EAR - Chronic Suppurative Otitis Media

What is chronic suppurative otitis media?

Chronic suppurative otitis media is chronic infection in part or whole of the middle ear cleft.

What are the different types of chronic suppurative otitis media (CSOM)?

1. Tubotympanic type: (safe type)

Aetiology:

  • Usually sequelae of acute otitis media infection, leaving behind a perforation.
  • Recurrent infections via the eustachian tube commonly from the tonsils or adenoids
  • Traumatic perforation.

Clinical features:

  • Perforation: It is usually a central perforation with a safe margin of healthy remanant tympanic membrane around it in the pars tensa.
  • Hearing loss: It is a purely conductive type of hearing loss, rarely exceeding 40-45 db.
  • Discharge: It is mucoid, copious, non-foul smelling and is related to a bout of upper respiratory tract infection.
  • A quiescent phase in the ear symptoms may be present.

2. Atticoantral type: (unsafe type)

It involves the posterio-superior part of the middle ear cleft and is usually associated with cholesteatoma.

Aetiology:

  • Congenital: These are squamous epithelial cell nests arising within the temporal bone.
  • Acquired:
    • Primary: Develops in continuity with the pars flacida of the tympanic membrane
    • Secondary: This can occur by:
      - Immigration of the tympanic membrane epithelium
      - Metaplasia: Middle ear mucosa undergoes metaplasia due to repeated infections.
      - Negative middle ear pressure.

Clinical features:

  • Perforation: It is usually in attic region, postero-superior region, or marginal.
  • Retraction pocket: A retraction or invagination of the tympanic membrane is seen in attic or postero-superior region of pars tensa
  • Cholesteatoma: This can be seen in the form of pearly white flakes.

What are the investigations required to confirm the diagnosis of chronic suppurative otitis media (CSOM)?

  • Suction Microscopy: To suck out any discharge, confirm clinical findings and examination of the discharge for pus culture and antibiotic sensitivity.
  • Tuning fork tests: They help in clinical evaluation of hearing loss.
  • Pure tone audiogram: This is useful for a qualitative and quantitative analysis of the patients hearing. It also helps for pre-operative and post operative assessment of the hearing loss and for medico-legal purposes.
  • X-ray mastoid Schuller's view: To diagnose the extent of disease and status of the mastoid air cells
  • Routine blood investigations from fitness point of view.
  • High resolution CT scan of the temporal bone is extremely useful in patients with complications or impending complications.

What is the treatment for chronic suppurative otitis media (CSOM)?

1) Tubotympanic type

A) Medical:

  • Local
    • Aural toilet
    • Antibiotic ear drops
    • Chemical cautery for small perforations
  • Systemic
    • Antibiotics
    • Decongestant in case of sinusitis.
    • Antioxidants

B) Surgical

  • Myringoplasty
  • Tympanoplasty with or without a mastoidectomy.

2) Atticoantral Type:

A) Medical:

  • Systemic antibiotics to control the infection prior to surgery and prevent spread of infection.
  • Medical line of treatment has limited role in unsafe CSOM.

B) Surgical:

  • Cortical mastoidectomy
  • Modified radical mastoidectomy
  • Radical mastoidectomy.



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