7 chronic suppurative otitis media with and without cholesteatoma

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7 chronic suppurative otitis media with and without cholesteatoma

  1. 1. Chronic suppurative otitis media with and without cholesteatoma Hongyan Jiang MD&PhD Otorhinolaryngology Hospital,The First Affiliated Hospital of Sun Yat-sen University
  2. 2. Chronic suppurative otitis media without cholesteatoma <ul><li>Chronic infection of the middle ear with a non-healing perforation of the tympanic membrane </li></ul><ul><li>Otorrhea (ear drainage) for 6-12 weeks </li></ul><ul><li>Middle ear mucosa becomes edematous, polypoid, or ulcerated </li></ul><ul><li>The tympanic cavity usually contains granulation tissue </li></ul><ul><li>Most common infecting organisms are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroids </li></ul><ul><li>Annual incidence approximately 40 cases/100,000 population </li></ul>
  3. 3. Chronic suppurative otitis media without cholesteatoma <ul><li>Patients present with hearing loss and otorrhea </li></ul><ul><li>Pain, vertigo, fevers, facial nerve palsy, mental status changes or fetid drainage signify impending intra-temporal or intra-cranial complications </li></ul>
  4. 4. Near Total TM Perforation
  5. 5. Cholesteatoma
  6. 6. Cholesteatoma <ul><li>Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining </li></ul><ul><li>Contain keratin and desquamated epithelium </li></ul><ul><li>Term “cholesteatoma” coined by Johannes Muller in 1838 </li></ul><ul><li>Misnomer because the cysts don’t contain cholesterol </li></ul><ul><li>Can be congenital or acquired </li></ul><ul><li>Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation </li></ul>
  7. 7. Cholesteatoma
  8. 8. Cholesteatoma <ul><li>Annual incidence is unknown </li></ul><ul><li>In 1978, there were 4.2 hospital discharges per 100,000 with cholesteatoma </li></ul><ul><li>( Ruben RJ: The disease in society: evaluation of chronic otitis media in general and cholesteatoma in particular . In Sadé J, editor: Cholesteatoma and mastoid surgery , Amsterdam, 1982, Kugler Publishing ) </li></ul><ul><li>Harker and coworkers estimated the incidence at 6/100,000 </li></ul><ul><li>(Harker LA: Cholesteatoma: an incidence study . In McCabe BF, Sadé J, Abramson M, editors: Cholesteatoma: first international conference , Birmingham, Alabama, 1977, Aesculapius Publishing) </li></ul><ul><li>Tos and colleagues found 3/100,000 in children and 12.6 per 100,000 in adults </li></ul><ul><li>(Tos M: Incidence, etiology and pathogenesis of cholesteatoma in children, Ann Otol Rhinol Laryngol 40:110, 1988) </li></ul>
  9. 9. Congenital cholesteatoma <ul><ul><li>Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice </li></ul></ul><ul><ul><li>Michaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestation. </li></ul></ul><ul><ul><li>(Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986) </li></ul></ul><ul><ul><li>Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease </li></ul></ul>
  10. 10. Acquired Cholesteatoma <ul><li>Pathogenesis </li></ul><ul><li>Invagination ( Pocket retraction ) </li></ul><ul><li>Basal cell hyperplasia </li></ul><ul><li>Migration (through a perforation) </li></ul><ul><li>Squamous metaplasia </li></ul>
  11. 11. Primary acquired cholesteatoma <ul><ul><li>Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane (invagination Theory) </li></ul></ul><ul><ul><li>Secondary to ETD </li></ul></ul><ul><ul><li>Keratin debris collects within a retraction pocket </li></ul></ul>Normal TM Mucoid effusion and primary acquired cholesteatoma Mesotympanic cholesteatoma
  12. 12. Primary acquired cholesteatoma
  13. 13. Secondary Acquired Cholesteatoma <ul><li>Migration Theory – most accepted </li></ul><ul><li>Originates from a tympanic membrane perforation </li></ul><ul><li>As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear </li></ul>
  14. 14. COM with and without cholesteatoma Diagnosis
  15. 15. COM with and without cholesteatoma Diagnosis <ul><li>History, physical examination , high resolution CT scan of the temporal bone </li></ul>Axial Section Coronal Section
  16. 16. Cholesteatoma Imaging
  17. 17. Cholesteatoma Imaging
  18. 18. COM with and without Cholesteatoma Treatment
  19. 19. Chronic suppurative otitis media without cholesteatoma <ul><li>Ototopical antibiotics </li></ul><ul><li>Surgical repair of the TM perforation </li></ul><ul><li>Repair of the ossicular chain if necessary </li></ul>
