Chronic Suppurative Otitis Media: Tubotympanic Type (CSOM TT)
- 1. Chronic Suppurative Otitis Media: Tubotympanic Disease (CSOM TT, COM Mucosal type) Dr. Krishna Koirala 2016-05-03
- 2. Definition • Pyogenic infection of middle ear cleft mucosa lasting for more than 3 months characterized by persistent perforation of pars tensa of tympanic membrane, ear discharge and decreased hearing
- 4. Perforations of Pars Tensa in CSOM TT
- 5. Involves only one quadrant or < 10% of pars tensa Small perforation
- 6. Medium perforation Involves two quadrants or 10 – 40 % of pars tensa
- 8. Retraction of pars Tensa of TM
- 9. Grade I retraction • Dull, lusterless T.M. • Prominent annulus • Cone of light absent • Prominent lateral process • Handle of malleus medialized • Malleal folds sickle shaped
- 10. Grade II retraction TM touches the incus
- 11. Grade III retraction TM touches the promontory (atelectasis) but mobile on Valsalva maneuver or Siegelization
- 12. Grade IV retraction TM firmly adherent to promontory & immobile on Valsalva maneuver or Siegelization
- 13. Predisposing factors for CSOM TT • 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
- 14. Bacteria responsible • Staphylococcus aureus • Pseudomonas aeruginosa • Klebsiella • Proteus • Streptococcus • Bacteroides
- 15. Routes of infection 1. Via Eustachian tube – U.R.T.I., nose blowing, regurgitation of milk 2. Via tympanic membrane perforation – Following A.S.O.M. or post-traumatic 3. Haematogenous (rare): exanthematous fever
- 16. Pathological Changes 1. Eardrum – Central perforation; myringosclerosis 2. Ossicles – Destruction (hyperemic decalcification) – Tympanosclerosis, Fibrosis + Adhesions 3. Middle ear mucosa: edematous, pale, congested 4. Mastoid bone: sclerosis
- 17. Clinical Features • Ear discharge: intermittent, profuse, mucoid to muco- purulent, whitish, odorless, not blood-stained • 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 • Tympanic membrane: central perforation
- 18. Stages of Tubotympanic disease Stage Otorrhoea Eardrum perforation Last ear discharge Active Present Present - Quiescent Absent Present < 6 months Inactive Absent Present > 6 months Healed Absent Absent -
- 19. Investigations for CSOM TTD • Examination under microscope • Ear discharge swab: for culture sensitivity • Pure tone audiometry • Patch test • X-ray mastoid: B/L 300 lateral oblique (Schuller) (Done when cortical mastoidectomy is required in CSOM TT not responding to antibiotics)
- 20. Examination under microscope • Confirmation of otoscopic findings • Epithelial migration at perforation margin • Cholesteatoma & granulations • Adhesions & Tympanosclerosis • Assessment of Ossicular chain integrity • Collection of discharge for culture sensitivity
- 21. Pure Tone Audiometry • Uses – Presence of hearing loss – Degree of hearing loss – Type of hearing loss – Hearing of other ear – Record to compare hearing post-operatively – Medico legal purpose
- 22. Patch Test • Performed when deafness is around 40-50 dB – Do pure tone audiometry: for hearing threshold – Put Aluminum foil patch over T.M. perforation – Repeat pure tone audiometry • Hearing improved Ossicular chain intact & mobile • Hearing same / worse Ossicular chain broken or fixed
- 23. Treatment of CSOM Tubo-tympanic Disease
- 24. Non-surgical Treatment • Precautions • Aural toilet • Antibiotics : Systemic & Topical • Antihistamines : Systemic & Topical • Nasal decongestants : Systemic & Topical • Treatment of respiratory infection & allergy • Tympanic membrane patcher
- 25. Precautions • Encourage breast feeding with 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
- 26. • Done only for active stage • Dry mopping with cotton swab • Suction clearance: best method • Gentle irrigation (wet mopping) • 1.5% acetic acid solution used T.I.D. • Removes accumulated debris • Acidic pH discourages bacterial growth Aural Toilet
- 27. Antibiotics • Topical Antibiotics: • Ciprofloxacin, Gentamicin, Tobramycin • Antibiotics + Steroid: for polyps, granulations • Neosporin + Betamethasone / Hydrocortisone • Oral Antibiotics: for severe infections • Cefuroxime, Cefaclor, Cefpodoxime, Cefixime
- 28. Antihistamines and Decongestants • Antihistamines – Chlorpheniramine – Cetirizine – Fexofenadine – Loratadine – Levocetrizine – Azelastine (topical) • Systemic Decongestants – Pseudoephedrine – Phenylephrine • Topical Decongestants – Oxymetazoline – Xylometazoline – Hypertonic saline
- 29. Kartush T.M. Patcher • Indicated in: – Perforation in only hearing ear – Patient refuses surgery – Patient unfit for surgery – Age < 7 years
- 30. Surgical Treatment • Indicated in inactive or quiescent stage –Myringoplasty –Tympanoplasty • Indicated in active stage –Cortical Mastoidectomy –Aural polypectomy
- 31. Methods to close perforation • T.M. perforation < 2 mm – Chemical cautery with silver nitrate –Fat grafting (Myringoplasty if these measures fail) • T.M. perforation > 2 mm – Tympanic membrane patcher – Myringoplasty
- 32. Chemical cautery
- 33. Surgical Approaches to the middle ear
- 37. Hearing Restoration • Myringoplasty – Surgical closure of tympanic membrane perforation • Ossiculoplasty – Surgical reconstruction of ossicular chain • Tympanoplasty – Surgical removal of disease + reconstruction of hearing mechanism without mastoid surgery
- 38. Principles of hearing restoration • Intact tympanic membrane • Intact ossicular chain • Functioning receiving & relieving windows • Acoustic separation of these windows • Functioning Eustachian tube • Absence of sensorineural hearing loss • Absence of active infection / allergy in middle ear cleft
- 39. Myringoplasty Surgical closure of perforation of pars tensa of Tympanic membrane without ossicular reconstruction
- 40. Aims • Permanently stop ear 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
- 41. Contraindications • Purulent ear discharge • Otitis externa • Respiratory allergy • Age < 7 yr (Eustachian tube not fully developed) • Only hearing ear • Cholesteatoma
- 42. Methods Techniques • Underlay: graft placed medial to fibrous annulus • Overlay: graft placed lateral to fibrous annulus Grafts used • Temporalis fascia, Tragal perichondrium, Vein graft, Fascia lata, Dura mater
- 50. Why temporalis fascia? • Basal metabolic 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
- 51. Onlay Underlay Graft cholesteatoma No Blunting of anterior tympano- meatal angle No Lateralization of graft No Delayed healing time (6 wk) 3-4 weeks No middle ear inspection Possible Difficult & takes more time Easier & quicker
- 52. Advantages of Local Anesthesia • Minimal bleeding • Hearing results can be tested on table • Facial palsy detected immediately • Labyrinthine stimulation detected immediately • No complications of General anesthesia
- 53. Tympanoplasty
- 54. Types
- 55. Type Pathology Graft placed 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 )
- 56. Ossiculoplasty • Ossicular graft material – Autograft • Ossicles : incus/malleus • Cartilage : Tragal/ conchal • Bone : spine of Henle/mastoid – Homograft: ossicles/cartilage/bone – Biomaterials: plastic(polyethylene)/ceramic/ teflon/gold (Biomaterials available as PORP and TORP)