Com squamous
- 1. Chronic Suppurative Otitis Media: Attico - antral disease (CSOM-AAD) (COM-Squamous) By Dr Amit Jha 1st Year PG Resident , ENT-HNS
- 2. Definition: • Chronic pyogenic infection of middle ear cleft lasting for >3 months with cholesteatoma & granulation tissue in attic or postero-superior quadrant of pars tensa • Unsafe/ Dangerous : Higher chances of complication due to bone erosion • Hallmark of Disease : Cholesteatoma/granulations
- 3. Cholesteatoma • Johannes Müller ( 1858) • Defined as a three dimensional sac lined by matrix of keratinizing stratified squamous epithelium that rests on a thin layer of fibrous tissue and contains desquamated keratin debris which grows at the expense of surrounding bone • Not a tumor and has no cholesterol ( Ludman ) • Better term : Epidermosis ( Tumarkin )
- 4. Cholesteatoma : •It is a three dimensional epidermal and connective tissue structure , formed due to accumulation of exfoliated Keratin in middle ear cleft . It has the capacity for progressive independent growth at the expense of underlying bone . - Abramson , 1977 It has been accurately described as Keratoma - by Schuknecht
- 6. Histologically • Cystic Content o is composed of fully differentiated anucleate keratin squames. • Matrix o contains keratinizing squamous epithelium lining a cyst like structure. • Perimatrix o known as lamina propria o peripheral part of cholesteatoma consists of granulation tissue and cholesterol granules. o This layer is in contact with the bone. It is the granulation tissue which releases enzymes that cause bone destruction.
- 7. Causes of bone destruction • Hyperaemic decalcification • Osteoclastic bone resorption – Acid phosphatase ,collagenase, acid proteases proteolytic enzymes, leukotrienes, cytokines •Pressure necrosis •Bacterial toxins
- 8. • Congenital • Primary Acquired – Retraction pocket (Wittmaack) – Basal cell hyperplasia (Ruedi) – Squamous metaplasia (Sade) • Secondary Acquired – Squamous metaplasia – Epithelial migration (Habermann) • Tertiary Acquired : Post-traumatic , post-tympanoplasty Types of Cholesteatoma
- 9. Congenital Cholesteatoma ⦁ Definition (Levenson, 1989) – 5 points White mass medial to normal tympanic membrane Normal pars flaccida and pars tensa No prior history of otorrhea or perforations No prior otologic procedures Prior bouts of otitis media not grounds for exclusion
- 10. Theories “Congenital cholesteatoma” ⦁ Epithelial cell rest theory ⦁ Squamous metaplasia theory ⦁ Epidermoid formation theory ⦁ Invagination theory ⦁ ESEI
- 11. Teed’s theory – Failure of involution of embryonic cell rest ⦁ Proposed in 1936 ⦁ The embryonic ectodermal epithelial cell rests that is present during fetal development in proximity to the geniculate ganglion fails to involute. ⦁ Persistence of embryonic squamous cell rests in the temporal bone led to the formation of congenital cholesteatoma. ⦁ Presence of squamous cell rests in the temporal bone – fairly common. Usually they involute at a later date to become mature middle ear lining
- 12. Wendt’s Squamous Metaplastic theory ⦁ This was first proposed by Wendt in 1873 ⦁ The attic area of the middle ear cavity is lined by pavement epithelium. ⦁ According to Wendt, this pavement epithelium undergoes squamous metaplasia in response to infection thus forming a nidus for cholesteatoma formation.
- 13. Michael’s epidermoid formation theory ⦁ Michaels in 1980s – fetal human temporal bones ⦁ Identified squamous cell tuft present from 10-33 wk of gestation. ⦁ This “epidermoid formation” was noted in anterosuperior wall of ME cleft. ⦁ Failure of involution could be basis of cholesteatoma in anterosuperior mesotympanum
- 14. Reudi’s invagination theory ⦁ First proposed by Ruedi ⦁ Suggested in-utero infection of TM causing it to invaginate into the middle ear cavity and produce stratified squamous epithelium. ⦁ These invaginations predispose to cholesteatoma formation.
- 15. Congenital Cholesteatoma ⦁ Origin remains uncertain ⦁ Usually starts from the antero superior quadrant ⦁ Spreads through the posterior superior quadrant, attic and finally into the mastoid cavity ⦁ Mean age of presentation is 4.5 yo ⦁ M:F ratio is 3:1 ⦁ Incidence is 0.12 per 100,000 people
- 16. ⦁ Anterosuperior quadrant > Posterosuperior quadrant
- 17. Acquired Cholesteatoma 1. Invagination / Retraction pocket (Wittmack’s theory) –One of the primary mechanism of cholesteatoma formation –Develops in posterosuperior quadrant of Pars tensa /Attic with adjacent canal wall erosion
- 18. Retraction pocket formation Retraction pocket in pars flaccida or Postero-superior quadrant of pars tensa due to E.T. dysfunction cerebellopontine angle
- 19. Reasons for Retraction pocket in posterosuperior quadrant : • Poser- superior part of pars tensa is thinnest • Rate of migration of epithelium is highest at posterosuperior canal wall • Poor ventilation of the postero-superioir mesotympanum due to too much crowding due to presence of ossicles • Presence of negative pressure in the posterosuperior mesotympanum because of : - Relatively large and deep posterior pouch - Proximity of the aditus ( due to large volume of the mastoid antrum )
- 20. 2. Basal cell hyperplasia (Ruedi) Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues . The cause for hyperplasia is subclinical inflammation in the attic .
