1. CSOM - TTD And Sugical Management
D.Nayana V G
Senior resident
Dept of ENT
Yenapoya MC

2. Middle ear Cleft
Series of interconnected air-filled cavities which are located within the temporal bone. The middle ear cleft comprises: 1. The eustachian tube, through which the middle ear cleft obtains its air supply 2. The tympanic cavity (middle ear) 3. The mastoid antrum, which connects the tympanic cavity to the mastoid air cells 4. The mastoid air cell system. .

3. Embryology

4. Embryology
The first pharyngeal pouch expands into an elongate tubotympanic recess
The expanded distal part of this recess contacts the first pharyngeal groove, where it contributes to the formation of the tympanic membrane (eardrum)
The cavity of the tubotympanic recess gives rise to the middle ear cleft (ET,tympanic cavity and mastoid antrum)

5. ANATOMY

6. ANATOMY

7. ANATOMY

8. MIDDLE EAR EPITHELIUM
Mucous membrane of the nasopharynx continues with the middle ear
ET-pseudostratified ciliated columnar epithelium
Ant.& inf. Part of tympanic cavity-ciliated columnar epithelium
Post. Part- cuboidal epithelium
Epitympanum & mastoid air cells-flat nonciliated epithelium

9. ANATOMY

10. EUSTACHIAN TUBE
Pharyngotympanic tube is a channel connecting the tympanic cavity with nasopharynx. Runs forwards, downwards and medially from middle ear to nasopharynx

11. EUSTACHIAN TUBE

12. EUSTACHIAN TUBE FUNCTIONS
Ventilation of the middle ear associated with equalization of air pressure in the middle ear with atmospheric pressure
Protection of the middle ear from sound and secretions
Drainage of middle ear secretions into the nasopharynx with the assistance of the mucociliary system of the ET and middle ear mucous membrane

13. Defence Mechanism of Middle Ear
Gradient driven transmucosal exchange of gases between middle ear and blood vessels also helps in maintaning ME pressure
Induvidual with impaired middle ear ventillation are prone fo Middle ear inflammation

14. Definition
Otitis Media: An inflammation of middle ear without reference to etiology or pathogenesis
Inflammation of tympanomastoid compartment

15. Csom-Definition
It is the permanent abnormality of pars tensa or flaccida due to earlier acute otitis media , negative middle ear pressure or otitis media with effusion
CSOM no longer used as not necessarily a result of “gathering of pus”
TTD- Long standing infection of part or whole of middle ear cleft charectorised by ear discharge and permanent perforation

16. CSOM/com
AAD/Unsafe Disease/Squamosal
TTD/Safe disease/Mucosal disease

17. TTD/Safe disease/Mucosal disease
Infection limited to mucosa and the anteroinferior part of middle ear cleft
No serious complications, No bony erosions
Central perforation
Infectivity related to URTI

18. EPIDEMiOLOGY Higher in developing countries Affects both sexes
poor socioeconomic standards
poor Nutrition
Lack of health education
Affects both sexes
All age groups

19. AETIOLOGY
Sequelae of acute otitis media following exanthematous fever

20. Ascending infections via eustachian tube infected
Ascending infections via eustachian tube infected nose,sinuses,adenoids, tonsils
Allergy to ingestants such as milk,egg,fish

21. PATHOLOGY-Stages Acute stage Actively discharging ear.
Mucosa hyertrophied and congested
Inactive stage:
Dry pefoation in ant infeior quadrant.
Middle ear mucosa normal

22. Quiescent stage:
perforation of ear drum is present
middle ear dry
mucosa normal or hyertrophied
Healed stage:
eardrum healed withthinscar
Tympanosclerosis
ossicular chain intact

23. PATHOLOGY 1.Perforation of Pars tensa Central Perforation
2.Middle ear mucosa
Inactive – normal
Active – Oedematous and velvety
3. PolyP
Smooth mass of Pale
and oedematous mucosa

