1. Chronic Suppurative Otitis Media:
Tubotympanic Disease (CSOM TT,
COM Mucosal type)
Dr. Krishna Koirala
2016-05-03
2. Definition
• Pyogenic infection of middle ear cleft mucosa
lasting for more than 3 months characterized
by persistent perforation of pars tensa of
tympanic membrane, ear discharge and
decreased hearing
15. Routes of infection
1. Via Eustachian tube
– U.R.T.I., nose blowing, regurgitation of milk
2. Via tympanic membrane perforation
– Following A.S.O.M. or post-traumatic
3. Haematogenous (rare): exanthematous fever
17. Clinical Features
• Ear discharge: intermittent, profuse, mucoid to muco-
purulent, whitish, odorless, not blood-stained
• Hearing Loss:
– Usually conductive (25-50 dB) but might be normal
in small, dry perforations
– Round window shielding by ear discharge leads to
better hearing in acute exacerbations
• Tympanic membrane: central perforation
19. Investigations for CSOM TTD
• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• Patch test
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
(Done when cortical mastoidectomy is required in
CSOM TT not responding to antibiotics)
20. Examination under microscope
• Confirmation of otoscopic findings
• Epithelial migration at perforation
margin
• Cholesteatoma & granulations
• Adhesions & Tympanosclerosis
• Assessment of Ossicular chain
integrity
• Collection of discharge for culture
sensitivity
21. Pure Tone Audiometry
• Uses
– Presence of hearing loss
– Degree of hearing loss
– Type of hearing loss
– Hearing of other ear
– Record to compare hearing post-operatively
– Medico legal purpose
22. Patch Test
• Performed when deafness is around 40-50 dB
– Do pure tone audiometry: for hearing threshold
– Put Aluminum foil patch over T.M. perforation
– Repeat pure tone audiometry
• Hearing improved Ossicular chain intact &
mobile
• Hearing same / worse Ossicular chain
broken or fixed
25. Precautions
• Encourage breast feeding with child’s head raised.
Avoid bottle feeding
• Avoid forceful nose blowing
• Plug E.A.C. with Vaseline smeared cotton while
bathing & avoid swimming
• Avoid putting oil , water or self-cleaning of ear
26. • Done only for active stage
• Dry mopping with cotton swab
• Suction clearance: best method
• Gentle irrigation (wet mopping)
• 1.5% acetic acid solution used T.I.D.
• Removes accumulated debris
• Acidic pH discourages bacterial growth
Aural Toilet
29. Kartush T.M. Patcher
• Indicated in:
– Perforation in only hearing ear
– Patient refuses surgery
– Patient unfit for surgery
– Age < 7 years
30. Surgical Treatment
• Indicated in inactive or quiescent stage
–Myringoplasty
–Tympanoplasty
• Indicated in active stage
–Cortical Mastoidectomy
–Aural polypectomy
31. Methods to close perforation
• T.M. perforation < 2 mm
– Chemical cautery with silver nitrate
–Fat grafting
(Myringoplasty if these measures fail)
• T.M. perforation > 2 mm
– Tympanic membrane patcher
– Myringoplasty
37. Hearing Restoration
• Myringoplasty
– Surgical closure of tympanic membrane
perforation
• Ossiculoplasty
– Surgical reconstruction of ossicular chain
• Tympanoplasty
– Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery
38. Principles of hearing restoration
• Intact tympanic membrane
• Intact ossicular chain
• Functioning receiving & relieving windows
• Acoustic separation of these windows
• Functioning Eustachian tube
• Absence of sensorineural hearing loss
• Absence of active infection / allergy in middle ear cleft
40. Aims
• Permanently stop ear discharge : make the ear dry and
safe
• Improve hearing if ossicles are intact and mobile and there
is absence of sensori-neural deafness
• Prevention of ongoing complications like further hearing
loss, tympanosclerosis, adhesions, mucosal bands, vertigo
• Wearing of hearing aid
• Occupational: military, pilots
• Recreation: swimming, diving
41. Contraindications
• Purulent ear discharge
• Otitis externa
• Respiratory allergy
• Age < 7 yr (Eustachian tube not fully developed)
• Only hearing ear
• Cholesteatoma
42. Methods
Techniques
• Underlay: graft placed medial to fibrous annulus
• Overlay: graft placed lateral to fibrous annulus
Grafts used
• Temporalis fascia, Tragal perichondrium, Vein
graft, Fascia lata, Dura mater
50. Why temporalis fascia?
• Basal metabolic rate lowest (best survival rate)
• Easy to harvest
• Large size graft can be harvested
• Autograft, so no rejection
• Same thickness as normal tympanic membrane
• Good resistance to infection
51. Onlay Underlay
Graft cholesteatoma No
Blunting of anterior tympano-
meatal angle
No
Lateralization of graft No
Delayed healing time (6 wk) 3-4 weeks
No middle ear inspection Possible
Difficult & takes more time Easier & quicker
52. Advantages of Local Anesthesia
• Minimal bleeding
• Hearing results can be tested on table
• Facial palsy detected immediately
• Labyrinthine stimulation detected immediately
• No complications of General anesthesia
55. Type Pathology Graft placed on
I Ear drum perforation only Malleus handle
II Malleus handle eroded Incus
III Malleus + Incus eroded Stapes head
IV Only footplate remains: mobile Footplate exposed
V Only stapes remains: fixed Lateral SCC
opening
VI Only footplate remains: mobile Round window
exposed (Sono
inversion )
56. Ossiculoplasty
• Ossicular graft material
– Autograft
• Ossicles : incus/malleus
• Cartilage : Tragal/ conchal
• Bone : spine of Henle/mastoid
– Homograft: ossicles/cartilage/bone
– Biomaterials: plastic(polyethylene)/ceramic/ teflon/gold
(Biomaterials available as PORP and TORP)
