The ear

Hiroshima 1945

Chronic Suppurative Otitis Media (CSOM)
Persistent disease, insidious in onset manifested clinically as long standing painless aural discharge with deafness. It is grouped into two clinical types; Tubotympanic (safe). Atticoantral (dangerous) disease.

Tubotympanic Disease

Benign. Rarely gives rise to any serious complications. Why it is called TUBOTYMPANIC ? Because the persisting or recurring infection spread via the ET to the tympanic cavity

Aetiology

It is a complication of AOM where there is persisting perforation of the TM. It therefore usually starts in infancy and early childhood. Reinfection either through the nasopharynx (tonsillitis, adenoid hypertrophy and sinusitis) perforation allows active infection to persist or to recur.

Bacteriology

gram negative (high incidence) proteus pseudomonas aeroginosa. Anaerobic

Pathology

Central perforation Polyp

Clinical Picture

Mucoid or mucopurulent discharge …intermittent or persistent. CHL

Examination

Otoscopy: Central TM perforation in the pars tensa. Tuning fork tests CHL.

Investigations

PTA: CHL. X-ray and CT scan shows sclerosis with clouding of the mastoid air cells. Swab of the aural discharge for c/s.

Treatment

Elimination of URTI Medical Treatment Aural toilet Local antibiotic /steroid drops Systemic antibiotics Surgical treatment Removal of polyps and granulation tissue Myringoplasty

Atticoantral Disease

Erosion of bone may extend to adjacent vital structures danger of serious complications; both intra- and extracranial. This type of infection is usually associated with cholesteatoma.
The bone of the attic, mastoid antrum and air cells are involved as well as the mucosa of the middle ear cleft (therefore called atticoantral disease).

Cholesteatoma

Sac of keratinizing sq. epithelium Surrounded by granulation tissue The surface layers of epithelium keep producing keratin leading to thin-walled sac containing cheesy material. The granulation tissue on the outside of the sac produces lysozymes and this gradually erodes the ossicles, ear drum and mastoid bone. The suffix “oma” may suggest that it is a tumour, this is not the case, though if untreated it will continue to expand and destroy surrounding structure. It is a skin in wrong place

Theories of origin of cholesteatoma

1. Congenial: This is unrelated to CSOM as it arises from embryonic epithelial tissue and occurs in the temporal bone and in the middle ear. 2. Acquired Invagination theory Emigration theory Metaplasia theory:

Clinical picture of Atticoantral disease

Insidious onset. Persistent or recurrent offensive purulent aural discharge CHL Bleeding from the ear Headache, vertigo and facial paralysis/complication.

Examination

Otoscopy Tuning fork test: CHL Fistula sign

Investigations

PTA: CHL. X-ray and CT scan of mastoid; Cholesteatoma appears as an area of translucency with a clearly out lined bony margin. Swab of the aural discharge for c/s.

Treatment

Conservative: no complications cholesteatoma is small and accessible removal of cholesteatoma and granulation tissue by fine crocodile forceps and suction clearance under magnification. Surgical: In most cholesteatoma surgical treatment is required.

Primarily the objective of surgical treatment

Eradication of potentially dangerous disease by mastoidectomy. Reconstruction of hearing mechanism



Complications of otitis media
(Infective process spreads beyond the confines of the middle ear).
Routes of infection
The bone
Venous spread to the cerebral venous sinuses
fracture line and fracture dehiscence
oval & round windows

Types of Complications

Extracranial Mastoiditis. Labyrinthitis Petrositis Facial nerve paralysis.
Intracranial Extradural abscess. Subdural abscess. Lateral (sigmoid) sinus thrombosis. Meningitis. Brain abscess. Otitic hydrocephalus.

Acute Mastoiditis

Acute infection of the mastoid antrum and air cells by virtue of the mucosal continuity between the middle ear cleft and mastoid process. The pus may break through the superficial cortex forming postauricular subperiosteal abscess.

Aetiology

Complication of AOM It can be superimposed on a chronic atticoantral disease in which the cholesteatoma has invaded the mastoid bone.

Clinical picture

children > adults. ..looks ill with fever and tachycardia. Earache aural discharge with relief of pain. cessation of discharge and recurrence of pain with pyrexia. If the disease continues uncontrolled the pus may break through the superficial cortex and forms postauricular abscess.

Examination

Retroauricular swelling and tenderness (+fluctuation if postauricular abscess forms) Soft tissue oedema with displacement of the auricle downwards and outwards. The postauricular sulcus tends to be retained. Narrowing of the EAM due to sagging of the posterosuperior meatal wall

Differential diagnosis Frunculosis /Infected sebaceous cyst.

Mastoiditis
Furuncle
1
Preceding history of OM
No such history
2
Deafness is present
No deafness until the canal is occluded
3
TM shows signs of OM
TM is normal
4
Tenderness on pressure over the mastoid
Tenderness on moving the auricle
5
Postauricular sulcus tends to remain
Postauricular sulcus tends to be obliterated with forward displacement.
6
Radiographic changes in mastoid
No radiographic changes in mastoid

Investigations

X-ray and CT scan shows opacity of the mastoid air cells.

Treatment

Medical Admission to hospital Antibiotic (in full dose): IV antibiotic according to c/s if there is discharge. If not IV penicillin for 48 h ,followed by oral antibiotic for a week. Surgical Indications: fluctuant area. pyrexia and tenderness continue. abscess drainage with or without cortical mastoidectomy - c/s -antibiotic for a week.

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