Csom_squamosal Type Anila

8/3/2019 Csom_squamosal Type Anila

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CSOM

SQUAMOSAL TYPEETIOLOGY, PATHOLOGY

CLINICAL FEATURES

MODERATOR DR.C .RAVISHANKARPRESENTER- DR. ANILA VISWANATH


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Definition of csom

Chronic inflammation of themucoperiosteal lining of the middle earcleft


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classification

Inactive mucosal com- perforation

Inactive squamosal com- retraction

Active mucosal com- Active squamosal com - cholesteatoma

Healed com


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Inactive squamosal

Negative static middle ear pressure lead toretraction of tm

Retraction pocket invagination of a partof tm into middle ear


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Retraction pocket

Fixed free

TM adherent to can move mediallyM E structures or laterally


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Epidermisation

Advanced type of retraction

Refers to replacement of middle earmucosa by keratinising squamous

epithelium without retention of keratindebris

Often remains quiescent


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Active squamosal com- cholesteatoma

History

Johannes Mller (1838) coined the termcholesteatoma

a pearly tumor of fatamong sheets of

polyhedral cells

Shucknecht coined the term keratoma.


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Definition

Cholesteatoma is a bag like cysticstructure lined by keratinizing squamousepithelium containing desquamated

epithelium having erosive properties andmostly seen in temporal bone.


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May develop anywhere within pneumatizedportions of the temporal bone

Most frequent locations:

Middle ear space

Mastoid


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Histologically made up of :

Cystic content anucleate keratin

squames Matrix keratinizing squamous epithelium

Perimatrix granulation tissue in contact

with bone (produces proteolytic enzymes)

Essential diagnostic feature presence ofkeratinising squamous epithelium

Epithelium shows maturation withoutdysplasia


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Histology


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Histology


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Cholesteatoma Classification

Congenital

Acquired

Primary

Secondary


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Congenital Cholesteatoma

Defined by Derlacki & Clemis as anembryonic rest of epithelial tissue in anear without tympanic membrane

perforation in a patient without a history ofear infection


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Criteria

Levenson, 1989

White mass medial to normal tympanicmembrane

Normal pars flaccida and pars tensa

No prior history of otorrhea or perforations

No prior otologic procedures

Prior bouts of otitis media were not groundsfor exclusion as was the case in originaldefinition


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Congenital cholesteatoma


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Pathogenesis theories

Failure of involution of ectodermal epithelialthickening called epidermoid formation that is

present during fetal development found atjunction of middle ear & ET (10 -33 wks ofgestation)


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Location -petrous pyramid,

mastoid and middle ear cleft

Male preponderanceMean age of presentation- 4.5 yrs


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Congenital Cholesteatoma

Anterosuperior > Posterosuperiorquadrant quadrant


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Congenital Cholesteatoma - TypeNelson

Type 1 Confined to the middle ear and do notinvolve the ossicles

Type 2 Involve the posterior superiorquadrants and attic, the site of the ossicular

chain Type 3 Involve the sites of type 1 and 2 as well

as the mastoid

Nelson et. al Congenital Cholesteatoma:Classification, Management and Outcome. ArchOto Head Neck Surg July 2002; 128: 810:814.


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Congenital Cholesteatoma -Stage

Stage I Limited to one quadrant

Stage II Involving multiple quadrants withoutossciular involvement

Stage III Ossicular involvement withoutmastoid extension

Stage IV Mastoid involvement (67% risk ofresidual cholesteatoma)

Potsic WP, Korman SB, Samadi DS, et al.Congenital cholesteatoma: 20 years experienceat The Childrens Hospital of Philadelphia.Otolaryngol Head Neck Surg 2002;126(4):409

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Primary Acquired Cholesteatomas

Eustachian tube dysfunction

Persistent negative pressure in middle ear

Results in poor aeration of epitympanic

space

attic or posterosuperior retraction pocket

N l i t tt f th t i


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Normal migratory pattern of the tympanicmembrane epithelium altered by retractionpocket

Enhances potential accumulation of keratin

primary acquired cholesteatoma


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Primary acquired

Pars tensa cholesteatoma

Pars flaccida cholesteatoma/ atticcholesteatoma


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Pathology of pars flaccidacholesteatoma

The epithelium of the cholesteatoma sac iscontinuous with that of pars flaccida and theaccumulation of white keratin debris is visible

Associated with osteitis, granulation tissue and

erosion of the outer attic wall Erosion of the ossicular heads occurs relatively

late in the disease process hence minordegree of hearing loss

The disease further progresses into the anteriorepitympanum and posteriorly in to the mastoidantrum and air cell system


