1. CHRONIC OTITIS MEDIA (COM)
Dr Ashar Alamgir
Assistant Professor ENT
Rawalpindi Medical University

2. DEFINITION
Chronic otitis media (COM) is a long- standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation More than 12 weeks (3 months)

3. EPIDEMIOLOGY Incidence is higher in developing countries
poor socioeconomic standards, poor nutrition and lack of health education.
It affects both genders
all age groups
single most important cause of hearing impairment in rural population
3Vikram BK, Khaja N, Udayashankar SG, Venkatesha BK, Manjunath D. Clinico-epidemiological study of complicated and uncomplicated chronic suppurative otitis media. J Laryngol Otol May. 122(5): [Medline].

4. In UK overall incidence of active COM is 1.1%
According to WHO COM is one of the most common ear diseases in South East Asia having a prevalence of approximately 5.2% in the general population.
In UK overall incidence of active COM is 1.1%
In Pakistan the exact incidence is unknown
 World Health Organization. Prevention of hearing impairment from chronic otitis media, Report of a WHO/CIBA Foundation Workshop, held at The CIBA Foundation. World Health Organization, London, U.K. 1996; 19–21. 

5. MICROORGANISMS Pseudomonas aeruginosa, Staphylococcus aureus
Proteus mirabilis
Klebsiella pneumoniae
E. Coli
Aspergillus
Candida
Mariam, Ahmed K Mir A et al. Prevalence of bacteria in CSOM patients. Pakistan J. Zool. Vol 45(6):

6. Old classification
Tubotympanic (safe)
Atticoantral (unsafe)

7. NEW CLASSIFICATION OF CHRONIC OTITIS MEDIA
COM
Mucosal disease
Inactive
(permanent perforation)
Active
(chronic suppurative otitis media)
Healed perforation
Squamous disease
Retraction pockets (in pars
tensa or pars flaccida)
(cholesteatoma with discharge)

8. MUCOSAL DISEASE INACTIVE

9. MUCOSAL DISEASE ACTIVE

10. HEALED TM DIMERIC MEMBRANE

11. SQUAMOUS DISEASE INACTIVE

12. SQUAMOUS DISEASE (ACTIVE) CHOLESTEATOMA

13. TYPES OF PERFORATIONS

14. SMALL CENTRAL

15. LARGE CENTRAL

16. SUBTOTAL

17. TOTAL PERFORATION

18. ATTIC PERFORATION

19. MARGINAL PERFORATION

20. CHOLESTEATOMA
Three dimensional collection of epidermal and connective tissues within the middle ear cleft
Grows independently
Locally invasive and destructive

21. HISTOLOGY OF CHOLESTEATOMA

22. CHOLESTEATOMA
Sac of keratinized squamous epithelium and fibrous stroma in the middle ear or mastoid

23. CLASSIFICATION OF CHOLESTEATOMA
The cholesteatoma is classified into:
Congenital
Acquired
Primary
Secondary

24. Congenital cholesteatoma
It arises from the embryonic epidermal cell rests in the middle ear cleft or temporal bone.

25. Primary acquired
It is called primary as there is no history of previous otitis media or TM perforation.
Theories on its genesis are:
Invagination of pars flaccida.
Basal cell hyperplasia.
Squamous metaplasia

26. Secondary acquired
A pre-existing perforation in pars tensa. This is often associated with posterosuperior marginal perforation or sometimes large central perforation.
Theories on its genesis include:
Migration of squamous epithelium.
Metaplasia.

27. CHARACTERISTICS OF CHOLESTEATOMA
invades surrounding structures,
first by following the path of least resistance, and then by enzymatic bone destruction.
An attic cholesteatoma may extend backwards into the aditus, antrum and mastoid; downwards into the mesotympanum; medially, it may surround the incus and/or head of malleus.
It may cause destruction of ear ossicles, erosion of bony labyrinth, canal of facial nerve, sinus plate or tegmen tympani

28. continued…
Bone destruction by cholesteatoma has been attributed to various enzymes
collagenase
acid phosphatase
proteolytic enzymes, liberated by osteoclasts.
mononuclear inflammatory cells.
The earlier theory that cholesteatoma causes destruction of bone by pressure necrosis is not accepted these days.

