1. Daekeun Joo Resident Lecture Series 11/18/09
Chronic Ear Disease
Daekeun Joo
Resident Lecture Series
11/18/09

2. ETD
URIs
Viral-induced damage to ET lining resulting in decreased mucociliary clearance
Viral invasion of ME mucosa results in inflamm
Reflux of NP bacteria through ET causing infection of ME
Allergies causing ME & ET inflammation
Anatomic abnormalities such as cleft palate or other craniofacial abnormalities
Know the difference b/w AOM, COME, CSOM
Inconclusive data: environmental factors such as daycare attendance, passive smoke exposure, pacifier usage. Also, method of feeding infants may contribute to ME infection, but all have been unsubstantiated.

3. 3 Physiologic functions of the ET
Ventilation or pressure regulation of the middle ear
Protection of the middle ear from NP secretions & sound pressures
Clearance or drainage of middle ear secretions in to the NP

5. Cholesteatoma
Squamous epithelium trapped w/in skull base, t-bone, middle ear or mastoid
Bone erosion occurs by 2 mechanisms:
1. Pressure effects (applied consistently over a long period of time) produce bony remodeling
2. Enzymatic activity at the margin of the chole enhances osteoclastic activity (increased when chole becomes infected)

6. Management
In the early half of the 20th century, cholesteatomas were managed by exteriorization (i.e. mastoid air cells exenterated, posterior EAC removed & ear canal widened) – CWD approach
In the 1950s & 60s, the House Clinic really clarified the anatomy of the facial recess to access the ME w/o taking the canal wall down

7. Goals of surgery for cholesteatoma
To make the ear safe by eliminating all chole & chronic infection
To make the ear problem-free for all usual activities of daily living including swimming
Conserve residual hearing
To improve hearing if possible

8. Patient with cholesteatoma in an only-hearing ear…what is the management?
CWD mastoidectomy with complete removal of chole
CWD mastoidectomy with exteriorization of chole
CWU mastoidectomy with 2nd look in 6-9 months
No surgery

9. 3 Types
Congenital – squamous epithelium trapped w/in t-bone during embryogenesis (usually found in ant. mesotympanum or periET area)
Primary acquired – arise as a result of TM retraction. Can occur in the epitympanum or posteriorly enveloping the stapes & retracting into the sinus tympani
Secondary acquired – occur as result of injury to the TM (i.e. AOM, trauma, even PE tubes)
1. Congenital choles usually identified in early childhood (6 mo to 5 years)
Unlike other forms, congenital choles are identified behind an intact & normal-appearing TM. The child often has no h/o recurrent suppurative ear disease, previous otologic surgery or TM perfs.
The classic primary acquired chole develops from deeper medial retraction of the pars flaccida into the epitympanum. Scutum is eroded and ossicular destruction is common. If the chole expands into the antrum, erosion of the tegmen can occur w/ exposure of dura as well as erosion of the lateral canal resulting in deafness and vertigo.
Primary acquired choles eroding posteriorly are likely to produce FN exposure & destruction of the stapedial superstructure
Posterior marginal perforations are the most likely to result in secondarily acquired chole formation.

10. What is the most common cause of continuous otorrhea in a patient that’s already had a CWD mastoidectomy?
Facial recess not drilled out enough
Remnant sinodural angle cells
Cholesteatoma left in sinus tympani
Answer would be air cells left in mastoid tip (most dependent area)….so pick this if this is an answer choice. Chole left in sinus tympani would be for a CWU procedure

11. What is this? Keratoma obturans Primary acquired cholesteatoma
Secondary acquired cholesteatoma
Primary cholesteatoma

12. A patient comes in with severe OE, pain and CN VII palsy, what is the best imaging modality for dx?CT
MRI
Radionucleotide scan
Technitium scans are positive in all MOE cases….allows for earlier dianosis than CT. Gallium scans return to normal after infection cleared so used to assess response to treatment.

