Chronic Otitis MediaChronic Otitis Media

Bastaninejad Shahin, MD, ORL & HNSBastaninejad Shahin, MD, ORL & HNS

COM with CholesteatomaCOM with Cholesteatoma

COM with Cholesteatoma• Epidermal inclusion cyst of the ME or Mastoid

cavity• Classification:

– Congenital (usually Ante.Sup.): appear behind or within an intact TM

– Acquired (usually Post.Sup.): • Otorrhea often malodorous (Mixed>Anaerobes>Aerobes

1 bacteroides, 2 Pseudomonas,...)• Keratin debris in the center of the perforation• Acute flare up may resemble AEO• Vertigo, hearing loss, Facial nerve paralysis,...

Pathogenesis

• Congenital: originates from areas of keratinizing epithelium within a small area in the Anterior tympanum

• Acquired: – Invagination (ex vacuo theory – in OME or

eustachian dysfunction)– Basal cell hyperplasia– Epithelial ingrowth– Squamous metaplasia

* Retraction pocket Cholesteatoma (Sundhoff & Tos)Retraction pocket Cholesteatoma (Sundhoff & Tos)

*

Complications

• Hearing loss through: perforation, ossicular erosion (mainly incusmainly incus), otic capsule erosions (mainly LSCCmainly LSCC, labyrinthine fistula may be found in up to 10% of the cases)

• Facial nerve paralysis (acute/chronic)• Tegmen erosion brain hernia or CSF

leakage,...• Intracranial infections

Management

• Surgical (see next slide for anatomy)– Canal wall down (CWD)

• Advantage: recurrence is low• Disadvantage: mastoid cavity problem

– Canal wall up (CWU)• Adv.: physiologic position of TM, no mastoid cavity

problem• Disadv.: recurrence is high, often nedd second

stage exploration

Anatomy outlines

COM without CholesCOM without Choles..

COM without Choles.

• Permanent perforation of the TM with or without recurrent infection

• Hearing loss regarding to the perforation size:– Small perforation: Low Freq. Air Bone GAP– Large Perforation: Low+High freq. ABG

• Bacteriology: usually Mixed>Aerobes>Anaerobes

Differentiate traumatic TM perforation with COMDifferentiate traumatic TM perforation with COM

Management

• Medical (mainly topical, in refractory infections use systemic therapy with Ciprofloxacin,...)

• Surgery:– Tympanoplasty (dry perforation, less than

25dB ABG)– Tympanomastoidectomy (several episodes of

otorrhea, more than 25dB ABG)

TympanosclerosisTympanosclerosis

Tympanosclerosis

• Acellular hyalin and calcified deposits accumulate within the TM and ME submucosa

• Pathogenesis:– Consequence of resolved otitis media of

trauma

• Ossicular fixation may occure (most frequently in the attic head of the malleus and incus)

Management

• Management is like COM without cholesteatoma, But ossicular fixation must be corrected simultaneously (except stapedius fixation)