Chronic otitis media İlhan TOPALOĞLU M.D Otolaryngology Department Yeditepe University, School of Medicine

Definition COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

Etiology Unresolved middle ear infection Dysfunction of Eustachian tube Chronic inflammation in nose and pharynx Dysfunction of immune system

Etiology Dysfunction of Eustachian tube Chronic inflammation in nose and pharynx Dysfunction of immune system

TYPES OF C.S.O.M. Tubo tympanic s.o.m. Safe Attico antral Unsafe

TYPES OF TUBO TYMPANIC C.S.O.M. Active Tubo Tympanic C.S.O.M. Inactive Tubo Tympanic C.S.O.M.

TUBO TYMPANIC C.S.O.M Deafness Discharge Central perforation

TUBO TYMPANIC C.S.O.M Patency of Eustachian tube Nidus of infection in U.R.T.I. Immune status of patient Aerobic and Anaerobic

ATTICO ANTRAL C.S.O.M. Cholesteatoma Keratinizing Squamous Epithelium. A small sac May involve whole middle ear cleft

Pathology Middle ear mucosa is lined by secretory epithelium forming glandlike structure. Hyalinization or tympanosclerosis A healing response It occurs during quiescent periods It is formed by fused collagenous fibers It is hardened by the deposition of calcium and phosphate crystals Conductive hearing loss is associated with masses restricting ossicular mobility

Pathology Ossicular erosion is frequent in COM Infection process per se Necrosis following vascular thrombosis It most commonly affect the lenticular process of the incus and head of the stapes

Pathology Cholesterol granulomas Presence of yellowish masses surrounded by granulation tissue, edematous mucosa and fibrous tissue It contains many cholesterol crystals and foreign body giant cells.

Pathology Cholesteatoma: cystlike, expanding lesions of the temporal bone, lined by stratified epithelium and containing desquamated keratin and purulent material. Classification Congenital cholesteatoma Acquired cholesteatoma

Pathology Mechanics of mucosal transformation and epithelial ingrowth have been the focal point of cholesteatoma Pocket retraction: dysfunction of Eustachian tube

Pathology Epithelial migration: the edge of a peripheral perforation Inward growth of the surface epithelium follows papillary proliferation of the germinative layer of the pars flaccida. Metaplasia from pseudostratified ciliated columnar epithelium

Cholesteatoma Formation

Cholesteatoma Formation

Pathology Pathogenesis of congenital cholesteatoma: Ectodermal epithelial in proximity of the geniculate ganglion, medial to the neck of the malleus

Pathology Diagnosis criteria: Patients without previous history of ear disease, with normal and intact TM The temporal bone pneumatization should be normal

Clinical presentations Otorrhea Malodorous associated with cholesteatoma Hearing loss Air conduction threshold is within 40 dB means TM proferation with intact ossicular chain If air-bone gap is more than 40 dB is associated with discontinuity of ossicular chain

Clinical presentations Physical findings Defect in the pars tensa of TM or the pars flaccida or both Atelectatic lesions in tensa or flaccida pars Squamous epithelial invasion may invade middle ear Granumoms, polyps, tympanosclerotic plaques in middle ear

Radiographic evaluation Indications for image study Uncontrollable aural discharge Complications such as facial paralysis, labyrinthitis When central nervous stystem involvement is suspected, MRI should be considered. Coronal CT scan is perferred

RADIOLOGICAL ASSESSMENT X-rays mastoid

Differential diagnosis Tuberculous otitis media Hematogenous route Multiple perforation and fetid Creamy aural discharge Active pulmonary disease Multiple antituberculosis agents

Differential diagnosis Middle ear carcinoma Middle age patient Long term otorrhea with blood Otalgia Neoplasm in tympanum CT scan showed temporal bone destruction

Managements Medical treatment Goals Infection control Stabilization of process Prevention of irreversible damage and development of serious complications 3%H202 clears up pus then antibiotics ear drops is used. With the decrease of pus, 3% boric glycerin, 3% boric alcohol can be used No aminoglycoside ear drops No powders containing antibiotic and erosion ear drugs

Managements Surgery Goals classification Safe ear: lesion removal Dry ear Hearing ear: reconstruction of ossiclar chain classification Myrigoplasty Tympanoplasty Tympanoplasty with mastoidectomy