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C.S.O.M.: Clinical Features

C.S.O.M.: Clinical Features. Dr. Vishal Sharma. Definition. Chronic (> 3 months) pyogenic infection of middle ear cleft mucosa , characterized by persistent perforation of tympanic membrane, ear discharge & decreased hearing Prevalence in Nepal: 7.2 %. Types of C.S.O.M.

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C.S.O.M.: Clinical Features

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  1. C.S.O.M.: Clinical Features Dr. Vishal Sharma

  2. Definition • Chronic (> 3 months) pyogenic infection of middle ear cleft mucosa, characterized by persistent perforation of tympanic membrane, ear discharge & decreased hearing • Prevalence in Nepal: 7.2 %

  3. Types of C.S.O.M. Tubo-tympanic: chronic pyogenic infection of middle ear cleft mucosa with persistent perforation in pars tensa Attico-antral:chronic pyogenic infection of middle ear cleft with cholesteatoma & granulations in attic or postero-superior quadrant of pars tensa

  4. Middle ear cleft

  5. Tubo-tympanic vs. Attico-antral

  6. Tympanic Membrane Perforations

  7. Types Perforation of Pars Tensa 1. Central tubo-tympanic  Small  Medium  Large  Subtotal 2. Central with ingrowing epithelium attico-antral 3. Marginal attico-antral 4. Total  attico-antral Perforation of Pars Flaccida 1. Attic  attico-antral

  8. 4 quadrants of T.M. umbo

  9. Small perforation Involves only one quadrant or < 10% of pars tensa

  10. Medium perforation Involves two quadrants or 10 – 40 % of pars tensa

  11. Medium perforation

  12. Large perforation Involves 3 or 4 quadrants with wide T.M. remnant or > 40 % of pars tensa

  13. Subtotal perforation Involves all 4 quadrants & reaches up to annulus fibrosus

  14. In growing epithelium T.M. perforation with inward migration of epithelium

  15. Marginal perforation Erodes annulus fibrosus & one margin is formed by bony tympanic annulus

  16. Marginal perforation

  17. Total perforation Total erosion of pars tensa & anulus fibrosus

  18. Attic perforation Involves pars flaccida

  19. Tympanic Membrane Retractions

  20. Grade 1 retraction • Dull, lustreless T.M. • Prominent annulus • Cone of light absent • Handle medialized • Prominent lateral process • Malleolar folds sickle shaped

  21. Grade 2 retraction Eardrum touches incus

  22. Grade 3 retraction TM touches promontory (atelectasis) but mobile on Valsalva maneuver or Siegalization

  23. Grade 4 retraction TM firmly adherent to promontory & immobile on Valsalva maneuver or Siegalization

  24. PSQ retraction pocket

  25. Attic retraction pocket

  26. Otological examination 1. Pre-auricular region: sinus, lymph node 2. Pinna: size, position, deformity, swelling 3. Post-auricular region: surgical scar, swelling, fistula, lymph node 4. External auditory canal: meatal opening, otitis externa, wax, fungal debris, ear discharge

  27. Otological examination 5. Tympanic membrane: intact:colour, position, mobility, tympanosclerosis, retraction pocket perforated:type, site, size & margin of perforationhandle of malleus; middle ear cavity (mucosa, ear discharge, polyp, granulations, cholesteatoma flakes); pars flaccida

  28. Otological examination 6. Mastoid cavity: size, facial ridge, discharge, epithelialization, granulations, polyps 7. Tragal tenderness: associated otitis externa 8. Mastoid tenderness: cymba conchae, mastoid body + tip & posterior zygoma root 9. Fistula sign 10. Facial nerve function 11. Tuning Fork Tests

  29. Tubo-tympanic Disease

  30. Predisposing factors • Upper respiratory tract infection (recurrent) • Upper respiratory tract allergy • Pre-existing otitis media with effusion • Cleft palate • Immune deficiency: diabetes, AIDS • Poor socio-economic status

  31. Bacteria responsible • Staphylococcus aureus • Pseudomonas aeruginosa • Klebsiella • Proteus • Streptococcus • Bacteroides

  32. Routes of infection • Via Eustachian tube: U.R.T.I., nose blowing, regurgitation of milk • Via tympanic membrane perforation:following A.S.O.M. or post-traumatic • Haematogenous (rare): viral exanthematous fevers

  33. Pathological Changes 1. Eardrum: central perforation; myringosclerosis 2. Ossicles:Destruction (hyperaemic decalcification) Tympanoslerosis Fibrosis + Adhesions 3. Middle ear mucosa:edematous, pale pink 4. Mastoid bone:sclerosis

  34. Clinical Features Ear discharge:profuse, mucoid / muco-purulent, intermittent, odourless, not blood-stained Hearing Loss: usually conductive (25-50 dB)  absent in small, dry perforations  round window shielding by ear discharge leads to better hearing Tympanic membrane:central perforation

  35. Stages of Tubotympanic disease

  36. Attico-antral disease

  37. Cholesteatoma • Term used by Johannes Müller in 1858 • Three dimensional sac lined by matrix of keratinizing stratified squamous epithelium which rests on a thin layer of fibrous tissue • Contains desquamated keratin debris • Grows at the expense of surrounding bone • Not a tumor & has no cholesterol • Epidermosis is a better term

  38. Cholesteatoma

  39. Histopathology

  40. Causes of bone destruction 1. Hyperaemic decalcification 2. Osteoclastic bone resorption due to:  Acid phosphatase  Collagenase  Acid proteases  Proteolytic enzymes  Leukotrienes  Cytokines 3. Pressure necrosis: No role 4. Bacterial toxins: No role

  41. Types of Cholesteatoma Congenital (McKenzie) Primary AcquiredSecondary Acquired 1. Retraction pocket 1. Squamous metaplasia (Wittmaack) 2. Epithelial migration 2. Basal cell hyperplasia (Habermann) (Ruedi) Tertiary Acquired 3. Squamous metaplasia 1. Post-traumatic (Sade) 2. Post-tympanoplasty

  42. Congenital cholesteatoma Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle

  43. Congenital cholesteatoma

  44. Retraction pocket formation Retraction pocket in pars flaccida or Postero-superior quadrant pars tensa due to E.T. dysfunction

  45. Basal cell hyperplasia Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues

  46. Primary squamous metaplasia Transformation of middle ear mucosa into squamous epithelium due to infection, with no T.M. perforation

  47. Secondary squamous metaplasia Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation

  48. Epithelial migration Migration of epithelium via T.M. perforation into middle ear

  49. Post-traumatic cholesteatoma Mechanisms: 1. Epithelial entrapment in fracture line 2. In growth of epithelium through fracture line 3. Traumatic implantation of epithelium into middle ear 4. Trapping of epithelium medial to E.A.C. stenosis

  50. Pathological Changes 1. T.M. perforation:marginal or attic 2. T.M. retraction pocket:attic or P.S.Q. 3. Cholesteatoma formation 4. Ossicles:destruction 5. Middle ear mucosa:edematous, red 6. Aural polyp:red, fleshy 7. Osteitis & granulation tissue formation 8. Mastoid bone:erosion, sclerosis

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