  20. 20. Ototopical Medications <ul><li>Antibiotic only otic drops </li></ul><ul><li>Floxin ( ofloxacin ) </li></ul><ul><li>Antibiotic with steroid otic drops </li></ul><ul><li>Ciprodex ( ciprofloxin and dexamethasone ) </li></ul><ul><li>Cipro HC ( ciprofloxin and hydrocortisone ) </li></ul><ul><li>Cortisporin ( neomycin, polymyxin, and hydrocortisone) </li></ul><ul><li>Ophthalmic antibiotic preparations </li></ul><ul><li>Tobradex ( tobramycin and dexamethasone ) </li></ul><ul><li>The concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically. </li></ul>
  21. 21. Tympanoplasty <ul><li>Paper patch myringoplasty </li></ul><ul><li>Fat myringoplasty </li></ul><ul><li>Underlay tympanoplasty (medial graft technique) </li></ul>
  22. 22. Underlay Tympanoplasty
  23. 23. Ossicular Chain Reconstruction
  24. 24. Chronic suppurative otitis media with cholesteatoma <ul><li>Ototopical antibiotics </li></ul><ul><li>Surgical repair of the TM perforation </li></ul><ul><li>Repair of the ossicular chain if necessary </li></ul><ul><li>Often requires mastoidectomy </li></ul>
  25. 25. Mastoidectomy <ul><li>Intact (bony ear) canal wall mastoidectomy </li></ul><ul><li>Canal wall down mastoidectomy </li></ul><ul><ul><li>Radical Mastoidectomy </li></ul></ul><ul><ul><li>Modified Radical Mastoidectomy </li></ul></ul>
  26. 26. Mastoidectomy Tympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicular reconstruction
  27. 27. Surgical development radical mastoidectomy (canal wall-down ,CWD) modified radical mastoidectomy close mastoidectomy(canal wall-UP ,CWU) modified close mastoidectomy Mastoid obliteration soft/hard canal-wall reconstruction endoscopic middle ear surgery endoscope-assisted surgery of middle ear
  28. 28. a: atticotomy; b:bridge; o: otosclerosis drilling; e: thin posterior bony ear canal wall; cm: cortical mastoidectomy ; aa :anterior attic, hc :horizontal semicircular canal; ib: incus body; mh : malleus head; m: malleus; f: facial canal; r : round window; c : chorda; s : tympanic sinus Tos 改良完壁式乳突根治 Tos modified close mastoidectomy
  29. 29. HongKong Flap Hung T ,et al. Laryngoscope 2007;117:1403-1407
  30. 30. Postauricular periosteal-pericranial flap Ramsey MJ ,et al. Otol Neurotol. 2004 Nov;25(6):873-8
  31. 31. Middle temporal artery flap Singh V, et al. Otolaryngology–Head and Neck Surgery (2007) 137, 433-438
  32. 32. Soft canal-wall reconstruction Takahashi H , et al. Eur Arch Otorhinolaryngol (2007) 264:867
  33. 33. endoscopic middle ear surgery
  34. 36. Surgical development radical mastoidectomy (canal wall-down ,CWD) classic radical mastoidectomy modified radical mastoidectomy close mastoidectomy(canal wall-UP ,CWU) modified close mastoidectomy Mastoid obliteration soft/hard canal-wall reconstruction endoscopic middle ear surgery endoscope-assisted surgery of middle ear
  35. 37. COM with and without Cholesteatoma Complications
  36. 38. Complications of Otitis Media <ul><li>Acute mastoiditis </li></ul><ul><li>Sub-periosteal abscess </li></ul><ul><li>Cholesteatoma </li></ul><ul><li>Labyrinthitis </li></ul><ul><li>Facial paralysis </li></ul><ul><li>Meningitis </li></ul><ul><li>Epidural/subdural abscess </li></ul><ul><li>Brain abscess </li></ul><ul><li>Sigmoid sinus thrombosis </li></ul><ul><li>Otitic Hydrocephalus </li></ul>
  37. 39. <ul><li>Due to antibiotics, the incidence of complications has greatly declined. </li></ul><ul><li>Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma. </li></ul><ul><li>Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures. </li></ul>Complications of Otitis Media
  38. 40. Acute mastoiditis with sub-periosteal abscess
  39. 41. Brain Abscess
  40. 42. Complications of Otitis Media <ul><li>Patients appear more ill than expected </li></ul><ul><ul><li>fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic ear </li></ul></ul><ul><ul><li>lethargy and mental status changes </li></ul></ul><ul><li>CT and MRI are indicated </li></ul><ul><ul><li>CT is superior for evaluating the bony details of the middle ear and mastoid space </li></ul></ul><ul><ul><li>MRI is more sensitive for diagnosing suspected intracranial complications. </li></ul></ul><ul><li>Broad spectrum antibiotics and surgery are required </li></ul>
  41. 43. Summary <ul><li>Eustachian tube dysfunction is central to the development of ear disease </li></ul><ul><li>Chronic otitis media without cholesteatoma is defined as prolonged otorrhea thru a non-healing TM perforation </li></ul><ul><li>Cholesteatomas are bone destructive epithelial cysts that require surgical removal </li></ul><ul><li>The temporal bone is a complex anatomic region with close proximity to a variety of critical structures. These structures are at risk during both acute and chronic otitis media </li></ul>
  42. 44. Thanks for your attention!

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