C.S.O.M.

: Investigations & Treatment

Dr. Vishal Sharma

Investigations for T.T.D.

Examination under microscope

Ear discharge swab: for culture sensitivity

Pure tone audiometry

Patch test
X-ray mastoid: B/L 300 lateral oblique (Schuller)

Done when cortical mastoidectomy is required

in ear discharge refractory to antibiotics

Exam under microscope

Uses of Audiometry
Presence of hearing loss Degree of hearing loss Type of hearing loss Hearing of other ear Record to compare hearing post-operatively Medico legal purpose

Patch Test
Done when deafness = 40-50 dB Do pure tone audiometry: for hearing threshold Put Aluminum foil patch over T.M. perforation Repeat pure tone audiometry: Hearing improved = ossicular chain intact & mobile Hearing same / worse = oss. chain broken or fixed

Investigations for A.A.D.

Examination under microscope Ear discharge swab: for culture sensitivity Pure tone audiometry X-ray mastoid: B/L 300 lateral oblique (Schuller)

CT scan: revision surgery, complications, children

Uses of E.U.M.
Confirmation of otoscopy findings Epithelial migration at perforation margin Cholesteatoma & granulations Adhesions & tympanosclerosis Assesment of ossicular chain integrity Collection of discharge for culture sensitivity

Uses of X-ray mastoid

1. Position of dural & sinus plates: helps in surgery

2. Type of pneumatization:
a. Cellular (80%): plenty of air cells b. Sclerotic (20%): small antrum, air cells absent c. Diploetic (<1%): bone marrow within few air cells 3. Cholesteatoma (cotton wool appearance) 4. Bone destruction: presence & extent 5. Mastoid cavity

Dural & sinus plates

Cellular mastoid

Sclerotic mastoid

Diploetic mastoid

Attic bone erosion

Causes for mastoid cavity

Cholesteatoma erosion Mastoidectomy cavity Tubercular mastoiditis

Coalescent mastoiditis
Malignancy Eosinophilic granuloma Mega-antrum Large emissary vein

C.T. scan temporal bone

Posterior canal wall erosion

C.T. scan temporal bone

Mastoid cholesteatoma

Treatment for Tubo-tympanic Disease

Non-surgical Treatment
Precautions

Aural toilet
Antibiotics: Systemic & Topical

Antihistamines: Systemic & Topical

Nasal decongestant: Systemic & Topical

Treatment of respiratory infection & allergy

Tympanic membrane patcher

Precautions
Encourage breast feeding with childs head raised. Avoid bottle feeding. Avoid forceful nose blowing Plug E.A.C. with Vaseline smeared cotton while bathing & avoid swimming Avoid putting oil & self-cleaning of E.A.C.

Aural Toilet
Done only for active stage

Dry mopping with cotton swab

Suction clearance: best method

Gentle irrigation (wet mopping)

1.5% acetic acid solution used T.I.D.

Removes accumulated debris

Acidic pH discourages bacterial growth

Antibiotics
Topical Antibiotics: Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin Antibiotics + Steroid: for polyps, granulations
Neosporin + Betamethasone / Hydrocortisone

Oral Antibiotics: for severe infections

Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

Antihistamines & Decongestants

Antihistamines Systemic decongestants

Chlorpheniramine
Cetirizine

Pseudoephedrine
Phenylephrine

Fexofenadine
Loratidine Levo-cetrizine Azelastine (topical)

Topical decongestants
Oxymetazoline Xylometazoline Hypertonic saline

Kartush T.M. Patcher

Indicated in: Perforation in only hearing ear Patient refuses surgery Patient unfit for surgery Age < 7 years

Surgical Treatment
Indicated in inactive or quiescent stage Myringoplasty Tympanoplasty Indicated in active stage

Cortical Mastoidectomy
Aural polypectomy

Methods to close perforation

T.M. perforation < 2 mm

Chemical cautery with silver nitrate

Fat grafting

Myringoplasty if these measures fail

T.M. perforation > 2 mm

Tympanic membrane patcher

Myringoplasty

Chemical cautery

Approaches to middle ear

Wildes post-aural incision

Lemperts end-aural incision

Rosens permeatal incision

Hearing Restoration
Myringoplasty:
surgical closure of tympanic membrane perforation

Ossiculoplasty:
surgical reconstruction of ossicular chain

Tympanoplasty:
Surgical removal of disease + reconstruction of
hearing mechanism without mastoid surgery

Principles of hearing restoration

Intact tympanic membrane

Intact ossicular chain

Functioning receiving & relieving windows Acoustic separation of these windows Functioning Eustachian tube Absence of sensori-neural hearing loss Absence of active infection / allergy in middle ear cleft

Myringoplasty

Aims
Permanently stop ear discharge: dry, safe ear

Improve hearing: provided: 1. ossicles are intact +

mobile; 2. absence of sensori-neural deafness Prevention of: tympanosclerosis, adhesions, vertigo, S.N.H.L. (cochlear exposure to loud sound) Wearing of hearing aid

Occupational: military, pilots

Recreation: swimming, diving

Contraindications
Purulent ear discharge
Otitis externa

Respiratory allergy
Age < 7 yr (Eustachian tube not fully developed)

Only hearing ear

Cholesteatoma

Methods
Techniques: Underlay: graft placed medial to fibrous annulus Overlay: graft placed lateral to fibrous annulus Grafts used: Temporalis fascia, Tragal perichondrium, Vein graft, Fascia lata, Dura mater

Underlay myringoplasty

Overlay myringoplasty

Steps of underlay myringoplasty

Tympanomeatal flap raised

Placement of graft

Tympanomeatal flap replaced

Tympanomeatal flap replaced

Why temporalis fascia?

Basal metabolic rate lowest (best survival rate) Easily harvested by post-aural incision Its an autograft, so no rejection Same thickness as normal tympanic membrane Large size graft can be harvested Good resistance to infection

Onlay
Graft cholesteatoma Blunting of anterior tympanomeatal angle Lateralization of graft

Underlay
No No

No 3-4 weeks
Possible Easier & quicker

Delayed healing time (6 wk)

No middle ear inspection Difficult & takes more time

Advantages of Local Anesthesia

Minimal bleeding
Hearing results can be tested on table Facial palsy detected immediately Labyrinthine stimulation detected

immediately
No complications of General anesthesia

Tympanoplasty

Types

Type
I II III IV V VI

Pathology
Ear drum perforation only Malleus handle eroded Malleus + Incus eroded Only footplate remains: mobile Only stapes remains: fixed Only footplate remains: mobile

Graft placed on
Malleus handle Incus Stapes head Footplate exposed Lateral SCC opening Footplate exposed

Malleus / Incus Autografts

Thank You