29. COMPLICATIONS
INTRATEMPORAL
INTRACRANIAL

30. INTRATEMPORAL Labyrinthine fistula Labyrinthitis
Serous
Suppurative
Facial nerve paralysis
Petrositis

31. INTRACRANIAL Meningitis Extradural abscess Subdural abscess
Cerebellar abscess
Temporal lobe abscess
Sigmoid sinus thrombophlebitis
Otitic hydrocephalus

32. Meningitis

33. Extradural abscess

34. Subdural abscess

35. Temporal lobe abscess

36. Sigmoid sinus thrombophlebitis

37. Otitic hydrocephalus

38. EXAMINATION UNDER MICROSCOPE
Microscopic evaluation of every ear with active COM to formulate a policy of management.

39. FINDINGS IN EUM size and site of the defect type of discharge
Remaining TM around the defect
appearance of the middle ear mucosa
polyp and granulations
integrity of the ossicular chain

40. AUDIOMETRY
essential for preoperative assessment and to confirm the degree and type of hearing loss.

41. RADIOLOGICAL FEATURES OF CHOLESTEATOMA DR FAKIHA AHMED CONSULTANT RADIOLOGIST

42. Congenital cholesteatoma:only 2% Acquired cholesteatoma: 98%
Cholesteatomas of the temporal bone and middle ear can be divided into:
Congenital cholesteatoma:only 2%
Acquired cholesteatoma: 98%
primary (no history of chronic otomastoiditis)
secondary (the vast majority):
pars flaccida
pars tensa
External ear canal cholesteatoma
Petrous apex cholesteatoma

43. PRACTICAL POINTS
Important CT features to comment on when reporting a cholesteatoma:
erosions of the
---Scutum ---ossicles ---lateral semicircular canal
dehiscence of the
---facial nerve canal ---tegmen tympani
the integrity of the
---epitympanum
---aditus ad antrum and mastoid antrum
---oval and round window
the presence of cholesteatoma in the sinus tympani (which is the most hidden recess of the middle ear): to avoid residual disease
Complications ---middle/posterior cranial fossa abscess

44. CT SCAN OF PATIENT

45. CT SCAN OF PATIENT

46. X-Ray mastoid/temporal bone is an obsolete examination
HRCT OF TEMPORAL BONE
Usual modality of choice
Excellent in delineation of the bony structures, including bony ossicles, scutum and lateral semicircular canal
Required for preoperative planning, to exclude perforation of the bony tegmen and rule out intracranial extension/complications

48. ATTIC
TYMPANIC
ATTICOTYMPANIC

49. CHOLESTEATOMA EXTENDING INTO MASTOIC ANTRUM
CHOLESTEATOMA EXTENDING INTO MASTOID AIR CELLS AND CAVITY

51. MRI
Conventional non-contrast MR imaging with diffusion-weighted imaging is recommended in all patients with a suspicion of cholesteatoma
Should be performed especially in patients with previous surgery for cholesteatoma since recurrence or residual lesion can be detected with great accuracy.
Differentiation between granulation tissue and cholesteotoma is far superior
If negative, it can obviate "second look" surgery

52. Case of recurrent cholesteatoma- showing mixed signal on T1WI, high signal on T2WI and showing bright signal on DWI sequence signifying diffusion restriction

53. Post-operative case of cholesteatoma
Large area of signal abnormality in right mastoid–middle ear complex (arrows).
No focal area of diffusion restriction is noted on SS TSE DW (c) sequence.
Delayed postcontrast (d) images reveal homogenous enhancement within the lesion.
This scan was interpreted as negative for cholesteatoma.
Surgery revealed presence of granulation tissue

54. Large well-defined expansile osteolytic lesion (asterisk) involving the right petrous apex, internal auditory canal (IAC) and geniculate fossa with associated soft tissue density lesion. Associated ossicular chain destruction
Large corresponding area of focal signal abnormality is seen on T1W and T2W axial images.
The lesion shows diffusion restriction (appears bright) on coronal SS TSE DW sequence
Delayed postcontrast axial images reveal non- enhancing nature of the lesion with thin marginal rim enhancement (arrows).
These findings are highly suggestive of a petrous apex cholesteatoma.