13. A pt inadvertently has a TM retraction pocket extending into the sinus tympani transected during middle ear exploration. The TM defect was repaired with a graft. Which postop complication is he at greatest risk for?
Chole in epitympanum lateral to incus
Chole in mesotympanum medial to incus
Perilymphatic fistula at oval window
Damage to the lateral semicircular canal
The mesotympanum includes the facial recess and sinus tympani (bound superiorly by the ponticulus and lateral SCC and inferiorly by the subiculum)…so remember OPSSR (superior to inferior). Since the sinus tympani is NOT in the epitympanum but rather lives in the mesotympanum as a depression along the medial wall along with the round window niche (inferior) and the oval window niche (superior) I would expect the cholesteatoma to recur in the mesotympanum medial to the incus

14. CSOM
Chronic serous OM is defined as a MEE w/o perforation that persists > 1-3 months
Chronis suppurative OM is a perforated TM w/ persistent otorrhea >6-12 wks
Pseudomonas, S. Aureus, Proteus and K. Pneumoniae are most common
Chronic suppurative OM can occur w/ or w/o chole. Cholesteatoma is a surgical disease whereas some cases of CSOM can be treated medically.
CSOM begins with irritation and subsequent inflamm. of the ME mucosa. With inflammation you get granulation tissue
Most common bacteria is Pseudomonas Aeruginosa
Obviously the larger the perf the greater the chance of developing CSOM

15. Medical vs. Surgical Management
Treatment aims include: antibiotic gtt, regular aggressive aural toilet and control of granulation tissue
Indications for surgery in CSOM include: perf > 6 wks, otorrhea > 6 wks despite gtts, chole, CT e/o chronic or coalescent mastoiditis, CHL
1. So when you’re at Harbor or OV…..how do you treat patients that come in with a draining ear you need to think about the etiology, length of treatment and if/when to turn to surgical management.
2. Complications of CSOM include all of the complications associated with otitis media…which include both intratemporal (petrositis, facial paralysis, labyrinthitis) and intracranial (lateral sinus thrombosis, meningitis and IC abscess) complications.

16. Child with OM & opacified mastoid air cells on CT but no coalescence
Child with OM & opacified mastoid air cells on CT but no coalescence. Cx not helpful and pt spiking temps despite 3 days of IV Abx…
Radical mastoidectomy
Complete mastoidectomy
Simple mastoidectomy
Antibiotic drops and steroids

17. 5 Types of T-plasties (Wullestein)
Type 1 – simple closure of TM w/o OCR
Type 2 – any kind of OCR involving malleus, incus or both
Type 3 – placing TM graft over stapes head
Type 4 – stapes head absent but footplate present, so footplate is exteriorized to mastoid & graft is placed over it
Type 5 – fenestration operation (not done anymore)
1. Fenestration operation is done by making fenestra in the lateral SCC & then putting a graft over it

18. Types of Mastoidectomies
Cortical mastoidectomy – removal of mastoid cortex & exteriorization of mastoid air cells
CWU – can be used to eradicate chole through a facial recess approach
Modified radical – CWD, but the ossicles & TM remnants are preserved for hearing recon
Radical – ME & mastoid are exteriorized into a single cavity. Ossicles removed except stapes footplate & ET closed off.

19. When performing a mastoidectomy, drilling too deep during a facial recess approach can result in injury to which structure?
Posterior semicircular canal
Lateral semicircular canal
Chorda tympani
Mastoid segment of facial nerve

20. What is the most common complication of revision cholesteatoma surgery
Labyrinthine fistula
Facial nerve injury
TM perforation
Hearing loss
Fistula probably most common complication of initial surgery; while facial nerve injury more likely in revision surgery

21. While in surgery the surgeon notes that the cog has been eroded by chole, what is the most likely other structure affected?
Lateral semicircular canal
Vertical segment of FN
Labyrinthine segment of FN
Tympanic segment of FN

22. Which of the following theories on the pathogenesis of acquired chole does not exist?
Invagination of the tympanic membrane
Transdifferentiation
Basal cell hyperplasia
Epithelial ingrowth through a perforation
Squamous metaplasia of middle ear epithelium

23. The diagnosis of petrous apicitis is suspected by….
Scintigraphy
Plain X-Ray
Surgical exploration
Clinical grounds and CT
Tympanometry

24. It has been observed that pts with a h/o COME have…
More sclerotic mastoids w/ decreased pneumatization compared w/ healthy pts
Less sclerotic mastoids with decreased pneumatization compared w/ healthy pts
More sclerotic mastoids w/ increased pneumatization compared w/ healthy pts
Less sclerotic mastoids w/ increased pneumatization compared w/ healthy pts
More sclerotic mastoids w/ absent pneumatization compared w/ healthy pts

25. Tympanosclerosis is associated with…
Atherosclerosis of the internal carotid artery
Necrosis of the tympanic membrane
Cholesteatoma
History of otosclerosis
Recurrent bouts of acute otitis media

26. The End