Chronic Otitis Media

1. Dr Somnath Saha

2.  COM is defined as chronic inflammation of
mucoperiosteal lining of the middle ear cleft.
 Classification
1)Tubotympanic type/Safetype/Mucosal variety
2)Atticoantral type/Dangerous type/Squamosal
variety
History taking and careful clinical examination is
very much essential to establish a proper
diagnosis

3. Common symptoms:
• Discharge
• Hearing impairment
• Pain in the ear (otalgia)
• Tinnitus
• Vertigo
• Feeling of fullness
• Autophonia
• Neuro-otological symptoms
• Swelling and deformity

4.  All the above mentioned symptoms has to be
analysed under the following heading
 Pertinent questions have to be asked to know
how did the disease start and what was the
duration?
 How has it progressed upto this moment?
 Whether onset is sudden or gradual?

5.  Onset
Sudden: ASOM
Gradual: CSOM
 Duration
Long duration :CSOM, Eczematous otitis
externa
Short duration: ASOM, Ruptured furunculosis
Intermittent :Tubotympanic type of CSOM

6.  Watery discharge : CSF otorrhea, otitis externa
 Serosanguinus : Fungal infection and diffuse
otitis externa.
 Mucoid : CSOM tubotympanic type,
Fungal infections, Granular myringitis
 Mucopurulent : CSOM, Secondary infection
to CSOM, Tuberculous
otitis media
 Purulent : Furunculosis, Mastoiditis, Malignant
otitis externa, Atticoantral type of
CSOM

7. QUANTITY
 Profuse : Tubotympanic (If it comes out the
ear canal and stains the pillow)
 Moderate: If discharge remains in the external
auditory canal
 Scanty : Atticoantral (If the tip of swab
stick is stained by the discharge.

8. Unsafe perforations are
a)In the attic or
b)In the posterio-supirior region.
These are often linear rather than oval
c) involve the eardrum margin
Anything else is generally Safe.
i.e.
a) In the anterior region or
b) In the inferior region
c) And not involving the eardrum
margin
MAKE SURE YOU ALWAYS INSPECT
THE ATTIC AREA ON OTOSCOPY!

9.  Central Perforation- When perforation is
surrounded all around by the tympanic
membrane. It occurs in pars tensa and found
in tubotympanic type of otitis media.
 Subtotal perforations- It is a large central
perforation and annulus is present as a rim.
 Total perforation- When annulus is not
present and destroyed all around

10.  Marginal perforation- It is not sourrounded
all around by the tympanic membrane. it is
associated with secondary acquired
choleasteatoma.
 Attic perforation- it is situated in the attic. It
indicates primary acquired cholesteatoma.
Marginal and attic perforation is found in
AAD.

11. UNSAFE SAFE
Source Cholesteatoma Mucosa
Odour Foul Inoffensive
Amount Usually scant,
never profuse
Can be profuse
Nature Purulent Mucopurulent

12.  Malodorous discharge-Long standing CSOM
due to super added infection with saprophytic
organism, Syphilitic otits media
 Blood stained otorrhoea-Granulation in the
ear, Carcinoma of the ear, Malignant otitis
externa

13. Discharge increases with cold, head bath,
pharyngitis and tonsillitis,enlarged adenoids
seen in tubotympanic type of CSOM

14.  Sudden
 Gradual
 Unilateral
 Bilateral
 Progresive –Tympanosclerosis, meniere
dis,otosclerosis, Acostic neuroma,
Presbyacusis.
 Fluctuating-Meniere’s dis, Perilymph leak

15.  Auto phony- ASOM, Secretary otitis media,
Patulous e tube (Excessive loudness of one’
own voice)
 Paracusis willisii – Otosclerosis (Patient hear
better in crowded environment)
 Diplacusis-Meniere (Sound heard at diff pitch
in the affected ear)
 Recruitment- cochlear pathology (A relatively
small increase in intensity of the auditory
stimulus may cause frank discomfort to the
listener)

16. Onset
Sudden: Furuncle, Otitis media, Barotrauma
Gradual: Otitis externa secondary to CSOM,
Malignancy, Malignant otitis externa
Nature of Pain
Dull :Eczematous otitis
externa,secretary otitis
media,impacted wax
Sharp : Furuncle,Otitis barotruama
Throbbing: ASOM

