Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Chronic Suppurative Otitis Media: Attico - antral disease (CSOM-AAD) (COM-Squamous) Dr. Krishna Koirala 8/24/2018."— Presentation transcript:

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

8

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)


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

Similar presentations


Ads by Google