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Csom.dr.bini,03.04.17
- 1. CHRONIC SUPPURATIVE OTITIS MEDIA– TUBOTYMPANIC DISEASE DR.BINI MOHAN
- 2. OBJECTIVES: At the endof this class, you should be able to describe: •Lining epithelium of the middle ear cleft •Definition of CSOM •Types of CSOM and clinical features of Tubotympanic disease(TTD) •Types of perforation. •Investigations for CSOM-TTD •Treatment of CSOM-TTD
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- 5. LINING EPITHELIUM OFMIDDLE EAR CLEFT •Antero inferiorly – ciliated columnar epithelium •Posteriorly – cuboidal type •Epitympanum and mastoid air cells – flat nonciliated epithelium (pavement epithelium)
- 6. Definition •Chronic suppurative otitismedia 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.
- 7. EPIDEMIOLOGY •Incidence is higherin developing countries •Predisposing factors : Poor socio-economic status, poor nutrition, lack of health education •Affects both sexes •All age groups
- 8. •In India overallprevalance rate is : Rural: 46 per thousand Urban : 16 per thousand •CSOM is the single most important cause of hearing impairment in rural population.
- 9. TYPES OF CSOM SafeTypeOr TuboTympanic Disease UnsafeType Or Attico Antral Disease Mucosal(active / inactive) Squamous (active/inactive) Healed
- 10. TUBOTYMPANIC DISEASE •Disease confinedto anteroinferior part of middle ear cleft -eustachian tube ,mesotympanum . • Presents with central perforation. •No risk of serious complication •Usually starts in childhood , so safe type is common in that age group •No underlying osteitis or osteomyelitis
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- 12. 1)Via tympanic membraneperforation •Following A.S.O.M. or post-traumatic (traumatic perforation)
- 13. Following exanthematous fever acuteotitis media leaving behind a central perforation ,perforation becomes permanent and permits repeated infection from the external ear.
- 14. •Middle ear mucosais exposed to the environment and gets sensitized to dust ,pollen and other aeroallergens causing persistent otorrhoea.
- 15. 2 ) ViaEustachian tube • Infection of tonsils, adenoids ,sinusitis, regurgitation of milk.
- 16. 3)Allergy to ingestantssuch as milk ,eggs,fish,etc
- 17. BACTERIOLOGY •Pseudomonas aeruginosa •Proteus aerobic •Escherichia.coli •StaphylococcusAureus •Bacteroides fragilis •Anaerobic streptococci anaerobic
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- 19. •SIGNS: Ear discharge: profuse,mucoid to mucopurulent ,odourless, non blood stained, constant or intermittent
- 20. •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.
- 21. ROUND WINDOW SHIELDING EFFECT •Patienthears better in the presence of discharge rather than dry ear • Effect is produced by discharge, by maintaining phase differential
- 22. •In dry ear,sound waves strike both the Oval and Round windows simultaneously, thus cancelling each other’s effect with no movement of perilymph, and thus, no hearing.
- 23. •Tympanic membrane: central perforation •Middleear mucosa – congested. •Polyp •Ossicular chain – erosion. •Tympanosclerosis :calcification of tissues in middle ear
- 24. Perforations of ParsTensa in CSOM TT
- 26. LAYERS OFTYMPANIC MEMBRANE •Outer epithelial layer : continuous with skin . • Middle fibrous layer : which encloses the handle of malleus and has three types of fibres –radial, circular and parabolic. • Inner mucosal layer :continuous with the mucosa of the middle ear
- 28. CENTRAL PERFORATION: •Perforation inthe pars tensa surrounded all around by pars tensa
- 29. Involves only onequadrant or < 10% of pars tensa Small perforation
- 30. Medium perforation Involves twoquadrants or 10 – 40 % of pars tensa
- 31. Large perforation:involves 3or 4 quatdrants withTM remnants
- 32. •Subtotal perforation: perforationin pars tensa which involves all 4 quadrants and is surrounded by annulus tympanicus •Annulus tympanicus: periphery of TM is thickened to form a fibrocartilaginous ring
- 33. •Total perforation :perforationin the pars tensa which involves all 4 quadrants with destruction annulus tympanicous
- 34. MARGINAL PERFORATION: •Perforation inthe pars tensa surrounded partly by pars tensa and partly by bone
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- 36. STAGES FEATURES ACTIVE STAGEDischarging 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.
- 37. Investigations •Examination under microscope •Ear discharge swab: for culture sensitivity •Pure tone audiometry •X-ray mastoid
- 38. Treatment of CSOMTubo-tympanic Disease
- 39. •Short term goals: Elimination of infection Control of otorrhoea •Long term goals :- Improvement of hearing Eventual healing of TM
- 40. Non-surgical Treatment •Precautions •Aural toilet •Antibiotics: Systemic & Topical •Antihistamines : Systemic & Topical •Nasal decongestants : Systemic & Topical •Treatment of respiratory infection & allergy
- 41. Precautions •Encourage breast feedingwith 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
- 42. • Done onlyfor active stage • Dry mopping with cotton swab • Suction clearance: best method • Gentle irrigation (wet mopping) Aural Toilet
- 43. Antibiotics • Topical Antibiotics: •Ciprofloxacin, Gentamicin, Tobramycin • Antibiotics + Steroid: for polyps, granulations • Neosporin + Betamethasone / Hydrocortisone • Oral Antibiotics: for severe infections
- 44. Antihistamines and Decongestants •Antihistamines • Chlorpheniramine • Cetirizine • Fexofenadine • Loratadine • Levocetrizine • Azelastine (topical) • Topical Decongestants • Oxymetazoline • Xylometazoline • Hypertonic saline
- 45. CHEMICAL CAUTERIZATION (MEDICAL MYRINGOPLASTY) •Trichloroaceticacid •Principle : The epithelium covering the margin of the perforation is destroyed and exposing the fibroblasts •Mild irritations induces hyperemia and secondary fibroblast proliferations
- 46. •Used in drysmall to medium perforations •Several sittings may be necessary
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- 48. Surgical Treatment •Indicated ininactive or quiescent stage •Myringoplasty •Tympanoplasty •Indicated in active stage •Cortical Mastoidectomy •Aural polypectomy
- 49. Myringoplasty Surgical closure ofperforation of pars tensa of Tympanic membrane without ossicular reconstruction
- 50. Aims • Permanently stopear 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
- 51. MYRINGOPLASTY •Prerequisites •Dry ear •Good cochlearreserve •Normal ET function •Predominantly conductive hearing loss •No cholesteatoma
- 52. Contraindications • Purulent eardischarge • Otitis externa • Respiratory allergy • Age < 7 yr (Eustachian tube not fully developed) • Only hearing ear • Cholesteatoma
- 53. Methods Techniques • Underlay: graftplaced medial to fibrous annulus • Overlay: graft placed lateral to fibrous annulus Grafts used • Temporalis fascia, Tragal perichondrium, Vein graft, Fascia lata, Dura mater
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- 61. Why temporalis fascia? •Basalmetabolic 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
- 62. TYMPANOPLASTY •An operation performedto eradicate disease in the middle ear and to reconstruct the hearing mechanisms with out mastoid surgery, with or without TM grafting
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- 68. Type Pathology Graftplaced 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 )
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