55. Management Tubotympanic (mucosal)
MEDICAL
SURGICAL
Local
Aural toilet
Antibiotic drops
Systemic
Antibiotics
Decongestants
Myringoplasty
Tympanoplasty

56. Management Atticoantral (squamous)
MEDICAL
SURGICAL
Systemic antibiotics
Cortical mastoidectomy
Modified radical
Radical

57. Role of antibiotics Very limited role Except in the management of AOM
and the prevention of its complications.

58. Why antibiotics are less effective in COM?
1. Poor drainage of inflammatory exudate:
2. Destructive disease
3. The lack of information on the efficacy of
antimicrobial therapy
4. The presence of keratinizing squamous epithelium
and keratin debris
5. Mixed aerobic and anaerobic bacterial flora.

59. (6) Failure of antibiotics to penetrate the inflammatory exudate.
(7) reinfection with a different strain
(8) certain strains may have particular virulence
(9) The presence of debris and inflammatory exudate in the middle ear
(10) Mucosal changes
(11) Pathological synergy between aerobes and anaerobes

60. AIMS OF SURGERY Eradication of disease Prevention of complications
An epithelialized, self cleaning ear
Hearing improvement
Scott Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th edition

61. Where surgical management is not helpful
Over the age of 65 years
Unfit for G/A
Small cholesteatoma sac confined to the attic with normal hearing
Who refuse surgery.

62. Surgical treatment
The surgical approach depends on the type of disease.
The following approaches are widely used:

63. MYRINGOPLASTY
It is an operation in which reconstructive procedure is limited to repair of tympanic membrane perforation

64. TYMPANOPLASTY WITHOUT MASTOIDECTOMY
Eradicate disease in the middle ear
Reconstruct the hearing mechanism
This mean ossicular reconstruction only or ossicular reconstruction with myringoplasty.
(TYMPANUM = MIDDLE EAR)

65. TYMPANOPLASTY WITH MASTOIDECTOMY
Eradicate disease in both the mastoid and middle ear cavity Reconstruct the hearing mechanism with or without tympanic membrane grafting.

66. CORTICAL MASTOIDECTOMY (SIMPLE MASTOIDECTOMY OR SCHWARTZ OPERATION)
It is an exenteration of all accessible mastoid air cells preserving the posterior meatal wall

67. MODIFIED RADICAL MASTOIDECTOMY
Eradicate disease of the attic and mastoid, both of which are exteriorized into the external auditory canal by removal of the posterior meatal and lateral attic walls.
Tympanic membrane remnant, functioning ossicles and the reversible mucosa and function of the Eustachian tube are preserved.
These structures are necessary to reconstruct hearing mechanism at the time of surgery or in a second-stage operation.

68. RADICAL MASTOIDECTOMY
Eradicate disease of the middle ear and mastoid in which mastoid, middle ear, attic and the antrum are exteriorized into the external ear by removal of posterior meatal wall.
All remnants of tympanic membrane, malleus, incus (not the stapes), chorda tympani and the mucoperiosteal lining are removed
opening of Eustachian tube closed by packing a piece of muscle or cartilage into the eustachian tube.

69. MEATOPLASTY
Crescent of conchal cartilage is excised to widen the meatus.
All canal wall down procedures, i.e. modified radical and radical mastoidectomies for easy access to mastoid cavity for periodic inspection and cleaning.
It is also done as an isolated procedure in a sagging auricle seen in older people. Sagging auricle obstructs the ear canal and causes hearing loss and retention of wax.

70. MASTOID OBLITERATION
Eradicate mastoid disease, when present, and to obliterate the mastoid cavity. Obliteration of mastoid cavity is done with pedicled temporalis muscle or musculofascial tissue raised as flaps.

71. TAKE HOME MESSAGE Refer to ENT specialist as early as possible
Should be treated aggressively to restore quality of life of patient and prevent complications