2. Definition
•PyogeGeorge G. Browning
•The diagnosis of chronic otitis
media (COM) implies a permanent
abnormality of the pars tensa or
flaccida, most likely a result of
earlier acute otitis media, negative
middle ear pressure or otitis media
with effusion .
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. 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
15. 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
17. 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
19. 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
20. Why is mucosal disease safe?
There is no risk of bone erosion
Not known to cause
intracranial complications
Discharge from middle ear flows
freely through the perforation in the
pars tensa
Usually the perforation of pars
tensa is surrounded by a rim of
intact drum
The annulus is intact in all these
21. Stages of Tubotympanic disease
Stage Otorrhoea Eardrum
perforatio
n
Last ear
discharg
e
Active Present Present -
Quiescent Absent Present < 6 months
Inactive Absent Present > 6 months
Healed Absent Absent -
22. Investigations for CSOM TTD
• Examination under microscope
• Ear discharge swab: for culture sensitivity
• Pure tone audiometry
• X-ray mastoid: B/L 300 lateral oblique (Schuller)
(Done when cortical mastoidectomy is required
in CSOM TTnot responding to antibiotics)
23. 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
24. 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
25. 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
28. 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
29. • 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
32. Kartush T
.M. Patcher
• Indicated in:
– Perforation in only hearing
ear
– Patient refuses surgery
– Patient unfit for surgery
– Age < 7 years
33. Surgical Treatment
• Indicated in inactive or quiescent
stage
– Myringoplasty
– Tympanoplasty
• Indicated in active stage
– Cortical Mastoidectomy
– Aural polypectomy
34. 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
35. Hearing Restoration
1) Myringoplasty
- Surgical closure of perforation of pars tensa of Tympanic membrane
without ossicular reconstruction
2) Tympanoplasty
- Tympanoplasty is the surgical operation performed to eradicate
disease in the middle ear with or without tympanic membrane
graft.
36. 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
38. 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
39. Contraindications
• Purulent ear discharge
• Otitis externa
• Respiratory allergy
• Age < 7 yr (Eustachian tube not fully
developed)
• Only hearing ear
40. Methods
Techniques
• Underlay: graft placed medial to fibrous
annulus
• Overlay: graft placed lateral to fibrous annulus
Grafts used
• Temporalis fascia, tragal cartilage, Tragal
41. 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
42. 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
43. 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
46. 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