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Pars flaccida retraction


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Pathology of para tensacholesteatoma

Retraction onto the long process of incus,incudostapedial joint and promontory

Long process involved early markedconductive deafness

Occasionally cholesteatoma hearer Invagination into facial recess, sinus tympani

and round window niche difficulty ineradication

In the region of posterior annulus there isexposed bone that can be the site of osteitisand granulation tissue


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Pars tensa retraction


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Primary acquired cholesteatoma


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Secondary Acquired

CholesteatomasRepeated infection through perforation

Metaplasia of epithelialmiddle ear mucosa Migration through

perforation

Metaplasia theory-Sade


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Metaplasia theory Sade

middle ear epithelium is transformed to keratinizedstratified squamous epithelium secondary tochronic or recurrent otitis media

Epithelial invasion theory - HabermannSquamous epithelium migrates along perforationedge medially along undersurface of tympanicmembrane

Papillary ingrowth theory- RuedisInflammatory reaction in Prussacks space with anintact pars flaccida (likely secondary to poorventilation) may cause break in basal membrane

allowing cord of epithelial cells to start inwardproliferation

Implantation theory

Squamous epithelium implanted in the middle earas a result of surgery, foreign body, blast injury,etc.


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Once cholesteatoma enters middle earcleft it invades surrounding structures firstby folllowing path of least resistance &

then by enzymatic bone destruction


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bone destruction produced by

cholesteatoma explained by

Pressure theory not accepted now

Enzymatic theory- first by Lautenslager

Acid po4ase

Collagenase

Acid protease

Pge2, IL-1a, IL-1b, TNF-a, TNF-b


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AnatomyMiddle Ear Regions

Epitympanum: superior to superior limit of EAC

Mesotympanum: bound superiorly by superior

limit of EAC and inferiorly by inferior limit ofEAC

Hypotympanum: inferior to inferior limit of

EAC


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Middle Ear Regions


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Epitympanum

Lies above the level of the short processof the malleus

Contents:

Head of the malleus

Body of the incus

Associated ligaments and mucosal folds


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Mesotympanum

Contents: Stapes Long process of the incus Handle of the malleus Oval and round windows

Eustachian tube exits from the anterior aspect Two recesses extend posteriorly that are often not visible

directly Facial recess

Lateral to facial nerve Bounded by the fossa incudis superiorly Bounded by the chorda tympani nerve laterally

Sinus tympani Lies between the facial nerve and the medial wall

of the mesotympanum


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Hypotympanum

Lies inferior and medial to the floor of thebony ear canal

Irregular bony groove that is seldominvolved by cholesteatoma


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Common Sites of CholesteatomaOrigin

Posterior epitympanum

Posterior mesotympanum

Anterior epitympanum


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Cholesteatoma Spread

Predictable in that they are channeledalong characteristic pathways by:

Ligaments

Folds

Ossicles


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B/w 3rd & 7th month 4endothelially linedsacs evaginate from

first branchial pouch.Mucosal folds and

ossicular suspensoryligaments formedwhen these sacscontact each other.


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Saccus anticus

Smallest pouch

Form anterior pouch of von TroltschContact with anterior most saccule from

saccus medius -Tensor fold. Above it isanterior compartment of attic.


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Saccus medius

Breaks into three saccules

Anterior sacculeatticMedial sacculesuperior incudal space.

Sends an offshoot between lateral mallear

and lateral incudal prussaks space. Posterior saccule pneumatise petrous

temporal


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Saccus superior

Extends b/w malleus handle and tip oflong crus of incus posterior pouch of vonTroltsch and inferior incudal space

Saccus posticus

Form round window niche , sinus tympanioval window niche


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Cholesteatoma Spread

Posterior epitympanic

cholesteatoma passing

from Prussaks space

through superior incudal

space and aditus ad

antrum


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Reaches middle ear by descendingthrough floor of prussaks space intoposterior space of von troeltsch


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Posterior mesotympanum

Extend to mastoid through

posterior tympanic isthmus

& inf. incudal space

sinus tympani and

facial recess commonlyinvolved


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Extend to mastoid viaposterior tympanic

isthmus & inf incudalspace


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Anterior epitympanum

Reach middle ear

via anterior pouch

of von Troltsch.facial n. dysfunction

common

may gain access to

supratubal recess


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Bacteriology

Pseudomonas aeruginosa

Streptococcus

Proteus

E coli

Anaerobes- Bacteroids,

peptococcus, fusobacterium


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Clinical features

Symptoms

Discharge-

foulsmelling- anaerobic infection,

Bloodstained- granulation tissue & osteitis

scanty,

purulent

Tinnitus


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Hearing loss

perforation of tympanic membrane- 10 40dB

- ossicular interruption with intact drum 54 dB

- ossicular interruption with perforation 38 dB

- closure of oval window 60 dB Sometimes , patient hears better in presence of

cholesteatoma- cholesteatoma hearer

Ear acheDizziness- labyrinth involved

Facial deviation- facial canal eroded

Signs


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Signs

Foul smelling discharge in eac

Attic perforation/ marginal perforation

Attic retraction

Cholesteatoma flakes- fishy odour

Granulation tissue

Aural polyp


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Pars tensa retraction - sade