- 21. 3. Primary squamous metaplasia( Ruede , Tumarkin and McGuckin) Transformation of middle ear mucosa into squamous epithelium due to infection without TM perforation
- 22. 4. Secondary squamous metaplasia( Wendt and Sade ) Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation
- 23. 5. Epithelial migration Migration of epithelium via T.M. perforation into middle ear
- 24. 6. Tertiary / Post-traumatic cholesteatoma • Mechanisms: 1. Epithelial entrapment in fracture line 2. Ingrowth of epithelium through fracture line 3. Traumatic implantation of epithelium into middle ear 4. Entrapment of epithelium medial to E.A.C. stenosis
- 25. Sade classification of Pars Tensa Retraction :
- 26. GradeIretraction • Dull, lusterless T.M. • Prominent annulus • Cone of light absent • Prominent lateral process • Handle of malleus medialized • Malleal folds sickleshaped
- 28. Grade III retraction • TMtouches thepromontory (atelectasis) butmobile onValsalva maneuverorSiegelization
- 29. GradeIVretraction TM firmly adherent to promontory & immobile onValsalva maneuver or Siegelization
- 30. Tos classification – Pars Flaccida Retractions: •Grade 1 – Simple Attic dimple •Grade 2 – Pars flaccida retracted maximally and drapped over neck of malleus •Grade 3 – As grade 3 with erosion of outer attic wall •Grade 4 – Deep Retraction with unreachable accumulated keratin
- 32. Pathological Changes (Pathology) 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, polypoid 6. Aural polyp: red, fleshy 7. Osteitis & granulation tissue formation 8. Mastoid bone: erosion, sclerosis
- 33. Sites for congenital cholesteatoma : •cerebellopontine angle •Petrous apex •Middle ear cleft •Jugular fossa
- 34. Clinical Features Ear discharge: scanty, purulent, continuous, foul- smelling, blood-stained Hearing Loss: conductive or sensori-neural T.M. perforation: marginal /attic /total T.M. retraction pocket: attic or P.S.Q. Cholesteatoma flakes Aural polyp, osteitis & granulation tissue
- 35. Features of Complications • Severe otalgia, painful swelling around ear • Vertigo, nausea, vomiting • Headache + blurred vision + projectile vomiting • Fever + neck rigidity + irritability / drowsiness • Facial asymmetry • Headache/retro-orbital pain (apex petrositis) • Ataxia
- 37. PSQ cholesteatoma & granulation tissue
- 38. Spread of cholesteatoma - In the middle ear cleft, cholesteatoma follows the path of least resistance and causes enzymatic bone destruction. - The growth of attic cholesteatoma is limited by the mucosal folds and suspensory ligaments of the ossicles. - Attic cholesteatoma first invades Prussak’s space (lateral most portion of epitympanum) and then into the recesses of epitympanum posteriorly, lateral to the body of incus.
- 39. •Inferiorly it goes into the middle ear via pouch of von Troltsch. (anatomical spaces between the malleolar folds & the tympanic membrane ) • Anteriorly cholesteatoma enters into the protympanum. •An attic cholesteatoma thus extends posteriorly into the aditus, antrum and •mastoid, inferiorly into the mesotympanum and medially surrounds the incus and head of the malleus
- 40. Prussak space : • Prussak space is a subcomponent of the lateral epitympanic • Boundaries : • lateral: pars flaccida of the tympanic membrane • medial: neck of the malleus • superior: lateral malleal ligament fold • inferior: lateral (short) process of the malleus
- 41. Destruction of bone : • Cholesteatoma destroys the bones, which come in its way such as ear ossicles, bony labyrinth, canal of facial nerve, sinus plate and tegmen tympani. • Formerly bone destruction was believed to be due to pressure necrosis. Currently, bone destruction has been attributed to enzymes. • They are liberated by osteoclasts and mononuclear inflammatory cells (associated with cholesteatoma) and include as collagenase, acid phosphatase and proteolytic enzymes.