17.  Pain in the ear may be local and referred
causes.
 Relieving factors-Pain relieves with discharge
frm the ear(ASOM)
 Aggravating factors
 Pain increases on swallowing-ASOM
 Pain increases on yawning and chewing-
furunculosis
 Pain increase on pulling the pinna and
pressing tragus-Otitis externa

18.  Referred pain to the ear is because of nerve
supply from 5th,9th and 10 th cranial nerve
and c2,3 to the ear.
 Referred pain via 5th nerve-Dental caries,
impacted tooth, malocclusion.Benign and
malignant ulcer in oral cavity.TM joint
problem.
 Referred pain via 9th cranial nerve-base of
tongue malignancy,oropharyngel lesion,eagle
syndrome.

19.  Referred from 10th cranial nerve- lesion in
epiglottis, valecula, Laryngopharynx.
 Referred pain via c2,3- Cervical spondylosis,
caries spine.

20.  It may be defined as a noise within the ear or
head, produced in absence of any external
stimulus.
 Short duration-Middle ear pathology
 Long duration-Inner ear
pathology(Menieredis,Acoustic
neuroma,palatal
myoclonus,ototoxicity,Glomus jugularies.

21.  Continous-Otosclerosis, Acoustic
neuroma,Acute noise trauma
 Intermittent or Fluctuating-Meniere’s dis
 Pulsatile-Glomus tumour,strychnine
poisoning
 Relieving factors-By putting prassureat the
side of the neck in vascular causes
 Aggravating Factors-By smoking(Cochlear
pathology,Ototoxicity) Yawning and blowing(E
tube dysfunction.

22.  Vertigo-Presence or absence of symptoms
during discharge
 Headache-Brain abscess and lateral sinus
thrombosis
 Fever-
 Facial asymetry- with ear discharge,facial
palsy with deafness(Acoustic neuroma)

23. Chief complain-Right ear discharge since
child hood,decreased hearing right ear-6
years.Headache since one year

24.  Right ear discharge started since child hood,
which was insidious
onset,intermittent,profuse,mucoid to
mucopurulent, nonfoul smelling, more during
episode of URTI and common cold. Relieved
on putting ear drops and antibiotics
prsecribed by the local Doctrs. Last discharge
was three months back.

25.  Decreased hearing in the right ear started five
years back, insidious in onset and slowly
progressive. No histrory of giddiness and
tinnitus.
 Headache- Eight months duration,insidious in
onset,gradually
progressive,intermittent,mainly
bifrontal,more on bending forward and more
during the morning and episode of
URTI.History of recurrent hawking sensation
is present.

26.  Provisional Diagnosis-Right
CSOM,Tubotympanic type,inactive stage with
DNS(S shaped) with chronic sinusitis

27.  Why do you say it is aTubotympanic disease?
 What are the diff types of Discharge associted
with otitis media?
 What could be the cause of otitis media in
this case?
 Can you mention the stages of TTD?
 Wht are the investgations u ask for?
 Wht is the aim of your treatment?

28.  Why do you say patient suffer from
mild/moderate /severe Conductive hearing
loss?
 How you perform patch test?
 Is it necessary to treat chronic sinusitis before
treating CSOM?

29.  Left ear discharge since 15 years
 Decreased hearing in the left ear since 10
years

30. Any defect or
apparent perforation
in the attic must be
considered unsafe
and should be
referred for ENT
assessment. This
crust in the attic
represents a large
underlying
cholesteatoma sac.
Note the bulging
eardrum too.

31.  Patient was apparently normal since 15 years
when he developed left ear discharge.
Discharge was continous,scanty,purulent foul
smelling, occasionally blood stained.
 Does not subside with ear drops and not
associated with URTI and common cold.
 History of decreased hearing since 10 years,
insidious in onset and gradually progressive

32. Unsafe because it is a
perforation involving the
drum margin (the yellowy
white flakes indicating a
cholesteatoma also gives
it away!).

33.  No history of tinnitus,giddiness,ear block and
pain
 No history of facial weakness and facial
assymetry
 No other ENT complain

34.  Why do you diagnose this case as a AAD?
 What is the definition of Cholesteatoma?
 What do you mean by secondary acquired
cholesteatom?
 How disease spread?
 What is the radiological finding you expect?
 What are the diff diagnosis of cavity in
Mastoid?