Stage 1-mild retraction not touching longprocess of incus

Stage 2- retracted drum touching long

process of incus

Stage 3- retracted drum touchingpromontory

Stage 4- drum plastered to promontory


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Pars flaccida retraction- tos

Stage 1-Mild retraction not touching neckof malleus

Stage 2-Attic retraction touching neck of

malleus

Stage 3-limited outer attic wall erosion

Stage 4- severe attic wall erosion


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Complications of CSOM

Causes

Pathway of spread


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Classification

Intra temporal

Mastoiditis

Petrositis

Facial Paralysis

Labyrinthitis


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Intra Cranial

Extradural abscess

Subdural abscess

Meningitis

Brain abscess

Lateral sinus thrombophlebitisOtitic Hydrocephalus


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Acute Mastoiditis Infection involve bony walls of mastoid

Beta hemolytic streptococcus

CL/F Pain behind ear, fever, ear discharge

Signs:

Mastoid tenderness

Sagging of posterosuperior meatal wall

Swelling over mastoid- Ironed out mastoid

Ab i R l i id i f i


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Abscess in Relation to mastoid infection

Post auricular abscess commonest

Zygomatic abscess

Bezold abscess

Meatal / lucs abscess

Citellis abscess

Petrositis


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Petrositis

Infection of petrous part of temporal bone

2 groups of air cell tracts-Posterosup & anteroinf

Attic ,around semicircular hypotympanum

Canal to apex around ET

around cochlea

to apex

6th N & trigeminal ganglion closely related


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Gradenigo syndrome

Triad of LR palsy, deep seated retro orbitalpain, persistent ear discharge

Fever

headache


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Facial paralysis

destruction of bony canal of facial nerve

by cholesteatoma or from penetratinggranulation tissue

genu or horizontal portion

Labyrinthitis


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Labyrinthitis

Diffuse serous Labyrinthitis

Diffuse suppurative Labyrinthitis


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Diffuse serous LabyrinthitisDiffuse intralabyrinthine inflammation

without pus formation

VertigoNausea

nystagmus

High frequency SN hearing loss


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Diffuse suppurative Labyrinthitis

Diffuse infection of labyrinth withpermanent loss of vestibular & cochlearfunctions

Severe vertigo nausea vomitingspontaneous nystagmus

Loss of hearing

Extradural abscess


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Extradural abscess

b/w bone & dura

Cl/f:Persistent headache

Severe pain in ear

Malaise

Low grade fever

persistent purulent ear discharge

disappearance of headache with free flowof pus from ear

S


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Subdural abscess

b/w dura & arachnoid

Meningeal irritation- headache fever malaiseneck rigidity

Cortical venous thrombophlebitis- aphasia

hemiplegia ,hemianopia

Raised ICT-papilloedema, ptosis


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Meningitis

Inflammation of leptomeninges

With bacterial invasion of CSF insubarachnoid space

Fever, headache, neck rigidity, nausea,vomiting


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Otogenic brain abscess

Stage of invasion pass unnoticed ,headache malaise

Stage of localisation pus localised bycapsule

stage of enlargement-oedema around

abscess, ICT

Stage of termination


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Lateralsinus thrombophlebitis


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Lateralsinus thrombophlebitis

Inflammation of inner wall of lateralsinus

with thrombus formationStage of perisinus abscess

Endophlebitis & mural thrombus formation

Obliteration of sinus lumen & intrasinusabscess

Extension of thrombus


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Picket fence fever Headache

Greisingers sign- oedema over posterior part ofmastoid- thrombosis of mastoid emissary vein

Pappiloedema

Tobey ayer test -rise in csf pressure on healthyside no effect on d/s side on compression of

jugular veinCrowe Back test- engorgement of retinal veins on

healthy side on pressure on jugular vein


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Otitic hydrocephalusRaised ICT with normal csf finding

Lateral sinus thrombosis obstructs venous

return, if extending to superior sagittalsinus impede absorption of villi to absorbCSF

headache diplopia blurring of visionpapilloeedema nystagmus CSF pr. >300mmwater


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Csom_squamosal Type Anila

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