Chronic suppurative otitis media (CSOM) is a long-standing ear infection characterized by persistent ear drainage through a perforated eardrum. It is more common in developing countries and affects all ages. CSOM can be tubotympanic type, confined to the middle ear space, or atticoantral type, involving the mastoid air cells. Atticoantral disease poses greater risks of complications due to bone erosion and possible cholesteatoma formation. Treatment involves topical and oral antibiotics as well as surgical procedures like myringoplasty, tympanoplasty, and ossiculoplasty to repair damaged structures and stop drainage.

1. CHRONIC SUPPURATIVE
OTITIS MEDIA
Dept. of ENT

2. DEFINITION OF CSOM
• Chronic suppurative otitis
media is a long standing
infection of a part or whole
of the middle ear cleft
characterised by
continuous or intermittent
discharge through a
persistent
tympanic membrane
perforation.

3. EPIDEMIOLOGY
• Incidence is higher in developing countries
• Predisposing factors: Poor socio-economic
status, poor nutrition, lack of health education
• Affects both sexes
• All age groups

4. TYPES OF CSOM
Safe Type Or
Tubo Tympanic
Disease
Unsafe Type Or
Attico Antral
Disease
Active
(Mucosal /
Squamous)
Inactive
(Mucosal /
Squamous )
Healed

5. TYPES:

6. property Tubotympanic Atticoantral
Discharge Profuse,mucoid,
odourless
Scanty,purulent, foul smelling
Perforation Central Marginal
Granulations Uncommon Common
Polyp Pale Red and fleshy
Cholesteatoma Absent Present
Complications Rare Common
Audiogram Mild to moderate
conductive deafness
Conductive or mixed deafness

7. Tubotympanic Atticoantral
Mucosal disease with no evidence of
invasion of squamous epi.
Squamous disease of middle ear
Active-perforation of pars tensa with
inflammation of mucosa and
mucopurulent discharge
Active-presence of cholesteatoma in
posterosuperior part of pars tensa/in
pars flaccida. Erodes bone ,form
granulation tissue,has purulent
offensive discharge
Inactive- permanent perforation of
pars tensa but middle ear mucosa
isn’t inflamed & there’s no discharge.
Inactive-retraction in pars tensa/pars
flaccida,no discharge
Healed-tm is healed (by 2 layers)is
atrophic,easily retracted if –ve
pressure in middle ear

8. TUBOTYMPANIC DISEASE
• Disease confined to eustachian tube , anterior
and inferior part of mesotympanum and
hypotympanum
• Usually starts in childhood , so safe type is
common in that age group
• Presents with central perforation
• No underlying osteitis or osteomyelitis

9. AETIOLOGY
• Sequelae of acute otitis media
• Ascending infections via the
eustachian tube
• Nasal Allergy
• GERD
• Cranio facial abnormalities
• Autoimmune disease

10. BACTERIOLOGY
• Pseudomonas aeruginosa
• B.Proteus
• Esch.coli
• Staph. Aureus
• Bacteroides fragilis
• Anaerobic streptococci.

11. SYMPTOMS
• Ear Discharge
• Hearing Loss
• Ear Pain
• Fever

12. SIGNS
• Profuse mucopurulent discharge, non foul
smelling, not blood stained.
• Hearing loss.
• Central Perforation.
• Middle ear mucosa – congested.
• Polyp
• Ossicular chain – erosion.
• Tympanosclerosis

13. TYPES OF PERFORATION
CENTRAL
PERFORATION:
• Perforation in the pars tensa
sorrounded all around by
pars tensa
MARGINAL
PERFORATION:
• Perforation in the pars tensa
surrounded partly by pars
tensa and partly by bone

15. STAGES FEATURES
ACTIVE STAGE Discharging at the time of
examination.
QUIESCENT STAGE In the recent past, discharge
present but there is no discharge
now.
INACTIVE STAGE No discharge for 3- 6 months.
Dry ear.
HEALED STAGE TM Perforation has healed.
Permanently controlled middle ear
infection.

16. ATTICO ANTRAL DISEASE
• Chronic inflammatory condition of the
middle ear cleft confined to posterior part of
the mesotympanum , attic and antrum
associated with bone eroding disease or
cholesteatoma charactersied by thick,
purulent, scanty, foul smelling, blood stained
persistent discharge and may be associated
with perforation in pars flaccida

18. CHOLESTEATOMA
• It is a cystic bag like structure lined by stratified
squamous epithelium containing desquamated
epithelial debris lying on a fibrous tissue stroma
of variable thickness
• Skin in the wrong place
• Synonym: keratoma, epidermosis

20. THEORIES OF CHOLESTEATOMA
FORMATION
1. Congenital cell rests
2. Invagination theory:
(Wittmack)
• Invagination of TM from
attic or posterosuperior
part of pars tensa

21. 3. Epithelial invasion
theory
(Habermann)
Squamous epithelium from
TM migrates to middle ear
via TM perforation

22. 4. Basal cell hyperplasia
theory:
• Infection or inflammation
• Basal membrane breaks
• Squamous epithelium
invade into sub epithelial
tissue in pars flaccida like
epithelial cones forming
microcholesteatoma
• This enlarges and
perforates secondarily
through the TM

