C.S.O.M.: Investigations &

TreatmentDr. Vishal Sharma

Investigations for T.T.D.• Examination under microscope

• Ear discharge swab: for culture sensitivity

• Pure tone audiometry

• Patch test

• X-ray mastoid: B/L 300 lateral oblique (Schuller) Done when cortical mastoidectomy is required in ear discharge refractory to antibiotics

Uses of Audiometry• Presence of hearing loss

• Degree of hearing loss

• Type of hearing loss

• Hearing of other ear

• Record to compare hearing post-operatively

• Medico legal purpose

Patch TestDone when deafness = 40-50 dB

• Do pure tone audiometry: for hearing threshold

• Put Aluminum foil patch over T.M. perforation

• Repeat pure tone audiometry:

Hearing improved = ossicular chain intact & mobile

Hearing same / worse = oss. chain broken or fixed

Investigations for A.A.D.• Examination under microscope

• Ear discharge swab: for culture sensitivity

• Pure tone audiometry

• X-ray mastoid: B/L 300 lateral oblique (Schuller)

• CT scan: revision surgery, complications, children

Uses of E.U.M.• Confirmation of otoscopy findings

• Epithelial migration at perforation margin

• Cholesteatoma & granulations

• Adhesions & tympanosclerosis

• Assesment of ossicular chain integrity

• Collection of discharge for culture sensitivity

Uses of X-ray mastoid1. Position of dural & sinus plates: helps in surgery

2. Type of pneumatization:

a. Cellular (80%): plenty of air cells

b. Sclerotic (20%): small antrum, air cells absent

c. Diploetic (<1%): bone marrow within few air cells

3. Cholesteatoma (cotton wool appearance)

4. Bone destruction: presence & extent

5. Mastoid cavity

Dural & sinus plates

Cellular mastoid

Sclerotic mastoid

Diploetic mastoid

Attic bone erosion

Causes for mastoid cavity• Cholesteatoma erosion• Mastoidectomy cavity• Tubercular mastoiditis• Coalescent mastoiditis• Malignancy• Eosinophilic granuloma• Mega-antrum• Large emissary vein

C.T. scan temporal bone

Posterior canal wall erosion

C.T. scan temporal bone

Mastoid cholesteatoma

Treatment for Tubo-tympanic

Disease

Non-surgical Treatment• Precautions• Aural toilet• Antibiotics: Systemic & Topical• Antihistamines: Systemic & Topical• Nasal decongestant: Systemic & Topical• Treatment of respiratory infection & allergy• Tympanic membrane patcher

Precautions• Encourage breast feeding with child’s head

raised. Avoid bottle feeding.

• Avoid forceful nose blowing

• Plug E.A.C. with Vaseline smeared cotton

while bathing & avoid swimming

• Avoid putting oil & self-cleaning of E.A.C.

Done only for active stage

– Dry mopping with cotton swab

– Suction clearance: best method

– Gentle irrigation (wet mopping)

1.5% acetic acid solution used T.I.D.

Removes accumulated debris

Acidic pH discourages bacterial growth

Aural Toilet

AntibioticsTopical Antibiotics:

Antibiotics: Ciprofloxacin, Gentamicin, Tobramycin

Antibiotics + Steroid: for polyps, granulations

Neosporin + Betamethasone / Hydrocortisone

Oral Antibiotics: for severe infections

Cefuroxime, Cefaclor, Cefpodoxime, Cefixime

Antihistamines & Decongestants Antihistamines Systemic decongestants

Chlorpheniramine Pseudoephedrine

Cetirizine Phenylephrine

Fexofenadine Topical decongestants

Loratidine Oxymetazoline

Levo-cetrizine Xylometazoline

Azelastine (topical) Hypertonic saline

Kartush T.M. PatcherIndicated in:

• Perforation in only

hearing ear

• Patient refuses surgery

• Patient unfit for surgery

• Age < 7 years

Surgical TreatmentIndicated in inactive or quiescent stage

• Myringoplasty

• Tympanoplasty

Indicated in active stage

• Cortical Mastoidectomy

• Aural polypectomy

Methods to close perforationT.M. perforation < 2 mm

Chemical cautery with silver nitrate Fat grafting Myringoplasty if these measures fail

T.M. perforation > 2 mm Tympanic membrane patcher Myringoplasty

Chemical cautery

Approaches to middle ear

Wilde’s post-aural incision

Lempert’s end-aural incision

Rosen’s permeatal incision

Hearing RestorationMyringoplasty: • surgical closure of tympanic membrane perforation

Ossiculoplasty: • surgical reconstruction of ossicular chain

Tympanoplasty: • Surgical removal of disease + reconstruction of

hearing mechanism without mastoid surgery

Principles of hearing restoration• Intact tympanic membrane• Intact ossicular chain• Functioning receiving & relieving windows• Acoustic separation of these windows• Functioning Eustachian tube• Absence of sensori-neural hearing loss• Absence of active infection / allergy in

middle ear cleft

Myringoplasty

Aims• Permanently stop ear discharge: dry, safe ear• Improve hearing: provided: 1. ossicles are intact +

mobile; 2. absence of sensori-neural deafness• Prevention of: tympanosclerosis, adhesions,

vertigo, S.N.H.L. (cochlear exposure to loud sound)• Wearing of hearing aid• Occupational: military, pilots• Recreation: swimming, diving

Contraindications• Purulent ear discharge• Otitis externa• Respiratory allergy• Age < 7 yr (Eustachian tube not fully developed)

• Only hearing ear• Cholesteatoma

MethodsTechniques:

• Underlay: graft placed medial to fibrous annulus

• Overlay: graft placed lateral to fibrous annulus

Grafts used:

• Temporalis fascia, Tragal perichondrium, Vein

graft, Fascia lata, Dura mater

Underlay myringoplasty

Overlay myringoplasty

Steps of underlay myringoplasty

Tympanomeatal flap raised

Placement of graft

Tympanomeatal flap replaced

Tympanomeatal flap replaced

Why temporalis fascia?• Basal metabolic rate lowest (best survival rate)

• Easily harvested by post-aural incision

• Its an autograft, so no rejection

• Same thickness as normal tympanic membrane

• Large size graft can be harvested

• Good resistance to infection

Onlay UnderlayGraft cholesteatoma No

Blunting of anterior tympano-meatal angle

No

Lateralization of graft No

Delayed healing time (6 wk) 3-4 weeks

No middle ear inspection Possible

Difficult & takes more time Easier & quicker

Advantages of Local Anesthesia

• Minimal bleeding

• Hearing results can be tested on table

• Facial palsy detected immediately

• Labyrinthine stimulation detected

immediately

• No complications of General anesthesia

Tympanoplasty

Types

Type Pathology Graft placed on

I Ear drum perforation only Malleus handle

II Malleus handle eroded Incus

III Malleus + Incus eroded Stapes head

IV Only footplate remains: mobile

Round window (Footplate exposed)

V Only stapes remains: fixed Lateral SCC opening

VI Only footplate remains: mobile

Stapes Footplate

Malleus / Incus Autografts

Thank You