- 42. Investigations • Examination under microscope • Ear discharge swab: for culture and sensitivity • Pure tone audiometry • X-ray mastoid : B/L 300 lateral oblique (Schuller) • CT scan: revision surgery, complications, children
- 43. Advantages of E.U.M. • Confirmation of otoscopic findings • Epithelial migration from margin of perforation • Cholesteatoma & granulations • Adhesions & tympanosclerosis • Assessment of ossicular chain integrity • Collection of discharge for culture sensitivity
- 44. Uses of X-ray mastoid 1. Position of dural & sinus plates 2. Type of pneumatization : Cellular (80%), Diploic (<1%), Sclerotic (20%) 3. Cholesteatoma (cotton wool appearance) 4. Bone destruction: presence & extent 5. Mastoid cavity
- 45. Dural & sinus plates
- 46. Cellular mastoid
- 48. Diploic mastoid
- 50. Causes of big mastoid cavity • Cholesteatoma erosion • Mastoidectomy cavity • Tubercular mastoiditis • Coalescent mastoiditis • Malignancy • Eosinophilic granuloma • Mega-antrum • Large emissary vein
- 51. C.T. scan of temporal bone Posterior canal wall erosion
- 52. C.T. scan temporal bone Mastoid cholesteatoma
- 53. Management History: 1. Hearing loss 2. Otorrhea: malodorous 3. Otalgia 4. Tinnitus 5. Vertigo Progressive unilateral hearing loss with a chronic foul smelling otorrhea should raise suspicion. ⦁ Previous history of middle ear disease 1. Chronic otitis media 2. Tympanic membrane perforation: Pars flaccida 3. Prior surgery
- 54. Examination: ⦁ Otoscopy ⦁ Microscopy ⦁ Positive fistula (pneumatic otoscopy will result in nystagmus and vertigo) response suggests erosion of the semicircular canals or cochlea ⦁ 512Hz tuning fork exam - Always relate with audiometry results
- 55. Hearing evaluation ⦁ PTA: Conductive hearing loss ⦁ Tympanometry May suggest decreased compliance
- 56. Imaging ⦁ Preoperative imaging with computed tomographies (CTs ) of temporal bones (2mm ) section without contrast in axial and coronal planes. 1. Allows for evaluation of anatomy 2. May reveal evidence of the extent 3. Screen for asymptomatic complications
- 57. Medical - Conservative • Topical ear drops + frequent suction clearance • Indications: – Early disease with shallow retraction pocket – Only hearing ear with cholesteatoma – Elderly patients – Pts who are not fit for surgery under G.A. – Pts who can regularly come for follow up Treatment Options
- 58. Management Cholesteatoma is a surgical problem Goals of surgery include: 1) To make the ear safe by eradicating the cholesteatoma and infection 2) To conserve residual hearing Improvement of hearing when possible 3) To provide acceptable cosmetic appearance 4) To reconstruct the ear in a manner that reduces the chances of recurrence
- 59. Surgeries • Grommet insertion (to manage early retraction pockets) • Canal wall down procedure • Canal wall up procedure
- 60. Canal wall down procedure • Most commonly used • Good access • Middle ear space reduced • Large cavity (cavity problems)
- 61. ⦁ Classic CWD operation is the modified radical mastoidectomy in which middle ear space is preserved ⦁ Radical mastoidectomy is CWD operation in which: Middle ear space is eliminated , Eustachian tube is plugged
- 62. Canal wall down procedure • Posterior canal wall is reduced up to the level of vertical portion of facial nerve • Middle ear, attic, antrum,and mastoid are exteriorized and made into a single cavity • Attic is obliterated • Large meatoplasty is performed
- 63. Indications of canal wall down • Cholesteatoma in the only hearing ear • Erosion of posterior canal wall • H/o vertigo suggesting labyrinthine fistula • Recurrent cholesteatoma after canal wall up surgery • Poor Eustachean tube function • Sclerosed mastoid with poor access to attic region
- 64. Canal wall down procedure : Advantages : • Residual disease is easily detected • Recurrent disease is rare • Facial recess is exteriorized Disadvantages : • Open cavity is created • Takes longer time to heal • Mastoid bowl maintenance can be life long problem • Shallow middle ear space makes OCR (Ossicular Chain Reconstruction) difficult • Dry ear precautions are essential
- 65. Bondy’s operation ⦁ A type of modified radical mastoidectomy in which the mastoid cavity is exteriorized without disturbing the intact ossicular chain and pars tensa. ⦁ Indication: epitympanic cholesteatoma with intact ossicular chain, normal pars tensa, and good hearing. ⦁ The advantages of the technique are one-stage surgery with preservation of preoperative hearing levels, which is not possible with any other procedure.
- 66. Canal wall up surgery • More conservative procedure • Posterior canal wall is retained • Middle ear space is maintained • Normal physiology is maintained • Usually is performed as a staged procedure
- 67. Canal -Wall Up : ⦁ CWU procedure developed to avoid problems and maintenance necessary with CWD procedures ⦁ CWU consists of preservation of posterior bony external auditory canal wall during simple mastoidectomy with or without a posterior with tympanotomy ⦁ Staged procedure often necessary with a scheduled second look operation at 6 to 18 months for: - Removal of residual cholesteatoma - Ossicular chain reconstruction if necessary ⦁ Procedure should be adapted to extent of disease as well as skill of otologist
- 68. Indications of canal wall up procedure • In patients with well pneumatized mastoid • Patients with good Eustachean tube function • In patient’s with limited disease (confined to the attic)
- 69. Contraindications of CWU • Patients with poor Eustachean tube function • Patient with labyrinthine involvement • Long standing ear disease • Patients with intra cranial complications
- 70. Advantages of CWU • Rapid healing time • No cavity problems • Hearing aids can be used without problems
- 71. THANK YOU !!!