35.  Definition-Myringo plasty is a surgical
procedure perform to repair or reconstruct
the tympanic membranewit a suitable graft
material.
It does not include removal of disease or
reconstruction of hearing mechinsm.

36.  Recurrent ear discharge
 Hearing loss, painless
 Perforation of the TM –
central
 Presence of cholesteatoma
 Marginal, Attic perforation
 Offensive discharge,
bleeding, granulations
 Complications:
. Vestibular symptoms
. Facial palsy
 . Intracranial complications

37.  Auto graft: Same person
 Isograft : Genitically identical twin
 Homograft: Another person(Same species)
 Heterograft: Xenograft,Animal another
species
Advantages of autograft
No immunological reaction
Inexpensive
No risk of HIV or other infection

38.  To make the ear dry and trouble free
 To improve hearing
 To enable proper hearing aid use

39.  Ear should be dry at least three months
 Healthy middle ear mucosa
 Patent E tube
 There should no focus of infections in nose
pns and nasopharynx
 Good cochlear reserve
 No ossicular discontinuity

40.  Acute urti and otitis externa
 Children below 8 years/12 years
 Only hearing ear with severe SN hearing loss
of opposite side
 Conductive deafness more than 30 db
 Marked loss of speech discrimination
 Uncontrolled systemic disease HTN,DM
 Pregnancy

41.  Types of auto grafts
1)Temporalis fascia
2)Tragal perichondrium
3)Tragal cartilage
4)Perosteum
5)Vein
6)Facia Lata
7)Fatty tissue from Ear lobule
8) Skin

42.  Location of donor site
 Easy to harvest
 Close histological
 Low BMR
 No size limitation
 Only suitable autologous membrane for
reconstruction of ear canal and tympanic
cavity

43.  Wound infection and gaping
 Bat ear
 Granullation and epithelial pearl
 Blunting
 Lateralization
 Retraction pocket and cholesteatoma
 Injuiry to chorda and ossicle
 Re-perforation

46.  The graft acts as a scaffolding to support the
regenerating mucosa on its medial surface
and squamous epithelium on its lateral
surface.

47.  Myringotomy is the incision of the tympanic
membrane in order to drain suppurative or
nonsuppurative effusion of the middle ear or
to provide aeration in case of a
malfunctioning eustanian tube.
 The procedure may be combined with
insertion of a ventilation tube or grommet
which keeps the opening patent.

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53.  E tube by pass
 Support function and aeration and drainage
Disadvantages of tube
Promote otitis media in children
Contamination of EAC
Does not serve barrier protection

54.  OME
 Persistent retraction of tympanic membrane
 Radion induced secretary otitis media
 Patulous Etube
 Treatment of Meniere’s disese
Myringotomy-Relief of severe
otalgia,Suppurative complication of otitis
media,Suspected case of middle ear
effusion,Haemotympanum.

55.  Accurate history
 PTA/impedense(B type)
 Radiography soft tissue neck
 Routine investigation
TUBE SELECTION
Short term(Shepherd grommet style)
Permanent –T tubes.

56.  Circumferential incision in postero inferior
quadrant of myringotomy in ASOM
 Radial incision in antero inferior quadrant is
used for grommet insertion
 Middle ear effusion aspirated and
tympanoplasty tube inserted.
 AVOID POST SUP Quadrant-Ossicular injuiry
and retraction pocket.

57.  Easy to insert
 Remain in place as long as desired
 Can be easily removed
Material-Polythene,Titanium,Silver oxide
impregnated type,Sillastic.

58.  Self extrudes by 6 to 12 months
 Frequently recurrent ottohea not responding
to antimicrobials.
 T tube embeded in granulations

59.  Ossicular injuiry
 Bleeding due to high jugular bulb
 Recurrent otorrhea
 Myringosclerosis
 TM perforation
 Tympanostomy tube lost in middle ear
 Early extrusion
 Plugging of tube
 Tympanic membrane
atrophy,retraction,atelectasis and cholesteatoma

60. A Teacher can never
truly teach, unless he is
still learning himself
Gurudev Rabindranath
Tagore