1. Chronic otitis media Chunfu Dai M.D & Ph. D Otolaryngology Department
Eye Ear Nose and Throat Hospital
Fudan University

2. Definition
COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

3. Etiology Unresolved middle ear infection.
Uncomplicated inflammatory process of the middle ear may evolve over time to produce persistent effusion and irreversible mucosal change
Fluid contains enzymes to alter the mucosal lining of the middle ear, it results in collapse or chronic perforation
Obstruction of narrow communication between the antrum and the attic, the aditus.

4. Etiology Dysfunction of Eustachian tube
Chronic inflammation in nose and pharynx
Dysfunction of immune system

5. Bacteriology Pseudomonas aeruginosa (40-60%)
Straphylococus aureus (10-20%)
Anaerobic bacteria

6. Pathology
Middle ear mucosa is lined by secretory epithelium forming glandlike structure.
Hyalinization or tympanosclerosis
A healing response
It occurs during quiescent periods
It is formed by fused collagenous fibers
It is hardened by the deposition of calcium and phosphate crystals
Conductive hearing loss is associated with masses restricting ossicular mobility

7. Pathology Ossicular erosion is frequent in COM
Infection process per se
Necrosis following vascular thrombosis
It most commonly affect the lenticular process of the incus and head of the stapes

8. Pathology Cholesterol granulomas
Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue
It contains many cholesterol crystals and foreign body giant cells.

9. Pathology
Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material.
Classification
Congenital cholesteatoma
Acquired cholesteatoma

10. Pathology
Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma
Pocket retraction: dysfunction of Eustachian tube

11. Pathology Epithelial migration: the edge of a peripheral perforation
Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida.
Metaplasia from pseudostratified ciliated columnar epithelium

13. Cholesteatoma Formation

14. Cholesteatoma Formation

15. Pathology Pathogenesis of congenital cholesteatoma:
Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus

16. Pathology Diagnosis criteria:
Patients without previous history of ear disease, with normal and intact TM
The temporal bone pneumatization should be normal

17. Clinical presentations
Otorrhea
Malodorous associated with cholesteatoma
Hearing loss
Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain
If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain

18. Clinical presentations
Physical findings
Defect in the pars tensa of TM or the pars flaccida or both
Atelectatic lesions in tensa or flaccida pars
Squamous epithelial invasion may invade middle ear
Granumoms, polyps, tympanosclerotic plaques in middle ear

19. Radiographic evaluation
Indications for image study
Uncontrollable aural discharge
Complications such as facial paralysis, labyrinthitis
When central nervous stystem involvement is suspected, MRI should be considered.
Coronal CT scan is perferred

20. Differential diagnosis
Tuberculous otitis media
Hematogenous route
Multiple perforation and fetid
Creamy aural discharge
Active pulmonary disease
Multiple antituberculosis agents

21. Differential diagnosis
Middle ear carcinoma
Middle age patient
Long term otorrhea with blood
Otalgia
Neoplasm in tympanum
CT scan showed temporal bone destruction

22. Managements Medical treatment Goals
Infection control
Stabilization of process
Prevention of irreversible damage and development of serious complications
3%H202 clears up pus then antibiotics ear drops is used.
With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used
No aminoglycoside ear drops
No powders containing antibiotic and erosion ear drugs

23. Managements Surgery Goals classification Safe ear: lesion removal
Dry ear
Hearing ear: reconstruction of ossiclar chain
classification
Myrigoplasty
Tympanoplasty
Tympanoplasty with mastoidectomy