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

2. 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

3. 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

4. Cholesteatoma

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

6. 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

7. 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

9. 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

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

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

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

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

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

15. 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

16. 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

17. 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

18. 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

19. Attic cholesteatoma

20. PSQ cholesteatoma & granulation tissue

21. 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

22. 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

23. 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

24. 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

25. Dural & sinus plates

26. Cellular mastoid

27. Sclerotic mastoid

28. Diploic mastoid

29. Attic bone erosion

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

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

32. Mastoid cholesteatoma
C.T. scan temporal bone
Mastoid cholesteatoma

33. 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

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