Chronic otitis mediaDr. AJAY MANICKAMJUNIOR RESIDENTDEPARTMENT OF OTOLARYNGOLOGYRG KAR MEDICAL COLLEGE

COMCHRONIC INFLAMATION OF THE

MUCO-PERIOSTEAL LINING OF THE MIDDLE EAR CLEFT

Tubotympanic / safe

type Atticoantral / Unsafe type

Tubotympanic typeSafe typeInactive / Active / Healed

mucosal typePredisposing factors 1. Inadequate treatment of AOM2. Infection of Nose, naso or

oropharynx3. Tuberculosis4. Sclerotic mastoids

COM aetiologyStreptococcusStaphylococcusGram negative organisms like pseudomonas, proteus, E coli

Pathogenesis Middle ear mucosa became

edematous and velvety in active disease Ossicular chain may undergo necrosis, particularly the long process of incus

Hyalinization and subsequent calcification of sub epithelial connective tissue leading to

Symptoms Discharge – profuse, mucoid, nonpurulent, increasing with attack of cold

Deafness – mild conductiveEarache – otitis externa if associated

Signs Discharge in the EACCentral Perforation – usually pars

tensaTuning fork test – rhinne negative

weber lateralised to affected side

Central perforation Subtotal perforation

Total perforation

Investigations Pus for C/SExamination with otoscope /

microscopePTAX-ray of mastoids [lat obq]X-ray of PNS X-ray nasopharynx Diagnostic nasal endoscopy

Management Medical 1. Aural toilet – dry mopping

, suction clearance under microscope

2. Antibiotic ear drops 3. Systemic antibiotics if

acute exacerbation of the disease

Surgical managementRemoval of septic

foci – tonsillectomy , adenoidectomy , sinus clearance

Myringoplasty Tympanoplasty If associated

mastoiditis – cortical mastoidectomy

Atticoantral diseaseCHOLESTEATOMA skin in the

wrong place – sac in the middle ear which is lined by keratinizing squamous epithelium containg desquamated epithelium as keratin debris Congenital Acquired

1. Primary2. Secondary

Theories of cholesteatomaRetraction

pocket theoryTheory of

migrationMetaplasia

theoryImplantation

theory

Pathogenesis of cholesteatoma

Tubal occlusion BEZOLD

Embryonic cell remnant WITTMACK

Epithelial embryonic

cell Mc KENZIE

Negative attic pressure

Attic retraction pocket

Squamous epithelium in middle ear

Normal pavement epithelium TUMARKIN

Epithelial metaplasia

CHOLESTEATOMA

Symptoms Ear discharge – foul smelling

scanty predominantly purulent occasionally blood stained

Deafness Itching and pain in the ear – with

otitis externa Tinnitus & giddiness – early

symptoms of complication

Signs Attic, marginal or total perforation Granulation tissue or keratin flakes in

the postero superior quadrant of deep meatus

Tuning fork test – rinne negative , weber lateralized to the affected side

Investigations Examination under microscope C/S from dischargeRigid oto endoscopy – to see

facial recess and sinus tympani if possible

PTAX-ray mastoid schuller’s & laws

viewHRCT temporal bone

Management Primary – make ear safeRestore hearingMaintain anatomical appearance

of earMedical management – no role or

patients unfit for surgery . 5 flurouracil has been tried – regular follow up

Main line of management is SURGERY

SURGERYCanal wall down mastoidectomy

– radical or modified radicalCanal wall up mastoidectomy –

combined approach tympanoplasty