الرحيم الرحمن الله بسم

CHRONIC OTITIS MEDIA

Classification of Chronic Otitis Media

• Chronic Non Suppurative Otitis Media

– Otitis media with effusion “OME”

– Adhesive otitis media

• Chronic Suppurative Otitis Media “CSOM”

– Tubotympanic (Safe)

– Atticoantral (Unsafe)

OTITIS MEDIA WITH EFFUSION

DEFINITION

Presence of non-purulent fluid within the

middle ear cleft

SYNONYMS

• Secretory otitis media

• Middle ear effusion

• Sero-mucinous otitis media

• Catarrhal otitis media

• Glue ear

• Serous otitis media

• Non-suppurative otitis media

PREVALENCE

• Between 20% and 50% of children do have

OME at some time between 3 and 10 years

of age

• Two peaks at 2 and 5 years of age

RISK FACTORS

• Race• Age• Gender• Season• Nasopharyngeal anatomical abnormalities• Cleft palate• Smoking• ? Allergy

HISTOPATHOLOGY

• Changes in the mucosa– Vasodilatation & mononuclear cell infiltration– Metaplasia of the epithelium to ciliated columnar– Mucus secreting gland formation

• Formation of fluid in the middle ear– Transudate– Exudate– Secretion

ETIOPATHOLOGY

• Eustachian tube dysfunction

• Chronic inflammation

ETIOLOGY

• Eustachian tube dysfunction– Poor muscular function– Adenoids– Barotrauma– Others

• Infections– Unresolved AOM– Adenoiditis and other URTIs

SYMPTOMS

• Hearing impairment

• ± Otalgia

• Fluid sensation

Diagnosis

DIAGNOSIS

DIAGNOSIS

• Otoscopy

• Tuning fork tests

DIAGNOSIS

• Otoscopy

• Tuning fork tests

• PTA

DIAGNOSIS

• Otoscopy

• Tuning fork tests

• PTA

• Tympanometry

DIAGNOSIS

• Otoscopy

• Tuning fork tests

• PTA

• Tympanometry

• Myringotomy

TREATMENT

• Treatment of the cause if feasible

• Observation

• Medical treatment– Antibiotics– Decongestants, ?Auto-inflation– ?Steroids

• Surgical– Myringotomy– Ventilation tubes (grommets)

COMPLICATIONS OF VENTILATION TUBES INSERTION

• Infection

• Blockage

• Extrusion

• Tympanosclerosis

• Perforation

Iatrogenic Cholesteatoma

FACTORS AFFECTING TREATMENT

• Age• Duration• Unilateral or bilateral• Degree of hearing impairment• Previous treatment• Associated conditions• Tympanic membrane changes• Others

SEQUELAE

• Spontaneous resolution– 50% resolve within 3 months.

Only 5% persists for more than 12 months

• Tympanosclerosis

• Scarring, retraction and atelectasis

• Cholesteatoma

Conclusion

• OME is very common in children• Etiology is associated with ET dysfunction and

or chronic infection• In adults: Nasopharyngeal pathology should be

considered• Most cases resolve spontaneously• Conservative treatment is of doubtful value• VT insertion restore hearing in the selected

cases

Classification of Chronic Otitis Media

• Chronic Non Suppurative Otitis Media

– Otitis media with effusion “OME”

– Adhesive otitis media

• Chronic Suppurative Otitis Media “CSOM”

– Tubo-tympanic (Safe)

– Attico-antral (Unsafe)

Chronic Adhesive Otitis Media

• Formation of adhesion in the middle ear

after reactivation and subsequent healing of

either CSOM or OME

Clinical Features

• History of CSOM or

OME

• Deafness is usually the

only symptoms

• TM shows various

structural changes

Treatment

• Observation

• Surgical treatment

• Hearing aid

Classification of Chronic Otitis Media

• Chronic Non Suppurative Otitis Media

– Otitis media with effusion “OME”

– Adhesive otitis media

• Chronic Suppurative Otitis Media “CSOM”

– Tubo-tympanic (Safe)

– Attico-antral (Unsafe)

CHRONIC SUPPURATIVE OTITIS MEDIA

ETIOLOGY

• Environmental

• Genetic

• Previous OM

• Upper respiratory tract infections

• Eustachian tube dysfunction

Tubo-tympanic

CLINICO-PATHOLOGICAL TYPES

Attico-antral

PATHOLOGY

• Signs of suppurative infection

– Discharge & perforation

– Chronic inflammatory reaction in the mucosa and the

bone (ostietis)

• Signs of healing attempts

– Granulation tissue & polyps

– Fibrosis & tympanosclerosis

• Cholesteatoma (attico-antral type)

CHOLESTEATOMA

DEFINITION

• The presence of a desquamating stratified

squamous epithelium in the middle ear

PATHOGENESIS OF CHOLESTEATOMA

• Implantation (congenital or

acquired)

• Metaplasia

• Epithelial migration

CLASSIFICATION OF CHOLESTEATOMA

• Congenital

• Acquired– Primary

– Secondary

Effect of Cholesteatoma

• Keratin encourages

persistence of the infection

• Matrix causes bone erosion

Clinical Features of CSOM

Tubo-tympanic

CLINICO-PATHOLOGICAL TYPES

Attico-antral (cholesteatoma)

SYMPTOMS OF CSOM

• Otorrhea

– Intermittent, profuse & odorless in TT type

– Persistent, scanty & malodorous in AA type

• Deafness

• Tinnitus

N.B. Any other symptom means complication

OTOSCOPIC EXAMINATION

• Discharge– Present in TT type if active but may be absent– Usually is present in AA type

• Perforation– Central: in TT type– Marginal or attic in AA type with

cholesteatoma

PERFORATION IN TT CSOM

PERFORATION IN AA CSOM

OTOSCOPIC EXAMINATION

• Discharge– Present in TT type if active but may be absent– Usually is present in AA type

• Perforation– Central: in TT type– Marginal or attic in AA type with

cholesteatoma

• Polyps, granulation tissue, tympanosclerosis

Bacteriology

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INVESTIGATIONS

• Audiometry

• Bacteriology

• Imaging

Congenital Cholesteatoma

Cloudy middle ear in CSOM

Cholesteatoma with attic erosion

TREATMENT OF CHRONIC SUPPURATIVE OTITIS

MEDIA

• Depends on the type and presentation

Active TT type Inactive TT type

Attico-antral type

(usually active)

Active TT type Inactive TT type

Conservative treatment

Conservative Treatment•Treat any predisposing factor•Keep the ear dry•Ear toilet•Antibiotics•Removal of polyps and granulations

TYMPANOPLASTY

TYMPANOPLASTY

An operation performed to eradicate disease

in the middle ear cavity and to reconstruct the

hearing mechanism

MYRINGOPLASTY

An operation performed to repair the tympanic membrane

AIMS OF TYMPANOPLASTY

• To close the perforation

• To prevent re-infection

• To improve hearing

TREATMENT OF ATTICO-ANTRAL CSOM

Removal of cholesteatoma by mastoid operation

RADICAL MASTOIDECTOMY

An operation in which the mastoid antrum

and air cells, attic and middle ear are

converted into common cavity, exteriorized to

the external canal. The tympanic membrane,

malleus and incus are removed leaving only

the stapes in situ.

MODIFIED RADICAL MASTOIDECTOMY

An operation in which the mastoid antrum

and air cells, attic and middle ear are

converted into common cavity, exteriorized to

the external canal. The tympanic membrane

and ossicles remnants are retained

AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY

• Safety

• Dry ear

• Preserve hearing

Conclusion

• In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing.

• In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear

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