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Chronic Suppurative Otitis Media: Attico - antral disease (CSOM-AAD) (COM-Squamous)
Dr. Krishna Koirala 8/24/2018
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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
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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
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Cholesteatoma
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Causes of bone destruction
Hyperaemic decalcification Osteoclastic bone resorption Acid phosphatase ,collagenase, acid proteases proteolytic enzymes, leukotrienes, cytokines Pressure necrosis No role Bacterial toxins ?
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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
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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
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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
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Retraction pocket in pars flaccida or Postero-superior
quadrant of pars tensa due to E.T. dysfunction
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2. Basal cell hyperplasia (Ruedi)
Hyperplasia of basal cells in epithelial layer of T.M. & their invasion of sub-epithelial tissues
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3. Primary squamous metaplasia
Transformation of middle ear mucosa into squamous epithelium without TM perforation
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4. Secondary squamous metaplasia
Transformation of middle ear mucosa into squamous epithelium due to infection via T.M. perforation
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5. Epithelial migration Migration of epithelium via T.M. perforation into middle ear
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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
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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
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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
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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
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Attic cholesteatoma
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PSQ cholesteatoma & granulation tissue
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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
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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
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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
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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
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Dural & sinus plates
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Cellular mastoid
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Sclerotic mastoid
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Diploic mastoid
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Attic bone erosion
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Causes of big mastoid cavity
Cholesteatoma erosion Mastoidectomy cavity Tubercular mastoiditis Coalescent mastoiditis Malignancy Eosinophilic granuloma Mega-antrum Large emissary vein
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C.T. scan of temporal bone
Posterior canal wall erosion
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Mastoid cholesteatoma
C.T. scan temporal bone Mastoid cholesteatoma
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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
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Surgical Treatment - Mainstay
Canal Wall down Attico-antrostomy Modified Radical Mastoidectomy (MRM) Radical Mastoidectomy Canal Wall up Combined Approach Tympanoplasty (CAT)
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