Chronic Suppurative Otitis Media: Attico - antral disease (CSOM-AAD) (COM-Squamous) Dr. Krishna Koirala 8/24/2018

Definition: Chronic pyogenic infection of middle ear cleft lasting for >3 months with cholesteatoma & granulation tissue in attic or postero-superior quadrant of pars tensa Unsafe/ Dangerous : Higher chances of complication due to bone erosion Hallmark of Disease : Cholesteatoma/granulations

Cholesteatoma Johannes Müller ( 1858) Defined as a three dimensional sac lined by matrix of keratinizing stratified squamous epithelium that rests on a thin layer of fibrous tissue and contains desquamated keratin debris which grows at the expense of surrounding bone Not a tumor and has no cholesterol Better term : Epidermosis

Cholesteatoma

Causes of bone destruction Hyperaemic decalcification Osteoclastic bone resorption Acid phosphatase ,collagenase, acid proteases proteolytic enzymes, leukotrienes, cytokines Pressure necrosis No role Bacterial toxins ?

Types of Cholesteatoma Congenital (McKenzie) Primary Acquired Retraction pocket (Wittmaack) Basal cell hyperplasia (Ruedi) Squamous metaplasia (Sade) Secondary Acquired Squamous metaplasia Epithelial migration (Habermann) Tertiary Acquired : Post-traumatic , post-tympanoplasty

Congenital Cholesteatoma Persistence of congenital cell rests in middle ear, petrous apex, cerebello-pontine angle Diagnostic criteria Intact TM No previous H/O otitis media Origin from embryonal inclusion of squamous epithelium

Acquired Cholesteatoma 1. Invagination / Retraction pocket (Wittmack’s theory) One of the primary mechanism of cholesteatoma formation Develops in posterosuperior quadrant of Pars tensa /Attic with adjacent canal wall erosion

Retraction pocket in pars flaccida or Postero-superior quadrant of pars tensa due to E.T. dysfunction

2. Basal cell hyperplasia (Ruedi) Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues

3. Primary squamous metaplasia Transformation of middle ear mucosa into squamous epithelium without TM perforation

4. Secondary squamous metaplasia Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation

5. Epithelial migration Migration of epithelium via T.M. perforation into middle ear

6. Tertiary / Post-traumatic cholesteatoma Mechanisms: 1. Epithelial entrapment in fracture line 2. Ingrowth of epithelium through fracture line 3. Traumatic implantation of epithelium into middle ear 4. Entrapment of epithelium medial to E.A.C. stenosis

Pathological Changes (Pathology) 1. T.M. perforation (marginal or attic) 2. T.M. retraction pocket (attic or P.S.Q.) 3. Cholesteatoma formation 4. Ossicles: destruction 5. Middle ear mucosa: edematous, red, polypoid 6. Aural polyp: red, fleshy 7. Osteitis & granulation tissue formation 8. Mastoid bone: erosion, sclerosis

Clinical Features Ear discharge : scanty, purulent, continuous, whitish to yellowish, foul- smelling, blood-stained Hearing Loss: conductive or sensori-neural T.M. perforation: marginal /attic /total T.M. retraction pocket: attic or P.S.Q. Cholesteatoma flakes Aural polyp, osteitis & granulation tissue

Features of Complications Severe otalgia, painful swelling around ear Vertigo, nausea, vomiting Headache + blurred vision + projectile vomiting Fever + neck stiffness + irritability / drowsiness Facial asymmetry Headache/retro-orbital pain (apex petrositis) Ataxia

Attic cholesteatoma

PSQ cholesteatoma & granulation tissue

Attico-antral Tubo -Tympanic Otorrhea Scanty, continuous, Purulent, blood stained , foul smelling Profuse, intermittent, Mucoid, not blood stained and non foul smelling Perforation Attic / marginal retraction pocket Central perforation Cholesteatoma, granulation Yes No Complications Common Rare Treatment Mastoid Exploration Myringoplasty/ Tympanoplasty Disease categorization Unsafe Safe disease

Investigations Examination under microscope ( EUM) Ear discharge swab: for culture and sensitivity Pure Tone audiometry X-ray mastoid : B/L 300 lateral oblique (Schuller) CT scan: revision surgery, complications, children

Advantages of E.U.M. Confirmation of otoscopic findings Epithelial migration from margin of perforation Cholesteatoma & granulations Adhesions & tympanosclerosis Assessment of ossicular chain integrity Collection of discharge for culture sensitivity

Uses of X-ray mastoid 1. Position of dural & sinus plates 2. Type of pneumatization : Cellular (80%), Diploic (<1%), Sclerotic (20%)small antrum, air cells absent 3. Cholesteatoma (cotton wool appearance) 4. Bone destruction: presence & extent 5. Mastoid cavity

Dural & sinus plates

Cellular mastoid

Sclerotic mastoid

Diploic mastoid

Attic bone erosion

Causes of big mastoid cavity Cholesteatoma erosion Mastoidectomy cavity Tubercular mastoiditis Coalescent mastoiditis Malignancy Eosinophilic granuloma Mega-antrum Large emissary vein

C.T. scan of temporal bone Posterior canal wall erosion

Mastoid cholesteatoma C.T. scan temporal bone Mastoid cholesteatoma

Medical - Conservative Treatment Options Medical - Conservative Topical ear drops and frequent suction clearance Indications: Early disease with shallow retraction pocket Only hearing ear with cholesteatoma Elderly patients Pts who are not fit for surgery under G.A. Pts who can regularly come for follow up

Surgical Treatment - Mainstay Canal Wall down Attico-antrostomy Modified Radical Mastoidectomy (MRM) Radical Mastoidectomy Canal Wall up Combined Approach Tympanoplasty (CAT)