1. بسم الله الرحمن الرحيم

2. CHRONIC OTITIS MEDIA

3. Classification of Chronic Otitis Media
Chronic Non Suppurative Otitis Media
Otitis media with effusion “OME”
Adhesive otitis media
Chronic Suppurative Otitis Media “CSOM”
Tubotympanic (Safe)
Atticoantral (Unsafe)

4. OTITIS MEDIA WITH EFFUSION

5. DEFINITION
Presence of non-purulent fluid within the middle ear cleft

6. SYNONYMS Secretory otitis media Middle ear effusion
Sero-mucinous otitis media
Catarrhal otitis media
Glue ear
Serous otitis media
Non-suppurative otitis media

7. PREVALENCE
Between 20% and 50% of children do have OME at some time between 3 and 10 years of age
Two peaks at 2 and 5 years of age

8. RISK FACTORS Race Age Gender Season
Nasopharyngeal anatomical abnormalities
Cleft palate
Smoking
? Allergy

9. HISTOPATHOLOGY Changes in the mucosa
Vasodilatation & mononuclear cell infiltration
Metaplasia of the epithelium to ciliated columnar
Mucus secreting gland formation
Formation of fluid in the middle ear
Transudate
Exudate
Secretion

10. ETIOPATHOLOGY
Eustachian tube dysfunction
Chronic inflammation

11. ETIOLOGY Eustachian tube dysfunction Infections Poor muscular function
Adenoids
Barotrauma
Others
Infections
Unresolved AOM
Adenoiditis and other URTIs

12. SYMPTOMS
Hearing impairment
± Otalgia
Fluid sensation

13. Diagnosis

14. DIAGNOSIS

16. DIAGNOSIS
Otoscopy
Tuning fork tests

17. DIAGNOSIS
Otoscopy
Tuning fork tests
PTA

19. DIAGNOSIS
Otoscopy
Tuning fork tests
PTA
Tympanometry

22. DIAGNOSIS
Otoscopy
Tuning fork tests
PTA
Tympanometry
Myringotomy

23. TREATMENT Treatment of the cause if feasible Observation
Medical treatment
Antibiotics
Decongestants, ?Auto-inflation
?Steroids
Surgical
Myringotomy
Ventilation tubes (grommets)

29. COMPLICATIONS OF VENTILATION TUBES INSERTION
Infection
Blockage
Extrusion
Tympanosclerosis
Perforation

30. Iatrogenic Cholesteatoma

31. FACTORS AFFECTING TREATMENT
Age
Duration
Unilateral or bilateral
Degree of hearing impairment
Previous treatment
Associated conditions
Tympanic membrane changes
Others

32. SEQUELAE Spontaneous resolution Tympanosclerosis
50% resolve within 3 months. Only 5% persists for more than 12 months
Tympanosclerosis
Scarring, retraction and atelectasis
Cholesteatoma

33. Conclusion OME is very common in children
Etiology is associated with ET dysfunction and or chronic infection
In adults: Nasopharyngeal pathology should be considered
Most cases resolve spontaneously
Conservative treatment is of doubtful value
VT insertion restore hearing in the selected cases

34. Classification of Chronic Otitis Media
Chronic Non Suppurative Otitis Media
Otitis media with effusion “OME”
Adhesive otitis media
Chronic Suppurative Otitis Media “CSOM”
Tubo-tympanic (Safe)
Attico-antral (Unsafe)

35. Chronic Adhesive Otitis Media
Formation of adhesion in the middle ear after reactivation and subsequent healing of either CSOM or OME

36. Clinical Features History of CSOM or OME
Deafness is usually the only symptoms
TM shows various structural changes

37. Treatment
Observation
Surgical treatment
Hearing aid

38. Classification of Chronic Otitis Media
Chronic Non Suppurative Otitis Media
Otitis media with effusion “OME”
Adhesive otitis media
Chronic Suppurative Otitis Media “CSOM”
Tubo-tympanic (Safe)
Attico-antral (Unsafe)

39. CHRONIC SUPPURATIVE OTITIS MEDIA

40. ETIOLOGY Environmental Genetic Previous OM
Upper respiratory tract infections
Eustachian tube dysfunction

41. CLINICO-PATHOLOGICAL TYPES
Tubo-tympanic
Attico-antral

42. PATHOLOGY Signs of suppurative infection Signs of healing attempts
Discharge & perforation
Chronic inflammatory reaction in the mucosa and the bone (ostietis)
Signs of healing attempts
Granulation tissue & polyps
Fibrosis & tympanosclerosis
Cholesteatoma (attico-antral type)

43. CHOLESTEATOMA

44. DEFINITION
The presence of a desquamating stratified squamous epithelium in the middle ear

47. PATHOGENESIS OF CHOLESTEATOMA
Implantation (congenital or acquired)
Metaplasia
Epithelial migration

48. CLASSIFICATION OF CHOLESTEATOMA
Congenital
Acquired
Primary
Secondary

49. Effect of Cholesteatoma
Keratin encourages persistence of the infection
Matrix causes bone erosion

50. Clinical Features of CSOM

51. CLINICO-PATHOLOGICAL TYPES
Tubo-tympanic
Attico-antral (cholesteatoma)

52. SYMPTOMS OF CSOM Otorrhea Deafness Tinnitus
Intermittent, profuse & odorless in TT type
Persistent, scanty & malodorous in AA type
Deafness
Tinnitus
N.B. Any other symptom means complication

53. OTOSCOPIC EXAMINATION
Discharge
Present in TT type if active but may be absent
Usually is present in AA type
Perforation
Central: in TT type
Marginal or attic in AA type with cholesteatoma

54. PERFORATION IN TT CSOM

55. PERFORATION IN AA CSOM

56. OTOSCOPIC EXAMINATION
Discharge
Present in TT type if active but may be absent
Usually is present in AA type
Perforation
Central: in TT type
Marginal or attic in AA type with cholesteatoma
Polyps, granulation tissue, tympanosclerosis

58. Bacteriology

59. INVESTIGATIONS
Audiometry
Bacteriology
Imaging

60. Congenital Cholesteatoma

61. Cloudy middle ear in CSOM

62. Cholesteatoma with attic erosion

63. TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA
Depends on the type and presentation

64. Active TT type
Inactive TT type
Attico-antral type
(usually active)

65. Conservative Treatment
Active TT type
Inactive TT type
Conservative Treatment
Treat any predisposing factor
Keep the ear dry
Ear toilet
Antibiotics
Removal of polyps and granulations
TYMPANOPLASTY

66. TYMPANOPLASTY
An operation performed to eradicate disease in the middle ear cavity and to reconstruct the hearing mechanism

67. MYRINGOPLASTY
An operation performed to repair the tympanic membrane

68. AIMS OF TYMPANOPLASTY To close the perforation To prevent re-infection
To improve hearing

71. TREATMENT OF ATTICO-ANTRAL CSOM
Removal of cholesteatoma by mastoid operation

72. RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane, malleus and incus are removed leaving only the stapes in situ.

73. MODIFIED RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane and ossicles remnants are retained

74. AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY
Safety
Dry ear
Preserve hearing

75. Conclusion
In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing.
In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear

76. THANK YOU