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Chronic otitis media Chunfu Dai M.D & Ph. D Otolaryngology Department Eye Ear Nose and Throat Hospital Fudan University.

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Presentation on theme: "Chronic otitis media Chunfu Dai M.D & Ph. D Otolaryngology Department Eye Ear Nose and Throat Hospital Fudan University."— Presentation transcript:

1 Chronic otitis media Chunfu Dai M.D & Ph. D Otolaryngology Department Eye Ear Nose and Throat Hospital Fudan University

2 Definition COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss. COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

3 Etiology Unresolved middle ear infection. Unresolved middle ear infection. 1. Uncomplicated inflammatory process of the middle ear may evolve over time to produce persistent effusion and irreversible mucosal change 2. Fluid contains enzymes to alter the mucosal lining of the middle ear, it results in collapse or chronic perforation 3. Obstruction of narrow communication between the antrum and the attic, the aditus.

4 Etiology Dysfunction of Eustachian tube Dysfunction of Eustachian tube Chronic inflammation in nose and pharynx Chronic inflammation in nose and pharynx Dysfunction of immune system Dysfunction of immune system

5 Bacteriology Pseudomonas aeruginosa (40-60%) Pseudomonas aeruginosa (40-60%) Straphylococus aureus (10-20%) Straphylococus aureus (10-20%) Anaerobic bacteria Anaerobic bacteria

6 Pathology Middle ear mucosa is lined by secretory epithelium forming glandlike structure. Middle ear mucosa is lined by secretory epithelium forming glandlike structure. Hyalinization or tympanosclerosis Hyalinization or tympanosclerosis A healing response A healing response It occurs during quiescent periods It occurs during quiescent periods It is formed by fused collagenous fibers It is formed by fused collagenous fibers It is hardened by the deposition of calcium and phosphate crystals It is hardened by the deposition of calcium and phosphate crystals Conductive hearing loss is associated with masses restricting ossicular mobility Conductive hearing loss is associated with masses restricting ossicular mobility

7 Pathology Ossicular erosion is frequent in COM Ossicular erosion is frequent in COM Infection process per se Infection process per se Necrosis following vascular thrombosis Necrosis following vascular thrombosis It most commonly affect the lenticular process of the incus and head of the stapes It most commonly affect the lenticular process of the incus and head of the stapes

8 Pathology Cholesterol granulomas Cholesterol granulomas Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue It contains many cholesterol crystals and foreign body giant cells. It contains many cholesterol crystals and foreign body giant cells.

9 Pathology Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material. Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material. Classification Classification Congenital cholesteatoma Congenital cholesteatoma Acquired cholesteatoma Acquired cholesteatoma

10 Pathology Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma Pocket retraction: dysfunction of Eustachian tube Pocket retraction: dysfunction of Eustachian tube

11 Pathology Epithelial migration: the edge of a peripheral perforation Epithelial migration: the edge of a peripheral perforation Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida. Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida. Metaplasia from pseudostratified ciliated columnar epithelium Metaplasia from pseudostratified ciliated columnar epithelium

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13 Cholesteatoma Formation

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15 Pathology Pathogenesis of congenital cholesteatoma: Pathogenesis of congenital cholesteatoma: Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus

16 Pathology Diagnosis criteria: Diagnosis criteria: Patients without previous history of ear disease, with normal and intact TM Patients without previous history of ear disease, with normal and intact TM The temporal bone pneumatization should be normal The temporal bone pneumatization should be normal

17 Clinical presentations Otorrhea Otorrhea Malodorous associated with cholesteatoma Malodorous associated with cholesteatoma Hearing loss Hearing loss Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain

18 Clinical presentations Physical findings Physical findings Defect in the pars tensa of TM or the pars flaccida or both Defect in the pars tensa of TM or the pars flaccida or both Atelectatic lesions in tensa or flaccida pars Atelectatic lesions in tensa or flaccida pars Squamous epithelial invasion may invade middle ear Squamous epithelial invasion may invade middle ear Granumoms, polyps, tympanosclerotic plaques in middle ear Granumoms, polyps, tympanosclerotic plaques in middle ear

19 Radiographic evaluation Indications for image study Indications for image study Uncontrollable aural discharge Uncontrollable aural discharge Complications such as facial paralysis, labyrinthitis Complications such as facial paralysis, labyrinthitis When central nervous stystem involvement is suspected, MRI should be considered. When central nervous stystem involvement is suspected, MRI should be considered. Coronal CT scan is perferred Coronal CT scan is perferred

20 Differential diagnosis Tuberculous otitis media Tuberculous otitis media Hematogenous route Hematogenous route Multiple perforation and fetid Multiple perforation and fetid Creamy aural discharge Creamy aural discharge Active pulmonary disease Active pulmonary disease Multiple antituberculosis agents Multiple antituberculosis agents

21 Differential diagnosis Middle ear carcinoma Middle ear carcinoma Middle age patient Middle age patient Long term otorrhea with blood Long term otorrhea with blood Otalgia Otalgia Neoplasm in tympanum Neoplasm in tympanum CT scan showed temporal bone destruction CT scan showed temporal bone destruction

22 Managements Medical treatment Medical treatment Goals Goals Infection control Infection control Stabilization of process Stabilization of process Prevention of irreversible damage and development of serious complications Prevention of irreversible damage and development of serious complications 3%H202 clears up pus then antibiotics ear drops is used. 3%H202 clears up pus then antibiotics ear drops is used. With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used No aminoglycoside ear drops No aminoglycoside ear drops No powders containing antibiotic and erosion ear drugs No powders containing antibiotic and erosion ear drugs

23 Managements Surgery Surgery Goals Goals Safe ear: lesion removal Safe ear: lesion removal Dry ear Dry ear Hearing ear: reconstruction of ossiclar chain Hearing ear: reconstruction of ossiclar chain classification classification Myrigoplasty Myrigoplasty Tympanoplasty Tympanoplasty Tympanoplasty with mastoidectomy Tympanoplasty with mastoidectomy

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