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CSOM ATTICO ANTRAL DISEASE

CSOM ATTICO ANTRAL DISEASE. DR MUBEENA. CHOLESTEATOMA. The presence of stratified squamous epithelium in the middle ear or mastoid. Skin in the wrong place. Misnomer ?. “ Cholesteatoma " coined by the German physiologist Johannes Müller in 1838, is a misnomer

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CSOM ATTICO ANTRAL DISEASE

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  1. CSOMATTICO ANTRAL DISEASE DR MUBEENA

  2. CHOLESTEATOMA

  3. The presence of stratified squamous epithelium in the middle ear or mastoid. • Skin in the wrong place.

  4. Misnomer ? • “Cholesteatoma" coined by the German physiologist Johannes Müller in 1838, is a misnomer because this entity does not contain cholesterol • the white-yellow keratin flakes found within cholesteatomas grossly resemble cholesterol crystals • ‘oma’ is a suffix for tumour

  5. SYNONYMS:- • KERATOMA • EPIDERMOSIS • CHOLESTEATOSIS

  6. Choleasteatoma consists of : • PERIMATRIX – stroma of connective tissue • MATRIX – keratinising squamous epithelium resting on thin stroma of fibrous tissues . • KERATIN DEBRIS – central white mass produced by the matrix

  7. Cholesteatoma has the capacity for progressive and independent growth at the expense of underlying bone and has a tendency to recur after removal.”

  8. CLASSIFICATION:- • CONGENITAL • ACQUIRED- primary acquired secondary acquired

  9. CONGENITAL CHOLESTEATOMA

  10. Pathogenesis • Congenital • Arise from embryonal rests of epithelial cells • COMMON SITES- middle ear – ASQ commonest site mastoid cerbellopontine angle petrous apex

  11. CONGENITAL CHOLESTEATOMAS • Most involve the anterior superior quadrant of the middle ear

  12. Clinical symptoms • Conductive hearing loss. • Otalgia • Vertigo or SNHL if labyrinth is invaded . IMAGING HRCT CT Scan – confirm location and size

  13. LEVENSON’S CRITERIA • White mass behind the normal ear drum • • Normal pars flaccida and pars tensa • • No prior history of perforation / Otorrhoea • • No previous otological procedures

  14. High Resolution Computed Tomography

  15. Surgical management of a congenital cholesteatoma • complete removal of the cholesteatoma matrix • The isolated middle ear cholesteatoma • removed transtympanically • Routine middle ear reconstructive techniques may be used if ossicles are eroded or removed or if the tympanic membrane is sacrificed.

  16. ACQUIRED CHOLESTEATOMA

  17. The pathogenesis of acquiredcholesteatoma There are four basic theories : • Invagination of the tympanic membrane • (retraction pocket cholesteatoma) (2)basal cell hyperplasia (3) epithelial ingrowth through a perforation (the migration theory) (4)squamous metaplasia of middle ear epithelium

  18. Invagination theory- Wittmack 1939 Eustachian tube dysfunction -negative ME pressure -pars flaccida retraction -squamous debris collected in the sac

  19. 2. Epithelial invasion theory: Haberman 1889:- keratinising squamous epithelium from the surface of the TM or meatus invades into the middle ear from perforation in TM.

  20. 3. Basal cell hyperplasia theory: Reudi’s theory • The basal cells of germinal layer of skin proliferate under the influence of infection and lay down keratinising squamous epithelium

  21. 4. Squamous metaplasia theory: Wendt 1873:- Simple cuboidal epithelium of ME cleft could undergo metaplastic transformation into keratinising epithelium because of repeated infection.

  22. PRIMARY AQUIRED CHOLESTEATOMA

  23. Primary acquired cholesteatoma • Called primary as there is no history of previous perforation • Secondary to ET dysfunction • Retraction pocket choleasteatoma in Pars flaccida or PSQ retraction pocket • Invagination theory is most accepted • Keratin debris collects in the retraction pocket

  24. Primary acquired cholesteatoma Normal TM Mesotympanic cholesteatoma primary acquired cholesteatoma

  25. Primary acquired cholesteatoma

  26. WHY ATTIC AND PSQ IS PREDISPOSED FOR RETRACTION ? • There are a fewer connective tissue fibres within the lamina propria (middle layer of TM) as compared to pars tensa • Normal migratory pattern of TM epithelium changes within retraction pocket . This results in keratin formation and choleasteatoma • PSQ – weakest quadrant of the pars tensa

  27. SECONDARY AQUIRED CHOLESTEATOMA

  28. Secondary Acquired Cholesteatoma • Migration Theory – most accepted • Originates from a tympanic membrane perforation • As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear

  29. Microbiology:- Pseudomonas Proteus Mixed aerobic and anaerobic organisms

  30. Behaviour of choleasteatoma BONE RESORPTION • Pressure necrosistheory- unlikely • Enzymatic theory by cytokine mediated inflammation : Inflammation Release IL-1,IL-6, IL-11, TGF-alpha cause osteoclast activation Acid phosphatase, collagenase, acid proteases, cathepsin like proteolytic enzyme, matrix metalloproteases

  31. bone erosion • Ossicles : most long process of incus • Bony labyrinth • facial nerve canal • tegmen tympani • Sinus plate

  32. ATTICOANTRAL TYPE • It involves POSTERIOR SUPERIOR part of the middle ear cleft (attic, antrum , posterior tympanum and mastoid)

  33. PATHOLOGY • Cholesteatoma • Osteitis and granulation tissue • Ossicular necrosis • Cholesterol granuloma

  34. Osteitis and granulation tissue

  35. OSSICULAR NECROSIS • LONG PROCESS OF INCUS • Hearing loss more than TTD • Cholesteatoma hearers

  36. CHOLESTEROL GRANULOMA • Granulation tissue with foreign body giant cells surrounding cholesterol crystals • Reaction to longstanding retention of secretion or haemorrhage

  37. Symptoms • Ear discharge • Impaired hearing- cholesteatoma hearer • Tinnitus • Vertigo

  38. Signs • Retraction pocket in early stage • Characteristic discharge • ‘Fishy odor of cholesteatoma • Attic/ marginal or total perforation • Cholesteatoma seen as • Pearly white sac through translucent TM or as • Pearly white flakes of epithelium through mouth of the sac, or as • In-growing skin though perforation

  39. Retraction pocket

  40. MARGINAL PERFORATION

  41. Primary acquired cholesteatoma

  42. Other signs • Granulation tissue in the attic/ postero-superior quadrant • Attic crust • Vascular polyp • Attic widening

  43. Evaluation • Examination under microscope • Cultures should be obtained in infected ears • X RAY mastoid– extent of bone destruction Cholesteatoma- sclerosis with cavity. • Pure tone audiometry • HIGH RESOLUTION CT SCAN OF TEMPORAL BONE

  44. Evaluation 1. Examination under microscope • Retraction pocket • Choleasteatoma- suction clearance and examination • Granulation from diseased bone • Aural polyps • Ossicles

  45. Evaluation • PURE TONE AUDIOMETRY – usually conductive loss, may vary greatly; confirm with tuning forks • pre-operative assessment • degree of hearing loss • Type of hearing loss

  46. Audiogram

  47. Computed Tomography • Erosion of scutum • Destruction of ossicular chain • Erosion of the labyrinth (fistula) • Low tegmen / tegmen defect • Facial nerve dehiscence • Petrous Apex Involvement

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