2 Chronic Suppurative Otitis Media Attico-Antral Type CHOLESTEATOMAChronic Suppurative Otitis MediaAttico-Antral Type
3 It is skin in wrong place CholesteatomaIs epidermal cyst of the middle ear and/or Temporal bone with a squamous epithelial lining.Contain keratin and desquamated epithelium.Can be congenital or acquiredNatural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation.It is skin in wrong place
4 Cholesteatoma It erodes bone by: 1.Enzymatic activity. 2.Pressure necrosis (expansion of the sac).This may open pathways for spread of infection (Bony or Unsafe type o CSOM)
5 Pathogenesis of Cholesteatoma Congenital Cholesteatoma:Arises from embryonic epithelial tissue in the temporal bone ( may be in ME cavity or temporal bone especially the petrous apex).Epidermal cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice.
6 Congenital Cholesteatoma: Diagnosed as a pearly white mass behind an intact tympanic membrane in a child with no history of chronic ear disease.
7 Acquired Cholesteatoma PathogenesisSquamous epithelium may be found in the middle ear as a result of:InvaginationMigration (through a perforation)Squamous metaplasia
9 Acquired Cholesteatoma 1) Invagination Theory ( primary acquired )Prolonged ET obstruction creates negative ME pressure leading to retraction of pars flaccida (or the superior part of the membrana tensa) which becomes an invaginated into the ME (retraction pocket) and gradually distend with accumulated keratin and later on separate from the drum membrane.
14 Pathogenesis Of Cholesteatoma (cont.) 2) Migration Theory (Secondry acquired) The stratified squamous epithelium of the deep external auditory meatus grows through a marginal perforation into the middle ear cavity. 3) Metaplasia Theory Long standing suppuration can stimulate metaplasia of the simple squamous epithelium of the middle ear to stratified squamous epithelium.
15 Secondary Acquired Cholesteatoma Migration Theory – most acceptedOriginates from a tympanic membrane perforationAs the edges of the TM try to heal, the squamous epithelium migrates into the middle ear
16 Clinical Picture symptoms Signs 1) Hearing loss (marked) and tinnitus. Sometimes HL is minimal as the sac may bridges the gap between the necrosed ossicles.2) Foul smelling ear discharge.Signs1- Fetid scanty purulent ear discharge2- Perforated DM with cholesteatoma debris3- Conductive or mixed HL
17 Clinical PictureMass behind intact tympanic membrane in cases of congenital cholesteatomaSometimes the first presentation is with one of complications e.g. facial nerve paralysis or lateral sinus thrombophlebitisGranulation tissue or aural polyp may fill the ear canal with bloody ear discharge
19 Investigations1- Culture and Sensitivity: of the ear discharge. 2- Audiological assessment - CHL, mixed HL or dead ear 3- Imaging of the temporal bone: Only in cases with - Suspected or presence of complications, - Congenital cholesteatoma or - History of previous ear surgery
20 Imaging of TemporalAxial SectionCoronal Section
22 Treatment of Cholesteatoma Is Surgical, No role for medical treatment except for active ear infection (ototopical drops) Tympanoplasty with Mastoidectomy is the standard surgical procedure In cases with total HL radical mastoidectomy is indicated
23 Mastoidectomy Intact (bony ear) canal wall mastoidectomy Canal wall down mastoidectomyRadical Mastoidectomy ( dead ear)Modified Radical Mastoidectomy
24 Cholesterol Granuloma CGs, first reported in the mastoid and middle ear in 1894, may occur anywhere in the air cell system of temporal bone when eustachian tube obstruction, mucosal edema, temporal bone fracture, cholesteatoma, chronic otitis media or any another process blocks the air cell tracts.
25 Cholesterol Granuloma Cholesterol granuloma is a histological term used for the description of a tissue response to a foreign body such as cholesterol crystals released by the breakdown of blood and local tissue.It may arise any portion of the pneumatized temporal bone but most frequently involves the petrous apex
26 Cholesterol Granuloma CG can be a perfectly localized and isolated mass in any pneumatized area in the temporal bone, the middle ear cavity, mastoid antrum, external auditory canal and the petrous apex.
27 Cholesterol Granuloma Cholesterol granuloma (CG) of the middle ear typically presents with a conductive hearing loss and a blue eardrum; those at the petrous apex either manifest with side-effects from bony erosion (with sensorineural hearing loss, tinnitus, vertigo or cranial nerve impairment), or are identified as incidental findings.
28 OTORRHOEADefinition: Discharge of abnormal material through the external ear canal Ear Wax is considered as normal external ear secretion not discharge
29 OTORRHOEADescription Amount: Scanty or profuse Nature: Watery, mucoid (& muco-purulent), purulent or bloody (sanginous) Smell: Cholesteatoma & external otitis
31 WATERY OTORRHOEA CSF Otorrhoea: Mostly traumatic Skull base fracture (commonly the longitudinal type)Iatrogenic (post-operative)Rarely, malignant neoplasm eroding the skull base
32 Bloody Otorrhoea Traumatic: Trauma of the external, middle ear and skull baseInflammatory:Bullous myringitis, acute and chronic otitis mediaNeoplastic:glomus , carcinoma of external or middle ear
33 Mucopurulent Otorrhoea Always from middle ear; Acute and chronic otitis media Pulsating ear discharge: Acute or acute on top of chronic suppurative otitis media with small perforation of drum membrane Intra-cranial complications of suppurative otitis media ( extra-dural abscess)
34 Muc-opurulent Otorrhoea Reservoir Sign: Rapid recollection of discharge in the external ear canal which indicates coalescent mastoiditis
35 PURULENT OTORRHOEAExternal otitis and cholesteatoma Usually smelly (fetid) Management of cases of ear discharge is according to the cause N.B. No packing of external ear in suspected cases of CSF otorrhoea.