DISEASES of the EAR - II

NORMAL EARDRUM - tense and tense and

devoid of any retained epithelial debrisdevoid of any retained epithelial debris

middle elastic layermiddle elastic layerthe normal migration of the the normal migration of the epithelial layer from the drum epithelial layer from the drum along the meatal walls to the along the meatal walls to the exterior.exterior.

RETRACTION POCKETS AND ATELECTASIS

The 1-st condition: the closing of the

Eystachian tube

The 2-nd condition: some parts of the eardrum have

no elastic layer

The pressure inside is negative

The pressure outside is positive

Impression of the parts of the eardrum and

accumulation of debris in it

RETRACTION POCKETS AND ATELECTASIS

RETRACTION POCKETS AND ATELECTASIS

RETRACTION POCKETS

Part of the eardrum without elastic layer

(atelectasis)

Retraction pocket

Huge retraction pocket with

cholesteatoma

PERFORATION OF THE DRUM

• Three main types of perforation of the tympanic membrane are found in patients with chronic otitis media. They are central, marginal and attic.

CENTRAL PERFORATIONS

• In this type of perforation a part of the membrane remains all round, and the fibrous annulus remains intact even though the perforation may be a very large one.

ATTIC PERFORATIONS

• An attic perforation is one situated in the pars flaccida. Perforations of this kind are associated with the most serious variety of destructive middle-ear disease because of their invariable association with an invading cholesteatoma.

MARGINAL PERFORATIONS

• These are perforations in which the fibrous annulus is involved. This means that disease of bone is present and that such perforations are inevitably associated with osteitis, often with granulations and with cholesteatoma formation.

CHRONIC OTITIS

Chronic otitis may be confined to the mucosa, or may involve and destroy bone.

It may be classified as follows:1. Non-suppurative• A) Serous otitis• B) Mucous otitis or 'glue ear'2. Suppurative• A) Tubo-tympanic suppuration• B) Attico-antral disease3. Tuberculosis of the ear.

TUBO-TYMPANIC SUPPURATION

• It is the result of acute otitis media which has left a permanent perforation.

• The discharge is mucoid or mucopurulent. It may be constant, but it may dry up at times to reappear with the onset of upper respiratory infection or accidental entrance of water into the ear.

• The perforation of the drum is central, i.e. it does not involve the fibrous annulus. The middle-ear mucosa may be swollen and oedematous and may produce polyps.

• There is usually a conductive hearing loss present.• In untreated disease there is danger to the hearing, though

there is rarely any threat to life.• There is no evidence of cholesteatoma or disease of bone.

ATTICO-ANTRAL DISEASE

• This disease is not only destructive to hearing, but may be dangerous to life by virtue of its complications.

• Sometimes the symptoms are quite minor until such complications develop. There are two forms of the disease:

• (1) suppurative disease• (2) cholesteatomatous disease. • These may be combined. There is

destruction of bone towards the middle cranial fossa, posterior cranial fossa.

SUPPURATIVE DISEASE

• There is destruction of the mastoid cells with pus, polyp and granulation formation, and possibly some exposure of the dura or the lateral sinus.

• Discharge, which may be yellow, copious and foul, is a common feature, and hearing loss is marked. Occasionally, however, the discharge is scanty.

• Perforations of the drum are as a rule posterior, but do not necessarily follow any particular pattern when the disease follows an acute otitis media.

• Granulations are typical of disease of bone and grow on dead or dying bone.

Cholesteatomatous disease• Discharge can be scanty,

but is foul and creamy if secondary infection is present. It comes from a perforation which involves the attic or the posterior margin of the drum.

• If there is little infection the discharge may con sist of a flaky, waxy deposit which may obscure the attic or marginal perforation, which may be difficult to identify.

CHOLESTEATOMA

• Cholesteatoma is the result of invasion by squamous epithelium and the accumulation of its products in the middle ear and mastoid. The suffix '-oma' may suggest that it is a tumor. This is not the case, though as it expands it is destructive by pressure on other structures.

CHOLESTEATOMA

Cholesteatoma is classified as

(1) congenital cholesteatoma,

(2) acquired cholesteatoma,

which may be primary or secondary.

CHOLESTEATOMA

Closing the tube

The retraction pocket

Huge retraction pocket and

cholesteatoma

Bone destruction and spreading infection into the

middle cranium fossa

CHOLESTEATOMA

The second –

squamous metaplasia of the middle-ear mucosa may occur in response to a chronic infection

cholesteatoma

Retraction pocket

CHOLESTEATOMA

The ingrowth of squamous epithelium around the edges of a perforation, especially in the case of marginal

perforations

X-ray examination of mastoid cells

Normal Chronic purulent otitis

Surgical treatment

Ear surgery may be divided into two types:

1. Curative –

2. Reconstructive (Hear-improving or otoplastic)

Curative type of surgery

The main aim is to clean middle ear and to eliminate all pathological changes of mucous membrane, bone.

The most typicall operation is called radical middle ear operation or generalcavitary. Three cavities (tympanum, mastoid cells and meatus externus) are combined into one big cavity. All pathologic findings are eliminated.

It is prescribed in patients with:- non-effective conservative

treatment;- substantial destructive process in

temporal bone;- when cranial complications are

suspected or present.

Hear-improving or reconstructive surgery

The main aim is to reconstruct the passage of acoustic ways through the structures of middle ear. The surgeon reconstructs ossicle chain, covers the perforation of drum and screens round window. The volume of an operation depends of the intensity of destructive process in middle ear.

All operations are divided into 5 main types.

I type of tympanoplastic operations

It is prescribed in patients with perforation of the drum but when the ossicles are intact (myringoplastic).

The transplantat is put on the remains of the eardrum

II type of tympanoplastic operations

It is prescribed in patients with perforation of the drum and blasted handle of malleus.

The transplantat of new eardrum is put on the head of the malleus

III type of tympanoplastic operations

It is prescribed in patients with perforation of the drum and blasted malleus and incus.

The transplantat of new eardrum is put on the stapes and the small new tympanis cavity is formed.

IV type of tympanoplastic operations

It is prescribed in patients with perforation of the drum and blasted all ossicles. But the plate of the stapes in oval window must be mobile.

In this type of operations the transplantat of new eardrum plays role of screen to the round window.

So acoustic waves go through the oval window to the perylimph but not through the round window. Patient can hear due to the difference of sound pressure to the windows.

V type of tympanoplastic operations

It is prescribed in patients with perforation of the drum and blasted all ossicles. And the plate of the stapes in oval window can’t move.

In this type of operations the new oval window is created and the transplantat of new eardrum plays role of screen to the round window.

This type of operations is not used anymore nowdays.