23. 5. Squamous metaplasia theory:
• Cuboidal epithelium can undergo metaplasia
to sq.epithelium
• Middle ear cuboidal epithelium is pluripotent
can be stimulated by inflammation to become
keratinising sq.epithelium

24. TYPES OF CHOLESTEATOMA
• Congenital
• Acquired
- primary
- secondary

25. COMMON SITES OF CHOLESTEATOMA
• Most common sites of origin of acquired
cholesteatomas are
1. Posterior epitympanum
2. Posterior mesotympanum
3. Anterior epitympanum

26. PATHOLOGY
1. Cholesteatoma
2. Osteitis and granulation tisue
3. Ossicular necrosis
4. Cholesterol granuloma

27. ATTICO ANTRAL DISEASE SYMPTOMS
• Ear Discharge
• Hearing Loss
• Bleeding
• Ear Ache
• Dizziness
• Tinnitus
• Symptoms Of Complications

28. PARS TENSA CHOLESTEATOMA SIGNS
• Retraction Pockets
• Cholesteatoma Flakes
• Granulation Tissue
• Polyp
• Hearing Loss

29. INVESTIGATION
• Examination under microscope
• Pus for C/S
• Audiological Assessment
• X-ray both Mastoids
• CT Scan Temporal bone
• Basic Investigations
• X-ray PNS
• Diagnostic Nasal Endoscopy
• Eustachian Tube Function Tests

30. EXAMINATION UNDER MICROSCOPE
• To confirm Otoscopic findings
• Site & size of perforation
• Margin of perforation
• Appearance of Middle ear
• Presence of Polyp & granulation Tissue and its site

31. PURE TONE AUDIOGRAM
• Identifying the presence
or absence of auditory
functions
• Differentiating
conductive from
sensorineural hearing
loss
• Degree of hearing loss

32. X-RAY BOTH MASTOIDS
• Pneumatisation of
mastoid air cells
• Hazziness / clouding of
air cells
• Low lying tegmen or
anteriorly lying sinus
plate

33. BASIC INVESTIGATIONS
• Complete hemogram : Hb, TC, DC, BT, CT, ESR
• B. Sugar
• B. Urea, S. Creatinine
• Urine analysis
• ECG
• X-Ray Chest PA view

34. X-RAY PNS

35. DIAGNOSTIC NASAL ENDOSCOPY

36. EUSTACHIAN TUBE FUNCTION TESTS
• Valsalva Test
• Politzer Test
• Catheterisation
• Toynbees test
• Tympanometry
• Radiological Test

37. MEDICAL TREATMENT
• Short term goals :
Elimination of infection
Control of otorrhoea
• Long term goals :-
Improvement of hearing
Eventual healing of TM
• Aural Toileting - Dry Mopping
Wet mopping
Suction irrigation under microscope
• Topical Antibiotics
• Systemic Antibiotics

38. CAUSES OF FAILURE OF MEDICAL
TREATMENT
• Poor drainage of inflammatory exudate from the middle ear
• Presence of persistent osteitis with mastoid granulation
• Virulent & resistant organisms
• Reinfection via Eustachian tube – adenoid, sinuses
• Allergy
• Mastoid reservoir

39. CHEMICAL CAUTERIZATION
(MEDICAL MYRINGOPLASTY)
• Trichloroacetic acid
• Principle : The epithelium covering the margin
of the perforation is destroyed and exposing the
fibroblasts
• Mild irritations induces hyperemia and secondary
fibroblast proliferations
• Used in dry small to medium perforations
• Several sittings may be necessary

40. • Medical Treatment For Cholesteatoma :-
• Topical antibiotics with aural toileting
• Suction clearance
• Application of silver nitrate to granulation
tissue
• Antimetabolite - 5 – fluorouracil
• Reduces the activity of squamous epithelium &
curtail the production of keratin debris
• Ventilation Tubes In Attic Retractions

41. SURGICAL PROCEDURES
MYRINGOPLASTY
• An operation performed to repair or reconstruct the TM
TYMPANOPLASTY
• An operation performed to eradicate disease in the
middle ear and to reconstruct the hearing mechanisms
with out mastoid surgery, with or without TM grafting.
OSSICULOPLASTY
• An operation performed to repair or reconstruct the
ossicular chain

42. MYRINGOPLASTY
• Prerequisites
▫ Dry ear
▫ Good cochlear reserve
▫ Normal ET function
▫ Predominantly conductive hearing loss
▫ No cholesteatoma
• Types
▫ Grafting techniques – onlay, underlay

43. TYMPANOPLASTY
• TYPE I :
-intact ossicular chain.
-sound protection for round window.
• TYPE II:
-slight defect of the ossicles.
-middle ear is of about normal size.
• TYPE III:
- malleus and incus are extremely eroded
- columella effect.
• TYPE IV:
- mobile stapes foot plate.
- sound pressure transformation is given
up.
• TYPE V:
- Fixed stapes foot plate.
- sound pressure through fenestration.