CHRONIC

SUPPURATIVE OTITIS MEDIA

Definition of CSOM -long-standing infection of the middle ear cleft

-characterized by ear discharge, permanent perforation of tympanic membrane, ear polyp
-the perforations edges are covered by squamous epithelium
-it does not heal spontaneously and become, a sort of an epithelium-lined fistulous track

Incidence -incidence is higher in poor socioeconomic standards, poor nutrition and lack of health education.
-leading cause of hearing loss

Bacteria -Aerobic organisms : Pseudomonas aeruginosa (most common), Proteus, Escherichia coli and
Staphylococcus aureus
-Anaerobes: Bacteroides fragilis (most common) and anaerobic streptococci

Types of CSOM -safe/benign
-involves anteroinferior part of middle ear cleft
1) Tubotympanic Features -a/w a permanent central perforation
(safe) -no risk of serious complications

Aetiology 1. Complication of AOM (incomplete resolution); usually follow exanthematous fever leaving
behind a large central perforation. The perforation becomes permanent and permits repeated
infection from the external ear
2. Exposure to the environment and gets sensitised to dust, pollen and other aeroallergens causing
persistent otorrhoea
3. Ascending infections via the eustachian tube. Upper airway infection from tonsils, adenoids and
infected sinuses may be responsible for persistent or recurring otorrhoea
4.Lowered resistance to infection : malnutrition, anaemia, immunological impairment

Pathological 1.Perforation of pars tensa
changes -it is a central perforation and its size and position varies
 2.Middle ear mucosa
-may be normal when disease is quiescent or inactive
-oedematous and velvety when disease is active

3. Polyp
-a polyp is a smooth mass which has protruded through a perforation and presents in the external
canal ; polyps in tubotympanic CSOM is pale

4.Tympanosclerosis
-hyalinisation and subsequent calcification of subepithelial connective tissue of TM
-seen in remnants of tympanic membrane or under the mucosa of middle ear
-present as white chalky deposit on the promontory, ossicles, joints, tendons and oval and round
windows

5.Ossicular chain
-ossicular chain usually remains intact and mobile but may show some degree of necrosis,
particularly of the long process of incus

6.Fibrosis and adhesions
-result from the healing process and may impair mobility of ossicular chain or block the ET

7.Granulations - seen over the remnant of tympanic membrane

Treatment 1.Aural toilet
-dry mopping with absorbent cotton buds, suction clearance under microscope or irrigation with
sterile normal saline




2. Ear drops
-antibiotic ear drops containing neomycin or gentamicin are used. They are combined with steroids
which have local anti-inflammatory effect
-acid pH helps to eliminate pseudomonas infection, and irrigations with 1.5% acetic acid are useful
-care should be taken as ear drops are likely to cause maceration of canal skin, local allergy, growth
of fungus or resistance of organisms
- ear should be examined regularly as ear drops can cause maceration of canal skin, local allergy,
growth of fungus and resistance of organisms

3. Systemic antibiotics
-useful in acute exacerbation of chronically infected ear, otherwise, role of systemic antibiotics in
the treatment of CSOM is limited

4.Precautions
-patients are instructed to keep water out of the ear during bathing, swimming
-avoid hard nose-blowing as it can push the infection from nasopharynx to middle ear.
-avoid self-cleaning of the ear.
-stop the ear drops once the ear

5. Surgical treatment
-ear polyp or granulations, if present, should be removed before local treatment with antibiotics
-ear polyp should never avulsed because it may be attached to the stapes, facial nerve and
horizontal semicircular canal and can lead to complications (such as facial paralysis and
labyrinthitis)

6. Tympanoplasty
-in a dry ear, myringoplasty/tympanoplasty restore hearing and check repeated infection from the
external ear canal
-tissue used for graft material ; autologous temporalis fascia