24. 4. Ossicular Chain: Intact and mobile Necrosis of long process of incus 5. Fibrosis and adhesions Due to healing process

25. 6. Tympanosclerosis Hyalinization and calcification of subepithelial connective tissue White chalky deposits on ossicles, promontory,joints,tendons windows

26. BACTERIOLOGY Aerobic pseudomonas Proteus Ecoli Staph Aureus Anaerobic
Bact.fragilis
Anaerobic stretococci

27. Symptoms
Ear discharge – Mucopurulent, profuse, non foul smelling and Non blood stained
Hearing Loss
Depends on Size of perforation
position of perforation
Ossicular chain,inner ear status
Fixation of drum to ossicles
Round window shielding effect
Mixed

28. Symptoms
Pain - occasionally indicate Otitis externa Fever

29. signs
Ear discharge Central perforation Middle ear mucosa Tuning Fork Test - CoHL Examination under microscope

30. Why TTD a Safe disease????... There is no risk of bone erosion
Not known to case intracranial complication
Discharge from middle ear flows freely through the perforation in pars tensa
Usually perforation surrounded by an intact TM
Annulus is intact in all cases

31. INVESTIGATIONS
PTA – CoHL
Xray Mastoid – Schullers View
/laws view

32. Ear discharge – Culture and Sensitivity
Xray PNS – Waters View
Nasal Endoscopy
Patch Test

33. TREATMENT AIM To control infections Eliminate ear discharge
Correct hearing loss
Conservative Management
Surgical Management

34. Conservative mangement
1.Aual Toilet Remove discharge and debris from ear Dry moping with absorbent cotton buds Suction clearance under microscope DA: NIHL Irrigation with sterile NS

35. 2. Ear drops Antibiotic with steroid drops
2. Ear drops Antibiotic with steroid drops. Increased absorption in case of perforation Avoid ototoxic drugs 3.Systemic antibiotics A/c exacerbation of c/c infected ear 4.Antihistamines and Decongestants

36. precaution 1.Keep ear dry Avoid water entry to ear Swimming avoided
Ear plugs
2. Pre existing sinus infection if any treated aggressively
3. Presence of focal sepsis is ruled out

37. SuRgical Management Aural polyp and granulation removed
Cauterization of perforation
RECONSTUCTIVE Surgery
Myringoplasty
Tympanoplasty
Eradication of disease - Cortical mastoidectomy + Tympanoplasty

38. Healing of perfoRation by cauteRy
Small and medium perforation
2o% AgNO3,Trichloroactetic acid, phenol
.5 mm of margin is cauterized .
repeated weekly until heals completely
rim of perforation kept moist
Heals in layers

39. Indication Central perforation Wide EAC Dry ear for 6 weeks

40. MYRINGOpLASTY
Surgical procedure to close the perforation of pars tensa
PRE-REQUISITE
Good ET tube function
Good cochlear function
No foci of infection in nose,PNS or nasopharynx
Dry ear for 6 weeks
CoHL

41. Approaches
Post aural Endaural
Trans canal

42. underlay/inlay
Edges freshened undersurface curetted Tympanomeatal flap elevated Graft kept under TM flap Flap repositioned High success Rate Medial displacement of graft Retraction of anterior edge and residual perforation

43. Onlay /overlay Edges freshened and undersurface curetted
Skin of EAC (TM Flap)is elevated
Epithelial layer over fibrous layer is elevated
Graft is placed
Skin is replaced
Easy and fast
Lateral displacement of graft
Anterior blunting
Trapping of squamous epithelium

44. Interlay Graft is placed between fibrous layer and mucosal layer of remnant TM

45. Tympanoplasty
An operation performed to eradicate disease in the middle ear and to reconstruct the hearing mechanism without mastoid surgery with or without tympanic membrane grafting
American academy of Ophthalmology & Otorhinolaryngology
Tympanoplasty – Coined by Wullstein in 1953

