Ossicular Chain Status in Unsafe Chronic Suppurative Otitis Media Dr. Navjot Kaur (JR) Dr. Dinesh Kumar (AP) Dr. Jagdeepak Singh (Professor) Dr. Sania Arya (JR) Department of ENT, Government Medical College Amritsar

Introduction The present study comprised of forty patients of either sex in the age group of 0-60 years with evidence of attico-antral type of pathology in the middle ear cleft were recruited. They were subjected to clinical, audiological, radiological and laboratory examination. The patients underwent canal wall down mastoidectomy. The surgical procedure involved completely exenterating the disease from middle ear cleft.

Age-wise distribution of patients Maximum number of patients (52.5%) were in the 11 to 20 years age group followed by 42.5% patients who more than 20 years of age. Age-wise distribution of patients

Symptoms at the time of presentation All the patients had history of ear discharge and 75% patients had complaint of difficulty in hearing. Symptoms at the time of presentation

Duration of symptoms at the time of presentation In 75.0% patients the duration of symptoms was ten years or less whereas in 20% patients the symptoms were present for more than fifteen years. Duration of symptoms at the time of presentation

Major Otoscopic Findings The most common findings on Otoscopic examination were erosion of outer attic wall and retraction pockets. Most of the patients had more than one finding on Otoscopic examination. Major Otoscopic Findings

Pre-operative Pure Tone Audiometry Values 72.5% patients had moderate to severe hearing loss Pre-operative Pure Tone Audiometry Values

In more than half of the patients malleus was found to be either eroded or absent Status of Malleus

Incus was completely absent in 30% of patients and eroded in another 35%. Status of Incus

Stapes was intact in 80% of patients. Status of Stapes

Comparison of status of the ossicles Incus was eroded or absent in 65% patients Malleus was eroded or absent in 55% patients Stapes was eroded or absent in 25% patients Comparison of status of the ossicles

Comparison with a similar study Ossicle Malleus Incus Stapes Study Present Study Varshney et al Present Intact 45.0% 55.0% 35.0% 15.0% 80.0% 48.33% Eroded 52.5% 35.% 17.5% 51.67%) Absent 2.5% 10.% 30.0% 40.0% ---

Operative Findings Cholesteatoma and granulations were two most common pathological entities encountered. These occurred either alone or in conjunction with one another. There was a varied involvement of various regions of middle ear cleft (MEC) such as mastoid antrum, aditus, epitympanum, mesotympanum or hypotympanum by these two entities.

Operative Findings Cholesteatoma was the predominant pathology in epitympanum, aditus and mastoid antrum either alone or in conjunction with granulations. Both in epitympanum and aditus, it was present in conjunction with granulations in 72.5% patients. In mastoid antrum and mesotympanum, this ominous combination was present in 65% and 37.5% cases respectively.

Discussion It has been suggested that destruction of ossicles is the most common complication of cholesteatomas. The type of destruction depends on the original site and expansion of the cholesteatoma. Cholesteatomas in the portion under tension have a 90% erosion rate. The incus has been found to be the most affected ossicle, followed by the malleus and the stapes.

A necrotic bone may remain in place for years without being resorbed. Discussion It is currently thought that ossicle defects result from active bone resorption processes, rather than necrosis. This theory assumes that live cells participate in the mechanisms of bone demineralization, erosion, and destruction. A necrotic bone may remain in place for years without being resorbed.

Conclusion Cholesteatoma was the predominant pathology in epitympanum, aditus and mastoid antrum either alone or in conjunction with granulations. Destruction of middle ear ossicles was the predominant complication that accompanied cholesteatoma or chronic granulation tissue.

Conclusion Incus was the most commonly involved ossicle. In 65 % patients, it was seen to be completely absent or eroded by the active bone resorption processes that occur in presence of above mentioned pathological entities. Next most commonly affected ossicle was malleus which was eroded or absent in 55% cases. Stapes supra-structure was next in line that was partially or completely eroded in 20 % patients. However foot plate of stapes offered maximum resistance to erosive processes.

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