2) Atticoantral Features -involves posterosuperior part of middle ear cleft or in the pars flaccida
(unsafe) -the bone affected is tympanic ring, ossicles, mastoid air cells, bony walls of attic, aditus and
antrum
-associated with cholesteatoma, which because of its bone eroding properties, causes risk of
serious complications
-unsafe or dangerous type of CSOM

Pathological 1.Cholesteatoma (not tumour, no cholesterol)
changes -epidermal inclusion cyst, which opens into the external auditory canal (EAC)
-it contains desquamated keratotic debris (mainly white-yellow keratin flakes resembling
cholesterol crystals) from its keratinizing squamous epithelial lining
-pearly white flakes of cholesteatoma can be seen in the retraction pockets
-the most common sites are attic and posterosuperior region but cholesteatoma may extend and
present into other parts of middle ear cleft
-has destructive nature and erodes bone and other structure (dura, facial nerve, semicircular canal)
-cholesteatoma has two parts :
*Matrix: made up of keratinizing squamous epithelium, which rests on a thin stroma of fibrous
tissues.
*Central white mass: consists of keratin debris, which is produced by the matrix

2.Osteitis and granulation tissue
-osteitis involves outer attic wall and posterosuperior margin of the tympanic ring
-a mass of granulation tissue surrounds the area of osteitis and may even fill the attic, antrum,
posterior tympanum and mastoid

3.Ossicular necrosis
-common in atticoantral disease
-destruction may be limited to the long process of incus or may also involve stapes superstructure,
handle of malleus or the entire ossicular chain
-therefore, hearing loss is always greater than in disease of tubotympanic type
 -occasionally, the cholesteatoma bridges the gap caused by the destroyed ossicles, and hearing loss
is not apparent (cholesteatoma hearer)

Ix 1. Examination under microscope
-all patients of chronic middle ear disease should be examined under microscope (Fig. 11.8). It may
reveal presence of cholesteatoma, its site and extent, evidence of bone destruction, granuloma,
condition of ossicles and pockets of discharge

2. X-ray mastoids/CT scan temporal bone
- indicate extent of bone destruction and degree of mastoid pneumatisation

Treatment The types of surgical procedures (mastoidectomy) are done to remove the cholesteatoma

Canal wall-up procedure (intact posterior meatal wall or closed procedure)
-This procedure employs combined approach
-Cholesteatoma is approached through the EAC and mastoid cavity
-The posterior canal wall remains intact and keeps the EAC and mastoid cavity separate (closed)
-Through it gives dry ear, better hearing and less postoperative care, patients need long
postoperative follow-up
-The chances of residual and recurrent cholesteatoma are high.
-The approaches for this procedure include: With facial recess approach
: Without facial recess approach

Canal wall-down procedure (open procedure)
-The cholesteatoma is fully exteriorized and mastoid cavity and EAC become one big cavity
-The commonly performed procedures include: Radical mastoidectomy
Modified radical mastoidectomy
Bondy procedure
Tympanoplasty reconstructive surgery
Regular aural toilet in annular osteotitis


Tubotympanic (safe) Atticoantral (unsafe)

Discharge Profuse, mucoid, odourless Scanty, purulent, foul smelling
Perforation Central Attic or marginal
Granulations Uncommon Common
Polyps Pale Red and fleshy
Cholesteatoma Absent Present
Complication Rare Common
Hearing Mild to moderate conductive deafness Conductive or mixed deafness


Complication of CSOM

Pain -pain is uncommon in uncomplicated CSOM

-its presence is considered serious as it may indicate extradural, perisinus or brain abscess
-sometimes, it is due to otitis externa a/w otorrhea
Vertigo -indicate erosion of lateral semicircular canal which may progress to labyrinthitis or meningitis
Persistent headache -suggestive of an intracranial complication

Facial weakness -indicates erosion of facial canal
Fever, nausea and vomiting -intracranial infection
Irritability and neck rigidity -meningitis
Diplopia -Gradenigo's syndrome
Ataxia -labyrinthitis or cerebellar abscess
Abscess round the ear mastoiditis