46. Mechanical conduction of sound ( Conductive apparatus
Pinna ->acts as a collecting tube for the sound signal.
EAC ->like a cylinder..
TM -> Sound waves passing through the EAC strikes the TM and it vibrates. Out of 90 mm2 area, effective vibrating area 55 mm2.
ME-> Consists of 3 ossicles and 2 muscles. Vibrations of TM are transmitted to the stapes footplate via a chain of ossicles coupled to TM

47. Transduction of Mech. Energy to electrical impulses.
Movements of stapes footplate-> Cochlear flds move the basilar membrane, setting up shearing force b/w the tectorial membrane and hair cells. The distortion of Hair cells gives rise to cochlear microphonics which trigger the N. impulse.

48. Goal of Tympanoplasty Eliminate disease in ME. Improve hearing by
Restoring sound pressure transformation at oval window by
Intact TM
Mobile stapes foot plate
Provide sound protection for round window by closed air containing, mucosa lined ME

49. Aim of Tympanoplasty
To restore hearing to within 15 dB of the other ear to benefit binaural hearing
Nearly 80% can close AB gap to within 10 dB

50. Pre requisites.. Conductive hearing loss Adequate cochlear reserve
Good aeration
Healthy mucosa
No focus of infection
Wide ear canal

51. Acute exacerbation of CSOM
Chronic mucoid discharge due to allergic rhinosinusitis
Chronic otitis externa
Non functioning eustachian tube
Repeated surgical failure – adhesion, extrusion
Age < 7 yrs
Only or significantly better hearing ear

52. Wullstein Zollner’s Classification: is based on two things-
The remaining structures of the ME after all pathology have been eradicated.
How sound is transformed to OW while RW is being protected.

53. Type I Type II Perforated TM with normal ossicular chain
Inspection & closure of perforation
Type II
Sound transmission through a functioning but deformed chain
Neo TM is joined to stapes via a remodelled ossicle or prosthesis to retain lever advantage

54. Wullstein Zollner’s Classification
Type III
TM & ossicles destroyed except for intact & mobile stapes
Graft kept over stapes head – Myringostapediopexy (columella type)
Type IV (Baffle Effect)
Only a mobile footplate of stapes remains
Graft from ET to round window, foot plate of stapes is left exposed (cavum minor/ oval window tympanoplasty)

55. Wullstein Zollner’s Classification
Type V
Fixed foot plate
Type Va
Fenestra made to horizontal SCC graft sealing ME for round window protection
Type Vb
Stapedectomy

56. Grafts
Autograft
Isograft
Allograft
Xenograft

57. Temporalis fascia grafts
Most commonly employed
Advantages
Same incision
Autograft
Any size
Low BMR
Same thickness as TM
Good resistance to infection
Good survival rates

58. Technique Postaural incision and temporalis fascia harvested
T shaped incision over mastoid periosteum, periosteum elevated and post canal skin elevated

59. Technique
Two incisions following tympanosquamous and tympanomastoid suture lines
TM flap elevated
Perforation edges and undersurface freshened and elevated

60. Technique Middle ear inspected and pathology dealt with
Ossiculoplasty done if indicated
Fascia graft shaped and placed underlay under the TM remnant

61. Technique
In cartilage shield Tympanoplasty technique, cartilage (from concha, tragus) is used to reinforce the graft
Done in
Atelectatic ears
Previous tympanoplasty failures
TM flap epositioned and EAC packed with gelfoam
Postaural wound closed in layers
Mastoid bandage given
Post op care

62. CORTICAL MASTOIDECTOMY
This is an operation performed to remove disease from mastoid antrum and air cell system, with out disturbing the existing ME contents
Indication in TTD
If middle ear mucosa is wet and polpoidal
Persistent ear discharge
CM +Tympanoplasty

64. Thank you
Dr.nayana