Chronic otitis media

BOROMA P.T
 Definition

 Chronic Otitis Media: unresolved

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

 Dysfunction of Eustachian tube

 Chronic inflammation in nose and pharynx
 Dysfunction of immune system
 Bacteriology

 Pseudomonas aeruginosa
 Straphylococus aureus
 Anaerobic bacteria
 Pathology
 Middle ear mucosa is lined by secretory
epithelium forming glandlike structure.
 Hyalinization or tympanosclerosis
 A healing response
 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
 Pathology
 Ossicular erosion is frequent
in COM
 Infection process
 Necrosis following vascular
thrombosis
 It most commonly affect the
lenticular process of the incus
and head of the stapes
 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.
 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
 Pathology
 Mechanics of mucosal
transformation and
epithelial ingrowth
have been the focal
point of
cholesteatoma
 Pocket retraction:
dysfunction of
Eustachian tube
 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
 Pathology

 Pathogenesis of congenital cholesteatoma:

 Ectodermal epithelial in proximity of the
geniculate ganglion, medial to the neck of the
malleus
 Clinical presentations
 Otorrhea
 Malodorous associated with cholesteatoma
 Hearing loss
 Pain is not usually experienced, except in
cases of acute mastoiditis, when the
postauricular area is tender and may be
erythematous and oedematous.
 Clinical presentations

 Physical findings
 Otoscopic examination may show a
perforation, and cholesteatoma can be
identified as a white mass behind the
tympanic membrane or coming through to
the external canal from a perforation
 Granumoms, polyps, tympanosclerotic
plaques in middle ear
 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.
 Differential diagnosis

 Tuberculous otitis media

 Hematogenous route
 Multiple perforation and fetid
 Creamy aural discharge
 Active pulmonary disease
 Multiple antituberculosis agents
 Differential diagnosis

 Middle ear carcinoma

 Middle age patient
 Long term otorrhea with blood
 Otalgia
 Neoplasm in tympanum
 CT scan showed temporal bone destruction
 Managements

 Medical treatment
 Goals

 Infection control (Antibiotics

(Instil quinolone drops
(such as ciprofloxacin,
norfloxacin, or ofloxacin)
 CT

 Dry the ear by wicking

Stabilization
of process
Prevention of irreversible
damage and development of
serious complications
 Managements
 Surgery
 Goals

 Safe ear: lesion removal

 Dry ear

 Hearing ear: reconstruction of ossiclar chain

 classification

 Myrigoplasty

 Tympanoplasty

 Tympanoplasty with mastoidectomy

 Tympanoplasty

 The purposes of tympanoplasty

are to:
 re-establish middle ear function,

 close the perforation, prevent

recurrent infection,
 improve hearing.
 The other procedures, types II
through V, involve more extensive
repair of middle ear structures.
The structures and the degree of
involvement can differ, but all
tympanoplasty procedures include
restoring the continuity of the
sound conduction mechanism.
 Tympanoplasty is performed through the
external auditory canal with a transcanal
approach or through a postauricular
incision.
 The contents of the middle ear are
carefully inspected, and the ossicular
chain (malleus and incus unit) is
 evaluated.
 Mastoidectomy

 The objectives of mastoid surgery are to:

 remove the cholesteatoma,
 gain access to diseased structures,
 create a dry (noninfected) and healthy
ear.
 A mastoidectomy is usually performed
through a postauricular incision.
 Infection is eliminated by removing the