicular
chain
 If air-bone gap is more than 40 dB is
associated with discontinuity of ossicular chain

18. Clinical presentations
 Physical findings
 Defect in the pars tensa of TM or the pars
flaccida or both
 Atelectatic lesions in tensa or flaccida pars
 Squamous epithelial invasion may invade
middle ear
 Granumoms, polyps, tympanosclerotic plaques
in middle ear

19. Radiographic evaluation
 Indications for image
study
 Uncontrollable aural
discharge
 Complications such as
facial paralysis, labyrinthitis
 When central nervous
stystem involvement is
suspected, MRI should be
considered.
 Coronal CT scan is
perferred

20. Differential diagnosis
 Tuberculous otitis media
 Hematogenous route
 Multiple perforation and fetid
 Creamy aural discharge
 Active pulmonary disease
 Multiple antituberculosis agents

21. Differential diagnosis
 Middle ear carcinoma
 Middle age patient
 Long term otorrhea with blood
 Otalgia
 Neoplasm in tympanum
 CT scan showed temporal bone destruction

22. Managements
 Medical treatment
 Goals
 Infection control
 Stabilization of process
 Prevention of irreversible damage and development of serious
complications
 3%H202 clears up pus then antibiotics ear drops is used.
 With the decrease of pus, 3% boric glycerin, 3% boric alcohol
can be used
 No aminoglycoside ear drops
 No powders containing antibiotic and erosion ear drugs

23. Managements
 Surgery
 Goals
 Safe ear: lesion removal
 Dry ear
 Hearing ear: reconstruction of ossiclar chain
 classification
 Myrigoplasty
 Tympanoplasty
 Tympanoplasty with mastoidectomy